Introduction: Pneumococcal pneumonia (PP) has a high burden of morbimortality in children. Use of pneumococcal conjugate vaccines (PCVs) is an effective preventive measure. After PCV 7-valent (PCV7) withdrawal, PCV 10-valent (PCV10) and PCV 13-valent (PCV13) are the alternatives in Peru. This study aimed to evaluate cost effectiveness of these vaccines in preventing PP in Peruvian children <5 yearsold. Methodology: A cost-effectiveness analysis was developed in three phases: a systematic evidence search for calculating effectiveness; a cost analysis for vaccine strategies and outcome management; and an economic model based on decision tree analysis, including deterministic and probabilistic sensitivity analysis using acceptability curves, tornado diagram, and Monte Carlo simulation. A hypothetic 100 vaccinated children/vaccine cohort was built. An incremental cost-effectiveness ratio (ICER) was calculated. Results: The isolation probability for all serotypes in each vaccine was estimated: 38% for PCV7, 41% PCV10, and 17% PCV13. Avoided hospitalization was found to be the best effectiveness model measure. Estimated costs for PCV7, PCV10, and PCV13 cohorts were USD13,761, 11,895, and 12,499, respectively. Costs per avoided hospitalization were USD718 for PCV7, USD333 for PCV10, andUSD 162 for PCV13. At ICER, PCV7 was dominated by the other PCVs. Eliminating PCV7, PCV13 was more cost effective than PCV10 (confirmed in sensitivity analysis). Conclusions: PCV10 and PCV13 are more cost effective than PCV7 in prevention of pneumonia in children <5 years-old in Peru. PCV13 prevents more hospitalizations and is more cost-effective than PCV10. These results should be considered when making decisions about the Peruvian National Inmunizations Schedule.
Objectives The objective of this study was to analyse the cost-effectiveness (C-E) of ceftazidime/avibactam (CAZ/AVI)-based therapy versus colistin (COL)-based therapy for pneumonia and bacteraemia caused by carbapenem-resistant enterobacteria (CRE) adjusted to Peruvian context. Methods A Markov decision model was extrapolated from literature to evaluate the clinical and economic consequences of CAZ/AVI-based therapy compared to COL-based therapy for a hypothetical cohort of patients with CRE pneumonia or bacteraemia according to Peruvian context. It was adopted a 5-year time horizon and a Markov-cycle length of 1 year. All patients in the model were assigned to CRE pneumonia or bacteraemia state and may transit through four different health states: home-care, long-term care without dialysis, long-term care with dialysis or death. Key findings Intervention with CAZ/AVI becomes progressively more cost-effective from a threshold of S/ 24,000 or US$ 6666 (equivalent to 1 Gross Domestic Product-per cápita [GDP-pc]). The model simulation allowed to calculate an average total cost of S/ 2’971,582 (US$ 825,440) for CAZ/AVI against S/2’056,488 (US$ 571.247) for COL treatment, yielding an incremental cost of S/ 915,094 (US$ 254,193). The cost/QALY for CAZ/AVI treatment against COL therapy approaches to S/23,154 (US$ 6432), something less than 1 annual GDP-pc. There were additional benefits associated with CAZ/AVI in the 5-year horizon, such as: 21 deaths avoided, 86 hospital days avoided, 1 CRF5 avoided and a NMB of S/6649 (US$ 1847). Conclusions The present transferability model demonstrates the C-E of CAZ/AVI over COL for the treatment of bacteraemia and CRE pneumonia according to peruvian payment thresholds.
Objective To evaluate cost‐effectiveness – from a local perspective – of cetuximab when it is added to conventional chemotherapy for the treatment of metastatic colon cancer. Methods A Markov model was structured based on the systematic review of the evidence and the opinion of local experts. The economic model consists of three health states: (a) progression free survival (PFS), (b) progressive disease (PD) and (c) death. The basic measure to determine the effectiveness of the intervention was the Quality Adjusted Life Year (QALY); however, other intermediate outcomes of impact on survival were considered, such as ‘R0 metastases resections’ and ‘early tumour shrinkage’ (ETS). Quarterly cycles were considered with a time horizon of 19 quarters (approximately 5 years). The analysis perspective was based on the Ministry of Health (MoH). Key findings The cost per quality adjusted life year (cost/QALY) for chemotherapy + cetuximab treatment (CT/Cet) with respect to the baseline strategy approaches S/. 20 078 (equivalent to 1 Gross Domestic Product per capita [GDP‐pc]). The probabilistic analysis of the ICER (Incremental Cost‐Effectiveness Ratio) shows that, in all the cases, the CT/Cet strategy becomes more cost‐effective with a payment threshold of S/. 30 000 (1.5 GDP‐pc). Likewise, the acceptability curves showed that, from a threshold of S/. 20 000, the intervention with cetuximab becomes more cost‐effective than chemotherapy alone (CT). Conclusions The cost/QALY was S/. 20 078 (1 local GDP‐pc) for the intervention with CT plus cetuximab. Other results of clinical relevance, such as ‘additional R0‐resections’, ‘additional ETS cases’, ‘disease progressions avoided’ and ‘deaths avoided’ also favour the combination treatment.
RESUMEN Objetivos Caracterizar el proceso de la Reforma del Sector Salud (RSS) en Perú expresada públicamente en 2013, identificando los principales avances en su implementación y los desafíos pendientes desde la perspectiva de los actores participantes. Métodos Se trata de un estudio de sistematización de la experiencia en el cual se realizaron entrevistas semiestructuradas a 21 informantes clave, incluyendo a tres exministros de salud, y empleando como marco temporal el decenio 2005–2015. Se analizaron bases de datos oficiales para comprobar las variaciones de los indicadores de salud. Resultados La propuesta se basa en la expansión del aseguramiento con predominio de un seguro público en salud bajo el modelo del pluralismo estructurado, con una clara separación entre las funciones de prestación, intermediación financiera, regulación y gobierno. Los principales avances de la RSS identificados son: haber trascendido el criterio de pobreza para el aseguramiento público, el refuerzo de la inversión física y de recursos humanos, el fortalecimiento de una superintendencia orientada a los derechos del usuario, y el del papel del Ministerio de Salud en la salud pública. Y los principales desafíos, la cobertura poblacional del aseguramiento no vinculada con la pobreza, la dotación de recursos humanos especializados y la reducción de gasto de bolsillo. Conclusiones La RSS en el decenio examinado es un proceso que se construye sobre avances de años precedentes al periodo analizado, que consolida en el país un modelo de aseguramiento encaminado a la cobertura poblacional universal sobre la base de un seguro público de salud, y que se expresa en un incremento demostrable del gasto público y de la cobertura, aunque sus avances se ven limitados principalmente en la dotación de recursos humanos especializados y en el gasto de bolsillo, que todavía es muy elevado.
A829Generalized linear regression models were used to examine associations between the total cost of hospitalization and various sociodemographic and clinical variables. Results: 301 patients were included; age 75.3 ± 11.8 years; 37% female; 57% with depressed ejection fraction; 46% of coronary artery disease. The blood pressure on admission was 129.8 ± 29.7 mmHg; renal function 26.2 ± 57.9 ml / min / 1.73 m2. In-hospital mortality was 7%. The length of stay was 7.82 ± 7.06 days (median 5.69), more prolonged in patients with renal impairment (8.59 vs. 8.18; p = 0.0329) and shorter in those with elevated blood pressure on admission (6.08 ± 4.03; p = 0.009). The average cost per patient was AR $ 68,861 ± 96,066 (US $ 8,071 ± 11,259; US $ 1 = AR $ 8.7928); 71% attributable to hospital stay, 20% for therapeutic procedures (mainly aortic valve surgery, implanted defibrillator and coronary angioplasty) and 6.7% for diagnostic studies (mainly radiology, laboratory and echocardiogram). In multivariate analysis, depressed ejection fraction, valve antecedent and impaired renal function at admission were associated with higher costs. ConClusions: Resource use and costs associated hospitalizations for heart failure are high, and the highest proportion is attributable to the costs of hospital stay.
Introducción. Los servicios de salud preventivos son muy importantes como inversión en la salud de las personas. Si se examinan los servicios preventivos secundarios para hacer frente al cáncer cérvico uterino (CCU) en el Perú, su acceso y demanda son inequitativos. En este artículo, se identifican y miden los factores determinantes de la demanda de servicios de Tamizaje de Papanicolaou (servicios PAP). Métodos. Se estudió a una población de mujeres de 30 a 49 años, con datos de la Encuesta Demográfica y de Salud Familiar (ENDES) de los años 2016 a 2019. Se utilizó un modelo logístico para explorar la relación entre demanda de servicios PAP y variables de decisión, socioeconómicas y de salud de las personas. Se examinó la predictibilidad del modelo en base al aprendizaje automático. Resultados. Los factores con mayor probabilidad de demandar los servicios PAP fueron, tener hipertensión (OR = 4.76; IC del 95%: 4.03 – 5.66) y pertenecer al estrato socioeconómico “más rico” (OR=3.39, IC del 95%: 2.96 – 3.87). Por el contrario, vivir en ciudades pequeñas (OR = 0.27; IC del 95%: 0.24–0.30), en Pueblos (OR = 0.26; IC del 95%: 0.23–0.30) y en la Sierra Altoandina (OR = 0.46; IC del 95%: 0.41–0.51) tenían menos probabilidades de demanda. Conclusiones. Los factores estructurales condiciones de vida y lugar de residencia son los principales determinantes de la demanda de servicios preventivos PAP en el Perú, lo cual implica mayores esfuerzos en la política de salud y la necesidad de articular con otros sectores.
Objectives: Colorado has the lowest rate of measles vaccination in the entire country, partially due to the ease of obtaining non-medical exemptions. Our primary objective was to determine the magnitude and cost of a measles outbreak in Denver at current vaccination coverage levels. We then simulated the effect of changing the Colorado non-medical exemption complexity to medium or difficult. MethOds: An agent based transmission model simulated the transmission of the measles virus in Denver following the introduction of a measles case. We modeled public health response, including contact tracing and quarantine of cases. Model outputs included the number of secondary cases, hospitalizations and deaths. Four vaccination scenarios were modeled: Colorado vaccination rate, national vaccination rate, Colorado vaccination rate under medium exemption regulations, and Colorado vaccination rate under difficult exemption regulations. Results: At the Colorado vaccination rate, seven secondary cases followed the introduction of an index case, two of which required hospitalization. This outbreak ranged in cost from $111,048-$338,304, which is equivalent to the purchase of 5,580-17,000 measles vaccines. This could increase 2-dose vaccination coverage in Denver by 1.3%. If Colorado increased their difficulty in obtaining non-medical exemptions, the number of secondary cases reduced by 86%, alleviating costs related to public health interventions and the negative consequences of a measles outbreak. At the national vaccination level, no other individuals became infected due to herd immunity. cOnclusiOns: Herd immunity is not established at the Colorado vaccination rate and thus an outbreak is likely following the introduction of an index case. There is an inverse relationship between non-medical exemption complexity and exemption rate. Increasing vaccination coverage by as little as 3.1% (from easy to medium complexity) would reduce the likelihood and magnitude of an outbreak. Adding a required education component or a written statement of objection would be a prudent public health nudge toward measles herd immunity.
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