Case management to improve adherence for HIV-infected patients receiving antiretroviral therapy in Ethiopia: a micro-costing study

Abstract

BackgroundAdherence to antiretroviral medication regimens is essential to good clinical outcomes for HIV-infected patients. Little is known about the costs of case management (CM) designed to improve adherence for patients identified as being at risk for poor adherence in resource-constrained settings. This study analyzed the costs, outputs, unit costs and correlates of unit cost variation for CM services in 14 ART sites in Ethiopia from October 2008 through September 2009.MethodsThis study applied standard micro-costing methods to identify the incremental costs of the CM program. We divided total CM-attributable costs by three output measures (patient-quarters of CM services delivered, number of patients served and successful patient exits) to derive three separate indices of unit costs. The relationships between unit costs and two operational factors (scale and service-volume to staff ratios) were quantified through bivariate analyses.ResultsThe CM program delivered 4,598 patient-quarters of services, serving 5,056 patients and 1,995 successful exits at a cost of $167,457 over 12 months, or $36 per patient-quarter, $33 per patient served and $84 per successful exit from the CM program. Among the 14 sites, mean costs were $11,961 (sd, $3,965) for the 12-month study period, and $51 (sd, $36) per patient-quarter; $48 (sd, $32) per patient served; and $183 (sd, $157) per successful exit. Unit costs varied inversely with scale (r, -0.70 for cost per patient-quarter versus patient-quarters of service) and with the service-volume to staff ratio (r, -0.68 for cost per patient-quarter versus staff per patient-quarter).ConclusionsFor those receiving CM, the program adds 0.52% to the lifetime cost of ART. These data reflect wide variation in unit costs among the study sites and suggest that high patient volume may be a major determinant of CM program efficiency. The observed variations in unit costs also indicate that there may be opportunities to identify staffing patterns that increase overall program efficiency.

High Loss to Followup and Early Mortality Create Substantial Reduction in Patient Retention at Antiretroviral Treatment Program in North-West Ethiopia

“…Case managers are trained high school graduates with modest experience of community health practice. They are required to conduct planned outreach activities to trace those lost to follow-up and onsite community support [23]. After ART initiation, patients were given monthly review appointments [2].…”

Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries

“…Only nine of these studies had sufficiently large samples to apply econometric methods to explore any associations between scale and costs. 23,69,74,75,[77][78][79]93,96 Most of these studies were focused on HIV prevention among key populations. None covered condom distribution, male circumcision or interventions that were targeted at men who have sex with men.…”

“…None covered condom distribution, male circumcision or interventions that were targeted at men who have sex with men. Scale was often found to explain statistically significant proportions of the variability seen in unit costs -including 48%, 42%, 28-83%, 25-88% and 45-96% of such variability in an ART programme, 23 a programme for the elimination of mother-to-child transmission of HIV infection, 96 HIV counselling and testing, 69,96 and programmes targeting that were not included in the earlier review by Sweeney et al (2012). 9 Most of the 23 studies related to HIV counselling and testing (n = 18) or ART (n = 3) but we also analysed single studies on three other types of programme: behaviourchange communications, male circumcision and the elimination of mother-tochild transmission (Appendix A).…”

Methodological Variation in Economic Evaluations Conducted in Low- and Middle-Income Countries: Information for Reference Case Development

“…Limited methodological quality is reported to be a significant barrier to the effective use of economic evaluation information [ 5 – 7 ]. This is of particular concern in low- and middle- income countries (LMICs) where research capacity in this field and reliable data sources are insufficient [ 7 , 8 ], and there are few methodological guidelines for performing locally-relevant economic evaluation [ 9 ]. As a result, BMGF, being a major funder of this type of research, aims to pioneer the development of a reference case for conducting health economic evaluations in developing countries to be referred to not only by its grantees but also by researchers who receive financial support from other funders.…”