Cost-effectiveness of intensive care for hospitalized Covid-19 patients: experience from South Africa

Abstract

Background: Amidst the shortages of critical care resources in the public sector resulting from the COVID-19 pandemic, the South African Government embarked on an initiative to purchase critical bed capacity from the private sector. Within an already under-funded public health sector, it is imperative that the costs and effects of potential interventions to care are assessed and weighed against the opportunity costs of their required investment. Objective: To assess the cost-effectiveness of ICU management for admitted COVID-19 patients across the public and private health sector in South Africa. Methods: Using a Markov modelling framework and a health system perspective, the costs and health outcomes of inpatient management of severe and critical COVID-19 patients in (1) general ward and intensive care (GW+ICU) and (2) general ward only were assessed. Disability adjusted life years (DALYs) were evaluated as health outcomes, and the cost per admission from public and private sectors was determined. The models made use of four variables: mortality rates, utilisation of inpatient days for each management approach, disability weights associated to the severity of the disease, and the unit cost per general ward day and per ICU day in public and private hospitals. The unit costs were multiplied by utilisation estimates to determine the cost per admission. DALYs were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). An incremental cost-effectiveness ratio (ICER) - representing the difference in costs and health outcomes of the two management strategies - was calculated and compared to a cost-effectiveness threshold to determine the value for money of ICU management. Results: A cost per admission of ZAR 75,127 was estimated for inpatient management of severe and critical COVID-19 patients in general wards only as opposed to ZAR 103,030 in GW+ICU. DALYs were 1.48 and 1.10 in the general ward only and GW+ICU, respectively. The ratio of difference in costs and health outcomes between the two management strategies produced an ICER equal to ZAR 73 091 per DALY averted, a value above the cost-effectiveness threshold of ZAR 38 465. Conclusions: This study indicated that purchasing additional ICU capacity from the private sector may not be a cost-effective use of limited health resources. The real time, rapid, pragmatic, and transparent nature of this analysis demonstrates a potential approach for further evidence generation for decision making relating to the COVID-19 pandemic response and the wider priority setting agenda in South Africa.

Cost-Effectiveness of Intensive Care for Hospitalized Covid-19 Patients: Experience From South Africa

“…The urgency to inform decision making and restrictions on primary data collection necessitated a reliance on secondary data while the ongoing emergence of new information required exibility in model building. To address these concerns (1) a comprehensive systematic review of the available evidence was carried out to ensure that all of the available information was fed into the model and 2an open access modelling framework [36] with a user guide [37] was developed to facilitate full exploration of uncertainty through sensitivity analysis and to allow for parameters to be quickly and easily updated as new information becomes available.…”

Essential Emergency and Critical Care – a consensus among global clinical experts

“…The WHO guidance, and others, 50 additionally include recommendations for advanced critical care (such as mechanical ventilation, vasopressors and extracorporeal oxygenation), which may be difficult to rapidly scale-up in settings of low resources. Advanced critical care can be necessary to save the lives of some patients, but has a high cost per recovery 51,52 and risks diverting scarce resources to a few individuals. 53-55 Fortunately the focus has shifted in the global pandemic response from advanced critical care towards securing basic oxygen delivery systems 56,57 underscored by statements from the WHO and other partners.…”