Browsing by Author "Watkins, David A"

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    Open Access
    A Cost-Effectiveness Analysis of a Program to Control Rheumatic Fever and Rheumatic Heart Disease in Pinar del Rio, Cuba
    (Public Library of Science, 2015) Watkins, David A; Mvundura, Mercy; Nordet, Porfirio; Mayosi, Bongani M
    BACKGROUND: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist in many low- and middle-income countries. To date, the cost-effectiveness of population-based, combined primary and secondary prevention strategies has not been assessed. In the Pinar del Rio province of Cuba, a comprehensive ARF/RHD control program was undertaken over 1986 - 1996. The present study analyzes the cost-effectiveness of this Cuban program. Methods and FINDINGS: We developed a decision tree model based on the natural history of ARF/RHD, comparing the costs and effectiveness of the 10-year Cuban program to a “do nothing” approach. Our population of interest was the cohort of children aged 5 - 24 years resident in Pinar del Rio in 1986. We assessed costs and health outcomes over a lifetime horizon, and we took the healthcare system perspective on costs but did not apply a discount rate. We used epidemiologic, clinical, and direct medical cost inputs that were previously collected for publications on the Cuban program. We estimated health gains as disability-adjusted life years (DALYs) averted using standard approaches developed for the Global Burden of Disease studies. Cost-effectiveness acceptability thresholds were defined by one and three times per capita gross domestic product per DALY averted. We also conducted an uncertainty analysis using Monte Carlo simulations and several scenario analyses exploring the impact of alternative assumptions about the program’s effects and costs. We found that, compared to doing nothing, the Cuban program averted 5051 DALYs (1844 per 100,000 school-aged children) and saved $7,848,590 (2010 USD) despite a total program cost of $202,890 over 10 years. In the scenario analyses, the program remained cost saving when a lower level of effectiveness and a reduction in averted years of life lost were assumed. In a worst-case scenario including 20-fold higher costs, the program still had a 100% of being cost-effective and an 85% chance of being cost saving. CONCLUSIONS: A 10-year program to control ARF/RHD in Pinar del Rio, Cuba dramatically reduced morbidity and premature mortality in children and young adults and was cost saving. The results of our analysis were robust to higher program costs and more conservative assumptions about the program’s effectiveness. It is possible that the program’s effectiveness resulted from synergies between primary and secondary prevention strategies. The findings of this study have implications for non-communicable disease policymaking in other resource-limited settings.
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    Delivery of health care for cardiovascular and metabolic diseases among people living with HIV/AIDS in African countries: a systematic review protocol
    (BioMed Central, 2016) Watkins, David A; Tulloch, Nathaniel L; Anderson, Molly E; Barnhart, Scott; Steyn, Krisela; Levitt, Naomi S
    Background: People living with HIV (PLHIV) in African countries are living longer due to the rollout of antiretroviral drug therapy programs, but they are at increasing risk of non-communicable diseases (NCDs). However, there remain many gaps in detecting and treating NCDs in African health systems, and little is known about how NCDs are being managed among PLHIV. Developing integrated chronic care models that effectively prevent and treat NCDs among PLHIV requires an understanding of the current patterns of care delivery and the major barriers and facilitators to health care. We present a systematic review protocol to synthesize studies of healthcare delivery for an important subset of NCDs, cardiovascular and metabolic diseases (CMDs), among African PLHIV. Methods/design: We plan to search electronic databases and reference lists of relevant studies published in African settings from January 2003 to the present. Studies will be considered if they address one or both of our major objectives and focus on health care for one or more of six interrelated CMDs (ischemic heart disease, stroke, heart failure, hypertension, diabetes, and hyperlipidemia) in PLHIV. Our first objective will be to estimate proportions of CMD patients along the “cascade of care”—i.e., screened, diagnosed, aware of the diagnosis, initiated on treatment, adherent to treatment, and with controlled disease. Our second objective will be to identify unique barriers and facilitators to health care faced by PLHIV in African countries. For studies deemed eligible for inclusion, we will assess study quality and risk of bias using previously published criteria. We will extract study data using standardized instruments. We will meta-analyze quantitative data at each level of the cascade of care for each CMD (first objective). We will use meta-synthesis techniques to understand and integrate qualitative data on health-related behaviors (second objective). Discussion: CMDs and other NCDs are becoming major health concerns for African PLHIV. The results of our review will inform the development of research into chronic care models that integrate care for HIV/AIDS and CMDs among PLHIV. Our findings will be highly relevant to health policymakers, administrators, and practitioners in African settings.
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    Integrating the prevention and control of rheumatic heart disease into country health systems: a systemic review
    (2018) Abrams, Jessica; Engel, Mark E; Zühlke, Liesl; Watkins, David A; Abdullahi, Leila
    Part A is a research protocol which describes the background and proposed methodology of this systematic review. This section contains the details of quantitative and qualitative methods to be used when analysing rheumatic heart disease (RHD) prevention and care programmes. Part B is a literature review which expands on the protocol. An in-depth explanation of the disease process is presented in order to understand the multiple opportunities for preventing RHD and its precursors. The importance of this research then is highlighted by contextualising RHD programmes within the health system and integrated care. Part C presents the research as a journal manuscript according the BMJ’s instructions for authors. The manuscript includes a brief introduction to the research followed by a summary of the methods and presentation of the results which are then discussed.
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    The household economic impact of Rheumatic Heart Disease (RHD) in South Africa
    (2018) Oyebamiji, Oyeleke; Alaba, Olufunke; Watkins, David A
    Background: Rheumatic heart disease (RHD) remains a major public health concern in African countries due to the high rates of complications such as atrial fibrillation, stroke, infective endocarditis, and heart failure, all of which can result in premature death. In 2015, RHD was estimated to affect 33 million people globally and resulted in at least 320,000 deaths, nearly all of which were in low and middle-income countries. Comparing to other non-communicable diseases (NCDs), RHD imposes economic burden on households that if measures are not in place to mitigate this, it can impoverish such household. However, there are several literatures on the intergenerational economic consequences of other chronic diseases. But, there is no study regarding the household economic of RHD. This mini-dissertation sets out to estimate the household economic impact of RHD. Methods: This study was a follow-on study from the Global Rheumatic Heart Disease Registry (REMEDY), which was a multi-center, international, hospital-based prospective registry of patients with RHD. It was designed as a cohort study to document the disease characteristics and outcomes of individuals with RHD across many countries. We recruited participants in the REMEDY study who were resident in Cape Town and received care at Groote Schuur Hospital (GSH). This study made use of patient and household member surveys to estimate the economic consequences of RHD among households in which REMEDY participants reside. REMEDY registry participants (index cases), their caregivers, and other household members were considered as respondents. 100 REMEDY participants receiving care at GSH was sampled. This sample size was chosen to balance feasibility and precision and to align with a parallel study of the cost of RHD to the health system that aimed to sample medical records from the same 100 REMEDY participants. Patient and household data collection was carried out between September 2017 to December 2017. Direct costs, indirect costs, and the downstream economic behaviors (coping strategies) that lead to medical impoverishment and other consequences were estimated. Cost of illness (COI) was used to assess the effect of ill-health and health-related expenditure on the consumption possibilities of households. Direct costs comprise both medical and nonmedical costs, which may include both the financial cost of resources as well as opportunity costs (e.g., of capital items). Human capital approach was used to calculate indirect cost. Implicit in the human capital approach is the assumption that changes in health status of household members can be reflected by losses in productivity, and losses in income generation. Productivity losses was estimated using the new South Africa minimum wage rate per month as proxy. Coping was estimated with the direct costs (e.g., borrowing from friends or relatives, or taking out formal loans) or indirect costs (e.g., intra-household labor substitution) and can be cost prevention strategies (e.g., ignoring illness, non-treatment) to cost management strategies (e.g., borrowing, selling assets, or labor substitution). Economic costs were valued in United State dollar (USD) converted from South African rand (ZAR) in 2017. Results: Direct medical cost was estimated to ZAR 0, because all patients were exempt from medical fees. Total direct non-medical cost for outpatient and inpatient visits was estimated to be ZAR 27,000 (USD 2000) and 29,000 (USD 2200) (respectively) over 302 and 74 encounters (respectively), an average of ZAR 270 (USD 20) and ZAR 290 (USD 22) per patient (respectively). Indirect costs incurred over the 302 outpatient encounters and 74 hospital admissions were estimated to be ZAR 41,000 (USD 3100) and ZAR 26,000 (USD 1900) (respectively), an average of ZAR 410 (USD 31) and ZAR 260 (USD 19) per patient. Direct cost had a very high impact on the household and they were compelled to adopt coping. Households observed in the study recorded that seventeen percent of households took out loans at an average of ZAR 1200 (USD 91) per loan (range ZAR 100 to ZAR 7000) (range USD 7 to 500). Fifteen percent received financial gifts at an average of ZAR 800 (USD 61) per gift. Two percent sold assets valued at ZAR 5600 (USD 120) on average. Five percent engaged in multiple coping strategies. Also, HH had to cope with indirect cost of illness as 15% of household caregivers changed jobs and 10% worked extra hours. About 4% of household members dropped out of school. Four percent adopted more than one coping strategy. A considerable share of participants reported that they had reduced education to take care of the affected patient. Most of the caregivers of patients with RHD were spouses and children, and 6 % were heads of household. The total cost of RHD to the average affected household is valued at about ZAR 1600 annually. In total, the overall annual economic impact of RHD in this sample of 100 households affected by RHD was estimated at ZAR 160,000 (USD 12200) (ZAR 1600 per household) (USD 120), representing 4.4% of annual household income or 4.9% of annual household expenditure patient spending that exceeded 10% threshold was estimated to be 8% and increasing the threshold to 40 % of non- food expenditure reduced the prevalence of catastrophic spending to 4%. Conclusions: The economic impact of RHD in South Africa is substantial despite government efforts to provide free care. The total cost of RHD to the average affected household is valued at about ZAR 1600 annually. A broader and more robust range of social policies will be required to mitigate non-medical and indirect costs and reduce distortions in household economic activity.