A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis
Background:
To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale.
Methods and Findings:
Our cost-effectiveness analysis from the provider's perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26–67.06) in intervention hospitals compared to US$31.1 (95% CI 30.67–47.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19–2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A “what-if” analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3.
Conclusion:
Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions.
: Please see later in the article for the Editors' Summary
Vyšlo v časopise:
A Multifaceted Intervention to Improve the Quality of Care of Children in District Hospitals in Kenya: A Cost-Effectiveness Analysis. PLoS Med 9(6): e32767. doi:10.1371/journal.pmed.1001238
Kategorie:
Research Article
prolekare.web.journal.doi_sk:
https://doi.org/10.1371/journal.pmed.1001238
Souhrn
Background:
To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment Plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale.
Methods and Findings:
Our cost-effectiveness analysis from the provider's perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26–67.06) in intervention hospitals compared to US$31.1 (95% CI 30.67–47.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19–2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A “what-if” analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3.
Conclusion:
Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions.
: Please see later in the article for the Editors' Summary
Zdroje
1. UNICEF 2011 Levels and trends in child mortality New York UNICEF
2. YouDWardlawTSalamaPJonesG 2009 Levels and trends in under-5 mortality, 1990–2008. Lancet 375 100 103
3. JonesGSteketeeRWBlackREBhuttaZAMorrisSS 2003 How many child deaths can we prevent this year? Lancet 362 65 71
4. ClaesonMGillespieDMshindaHTroedssonHVictoraCG 2003 Knowledge into action for child survival. Lancet 362 323 327
5. EnglishM 2005 Child survival: district hospitals and paediatricians. Arch Dis Child 90 974 978
6. SnowRWMung'alaVOFosterDMarshK 1994 The role of the district hospital in child survival at the Kenyan Coast. Afr J Health Sci 1 71 75
7. AyiekoPNtoburiSWagaiJOpondoCOpiyoN 2011 A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: a cluster randomized trial. PLOS Med 8 e1001018 doi:10.1371/journal.pmed.1001018
8. IrimuGWamaeAWasunnaAWereFNtoburiS 2008 Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya. Arch Dis Child 93 799 804
9. EnglishMNtoburiSWagaiJMbindyoPOpiyoN 2009 An intervention to improve paediatric and newborn care in Kenyan district hospitals: Understanding the context. Implement Sci 4 42
10. World Health Organization 2003 Making choices in health: WHO guide to cost-effectiveness analysis Geneva WHO
11. DrummondFMSculpherJMTorranceWGO'BrienJBStoddartLG 2005 Methods for the economic evaluation of health care programmes Oxford Oxford University Press
12. WalkerDKumaranayakeL 2002 Allowing for differential timing in cost analyses: discounting and annualization. Health Policy Plan 17 112 118
13. World Bank 2010 Data by country. Available: http://dataworldbankorg/country/kenya. Accessed 27 September 2010
14. MwakyusaSWamaeAWasunnaAWereFEsamaiF 2006 Implementation of a structured paediatric admission record for district hospitals in Kenya–results of a pilot study. BMC Int Health Hum Rights 6 9
15. NzingaJNtoburiSWagaiJMbindyoPMbaabuL 2009 Implementation experience during an eighteen month intervention to improve paediatric and newborn care in Kenyan district hospitals. Implement Sci 4 45
16. AyiekoPAkumuAOGriffithsUKEnglishM 2009 The economic burden of inpatient paediatric care in Kenya: household and provider costs for treatment of pneumonia, malaria and meningitis. Cost Eff Resour Alloc 7 3
17. World Health Organization 2005 CHOosing Interventions that are Cost Effective (WHO-CHOICE) Geneva WHO
18. BlackRECousensSJohnsonHLLawnJERudanI 2010 Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 375 1969 1987
19. Fox-RushbyJAHansonK 2001 Calculating and presenting disability adjusted life years (DALYs) in cost-effectiveness analysis. Health Policy Plan 16 326 331
20. MurrayCJ 1994 Quantifying the burden of disease: the technical basis for disability-adjusted life years. Bull World Health Organ 72 429 445
21. AnandSHansonK 1997 Disability-adjusted life years: a critical review. J Health Econ 16 685 702
22. LopezAMathersCEzzatiM 2006 Measuring the global burden of disease and risk factors, 1990–2001. LopezADMathersCDEzzatiMJamisonDTMurrayCJL Global burden of disease and risk factor New York Oxford University Press 1 13
23. WHO 2010 Choosing Interventions that are Cost Effective (WHO-CHOICE). http://wwwwhoint/choice/costs/unit_regions/en/indexhtml. Accessed 14 August 2010
24. NgandaBWang'ombeJFloydKKangangiJ 2003 Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Machakos District, Kenya. Int J Tuberc Lung Dis 7 14 20
25. GrimshawJMThomasREMacLennanGFraserCRamsayCR 2004 Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 8 iii iv, 1–72
26. RoweAKRoweSYHollowayKAIvanovskaVMuheL 2008 Does shortening the training on Integrated Management of Childhood Illness guidelines reduce effectiveness? Results of a systematic review Geneva WHO
27. EnglishMNzingaJMbindyoPAyiekoPIrimuG 2011 Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals - interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies. Implement Sci 2011; 6 124
28. BarasaEWEnglishM 2011 Viewpoint: economic evaluation of package of care interventions employing clinical guidelines. Trop Med Int Health 16 97 104
29. NtoburiSHutchingsASandersonCCarpenterJWeberM 2010 Development of paediatric quality of inpatient care indicators for low-income countries - A Delphi study. BMC Pediatr 10 90
30. OpondoCAyiekoPNtoburiSWagaiJOpiyoN 2011 Effect of a multi-faceted quality improvement intervention on inappropriate antibiotic use in children with non-bloody diarrhoea admitted to district hospitals in Kenya. BMC Pediatrics 2011, 11 109
31. EnglishMIrimuGWamaeAWereFWasunnaA 2008 Health systems research in a low-income country: easier said than done. Arch Dis Child 93 540 544
32. SchellenbergJAAdamTMshindaHMasanjaHKabadiG 2004 Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet 364 1583 1594
33. HaradenCLeitchJ 2011 Scotland's successful national approach to improving patient safety in acute care. Health Aff (Millwood) 30 755 763
34. BrookeBSPerlerBADominiciFMakaryMAPronovostPJ 2008 Reduction of in-hospital mortality among California hospitals meeting Leapfrog evidence-based standards for abdominal aortic aneurysm repair. J Vasc Surg 47 1155 1156; discussion 1163–1154
35. Castellanos-OrtegaASuberviolaBGarcia-AstudilloLAHolandaMSOrtizF 2010 Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study. Crit Care Med 38 1036 1043
36. Lipitz-SnydermanASteinwachsDNeedhamDMColantuoniEMorlockLL 2011 Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 342 d219
37. PronovostPJHolzmuellerCG 2004 Partnering for quality. J Crit Care 19 121 129
38. GoodmanCAMillsAJ 1999 The evidence base on the cost-effectiveness of malaria control measures in Africa. Health Policy Plan 14 301 312
39. LaxminarayanRChowJShahid-SallesSA 2006 Intervention cost-effectiveness: Overview of main messages. JamisonDTBremanJGMeashamARAlleyneGClaesonM Disease control priorities in developing countries Washington (D.C.) Oxford University Press 35
40. HayesRJBennettS 1999 Simple sample size calculation for cluster-randomized trials. Int J Epidemiol 28 319 326
41. MOH 2005 The Second National Heath Sector Strategic Plan of Kenya (NHSSP II 2005–2010): Reversing the Trends Nairobi Ministry of Health Kenya
42. MOMS, MOPHS 2010 Global fund round 10 single country application, Kenya Nairobi Ministry of medical services & Ministry of public health and sanitation
43. ValeLThomasRMacLennanGGrimshawJ 2007 Systematic review of economic evaluations and cost analyses of guideline implementation strategies. Eur J Health Econ 8 111 121
44. BishaiDMirchandaniGPariyoGBurnhamGBlackR 2008 The cost of quality improvements due to integrated management of childhood illness (IMCI) in Uganda. Health Econ 17 5 19
45. BryceJGouwsEAdamTBlackRESchellenbergJA 2005 Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illness in Tanzania. Health Policy Plan 20 Suppl 1 i69 i76
46. AkumuAOEnglishMScottJAGriffithsUK 2007 Economic evaluation of delivering Haemophilus influenzae type b vaccine in routine immunization services in Kenya. Bull World Health Organ 85 511 518
47. VictoraCGAdamTBryceJEvansDB 2006 Integrated management of the sick child. JamisonDTBremanJGMeashamARAlleyneGClaesonM Disease control priorities Washington (D.C.) Oxford University Press 1177
48. SinhaAConstenlaDValenciaJEO'LoughlinRGomezE 2008 Cost-effectiveness of pneumococcal conjugate vaccination in Latin America and the Caribbean: a regional analysis. Rev Panam Salud Publica 24 304 313
49. HayesRMoultonL 2009 Cluster randomised trials London Chapman & Hall/CRC
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