Measuring and Comparing the Cost-Effectiveness of Surgical Care Delivery in Low-Resource Settings

Abstract

Cleft lip and palate (CLP) care is the longest sustained global effort in humanitarian surgical care. However, the relative cost-effectiveness of surgical delivery approaches remains largely unknown. We assessed the cost-effectiveness of two strategies of CLP surgical care delivery in low resource settings: medical mission and comprehensive care center. We evaluated the medical records and costs for 17 India-based medical missions and a Comprehensive Cleft Care Center in Guwahati, India, from Operation Smile, a humanitarian nongovernmental organization. Age, sex, diagnosis, and procedures were extracted and cost/Disability-Adjusted Life Year (DALY) averted was calculated using a provider's perspective. The disability weights for CLP from the Global Burden of Disease (GBD) 2010 update were used as the reference case. Sensitivity analysis was performed using various disability weights, age-weighting, discounting, and cost perspective. The medical missions treated 3503 patients for first-time cleft procedures and averted 6.00 DALYs per intervention with a cost-effectiveness of $247.42/DALY. The care center cohort included 2778 patients with first-time operations for CLP and averted a mean of 5.96 DALYs per intervention with a cost-effectiveness of $189.81/DALY. The Incremental Cost-Effectiveness Ratio (ICER) of choosing medical mission over care center is $462.55. The care center provides cleft care with a higher cost-effectiveness, although both models are highly cost-effective in India, in accordance with WHO guidelines. Compared to other global health interventions, cleft care is very cost-effective and investment in cleft surgery might be realistic and achievable in similar resource-constrained environments.

Impact of short-term reconstructive surgical missions: a systematic review

“…Twelve studies (29%) reported on health gains of the mission, reporting heterogeneous methods and outcomes (table 1). Methods used in cleft studies included photographic assessment of aesthetic outcomes,30 69 speech evaluation16 47 or DALYs averted 41 43 48 55. Three cleft studies evaluated speech functionality postoperatively, either by questionnaires61 or speech tests 16 47.…”

“…Four cleft studies reported on DALYs averted by cleft lip and palate repair surgery. DALYs averted per patient were 3.9,43 6.041 and 10.1 per patient 48. In three noma missions, a surgeon-reported outcome scale was used to score aesthetic and functional outcome 32 50 52.…”

CORR Insights®: Does Strict Adherence to the Ponseti Method Improve Isolated Clubfoot Treatment Outcomes? A Two-institution Review

“…Professionals who see only one or two patients a month will not be able to develop the skills they need without good access to this sort of guidance; access to referral centers can also help address the more difficult or treatmentresistant patient presentation [1]. That is the approach used to treat cardiac congenital deformities, cleft palate, and certain kinds of oncologic pathology [2].…”

A Framework for the Monitoring and Evaluation of International Surgical Initiatives in Low- and Middle-Income Countries

“…The role of surgery in the development of comprehensive healthcare systems and health promotion is therefore increasingly recognized. Importantly, surgical care is also increasingly understood to represent a cost-effective component of primary care in LMICs [ 5 – 7 ] and could play a critical role in improving multiple domains of healthcare [ 8 ]. Despite such recognition, surgical access remains poor and within many LMICs, the majority of surgical services are largely concentrated in urban centres, leaving rural communities with virtually no access to such care.…”