©2013 MFMER | slide-1 Cost Effective Care in Resource Limited Settings: Doing More With Less...

Cost Effective Care in Resource Limited Settings:Doing More With Less

Stephen P. Merry, MD, MPH, DTM&HAssistant Professor of Family MedicineMayo Clinic, Rochester

Disclosures

• Financial Disclosures• None

• Off label drug use• None

Learning Objectives

• Treat chronic diseases in adults and children in resource limited settings in a rational, cost-effective way.

• Follow an income and country GNP based protocol for hypertension, type 1 and 2 diabetes, hyperlipidemia, and coronary artery disease diagnosis and care.

• Design treatment protocols based on guiding principles of cost-effectiveness.

Who has been here before…

• Asked to d/c an ill child b/c • the family is “out of money”• “they’re going to die anyway”

• Saw an elderly person in a LIC with a chronic disease and wondered if you should treat it…”Is it worth it?”

• …How to decide who to treat with what and when and how…

?Which of you would withhold treatment for a life-threatening disease if you had the medication to treat it?

Medical Missionaries Behaving Badly

• Follow US treatment protocols

• Disregard WHO or MOH country guidelines

• “We shouldn’t treat them any differently than we’d want to be treated…”

• Treating chronic diseases regardless of benefit or cost

• Expensive testing• Expensive monitoring• Expensive meds• Frequent rechecks

The Summary Slide

Careful consideration of the whole care process from care access to care follow-up including all costs including harms and benefits coupled with compassion

Cost effective care

Disclaimer

• I’m a clinician• Patient-centric, practice-based view on cost

effectiveness analysis• Goal – practical concepts and tools

• I’m not an economist

Cost-Effective Health Care

• Caring for people in resource limited setting• Less tests, technology, meds; just the

essentials• Less specialists• Less physician driven – lifestyle/public health

primary• Avoid futility

• Person centered, coordinated, comprehensive care by an accessible primary care provider

Tribute to Barbara Starfield, MD

Cost Effective Care

• Requires analysis of the “care delivery value chain”

• Prevention• Testing/Screening• Staging• Delaying progression of disease• Initiation of therapy• Continuous disease management• Management of deterioration

Rhatigan et al. Applying the Care Delivery Value Chain: HIV/AIDS Care in Resource Poor Setttings. Harvard Business School working paper, 2009

Cost Effectiveness Analysis

• Searches for “best buys”• E.g. smoking cessation vs statins for CVD

prevention.

• Expresses decisions in cost per benefit (usually cost in US$/DALY gained)

• Requires clear knowledge (or an informed guess) of numbers needed to treat for one to benefit

WHO and World Economic Forum, “From Burden to ‘Best Buys’”, 2009

What Is A Reasonable Cost?

Options

1.How much are they willing to pay for the estimated value of the treatment?

2.What is 1 DALY wortha. 3 x the per capita income (WHO)b. The (income of the family / # in family) x 3

(my proposal)?

Case 1:The Hypertensive Guinean Farmer

A 55 yo Guinean farmer from 2 hours away sees you for a rash on his feet. His exam reveals a BP 159/99. He is a non-smoker, mildly obese (BMI 33) man with tinea pedis but otherwise well.

a)Recommend lifestyle changes, BP checks by a VHW, treat his tinea and return if consistently elevated above 160/100.

b)Do “a” but obviously start HCTZ daily now.

c)Do “b” but check a potassium, creatinine, fasting glucose, U/A, CBC, and ECG

d)Do “c” and also check his cholesterol level and initiate statin and ASA if elevated.

e)Do “d” and also begin Metformin if diabetic.

What is HTN?JNC 7 and WHO

• Normal = systolic <120 mmHg and diastolic <80

• Pre-hypertension: systolic 120-139 or diastolic 80-89

• Hypertension:• Stage 1: systolic 140-159 or diastolic 90-99• Stage 2: systolic 160 or diastolic 100

Hypertension in Africa

% Detected % Treated % Controlled

Adapted from Edwards R, Unwin N, Mugusi F et al. Hypertension prevalence and care in an urban and rural area of Tanzania 2000. J Hypertens; 18:145-52.

Should we treat mild HTN?

• > 140/90 even if no risk factors?

• NNT for 1 year = 700 to prevent 1 MI or stroke related death (mild HTN).

• If cost of Rx = US$50/year, is the Guinean farmer REALLY consenting to US $35,000 to save ?10 years life (WHO suggests max cost should be 3 x per capita GNP; perhaps a better method is 3x his income or about $1300 for a Guinean farmer)?

• Paternalism vs. shared decision making.

Initial Evaluation of HTN

• Hx

• Exam

• Labs• Dip U/A; maybe other if history, exam or

urinalysis suggests need and can afford.• Creatinine• (K+)• (ECG)• (Lipids)• (Fasting blood sugar)

Who to Treat?

• WHO & JNC 7 : > 140/90 or >130/80 in renal disease

• Depends…• Access to care and follow up• Availability/cost of meds• Comorbidity• Household finances

• Risk-Based treatment with full informed consent

Wait…Are You Saying Life Isn’t Worth That?

• No…

• This is normal, of course, in US practice too…(to a far lesser degree).

• Examine the total costs per benefit.

• Where is that money coming from • Children’s nutrition• Wife’s prenatal care

Choose Meds & Methods Wisely

Start with Thiazide diuretics - cheap, few side effects• Hydrochlorthiazide 25 mg daily # 400 + 1

banana/day• “See me in 6 months” (or 1 year) – sooner if

high risk.• Annual check on co-morbidities, compliance,

refills, (dip urine).

Risk Stratification of hypertensive patients

Grade 1Grade 1

(140-159/90-(140-159/90-99 mm Hg)99 mm Hg)

Grade 2Grade 2

(160-179/100-(160-179/100-109 mm Hg)109 mm Hg)

Grade 3Grade 3

((≥≥ 180/110 180/110 mm Hg)mm Hg)

No risk factorsNo risk factors Low riskLow risk Medium riskMedium risk High riskHigh risk

1-2 risk factors1-2 risk factors Medium riskMedium risk Medium-high Medium-high riskrisk

Very high Very high riskrisk

≥ ≥ 3 risk factors, 3 risk factors, LVH, proteinuria, LVH, proteinuria, raised creatinine, raised creatinine, grade 2 retinopathy.grade 2 retinopathy.

High riskHigh risk High riskHigh risk Very high Very high riskrisk

Associated clinical Associated clinical condition condition = stroke, CAD, = stroke, CAD, CHF, CRF, DM neph, grade CHF, CRF, DM neph, grade 3+ hypertensive retinopathy3+ hypertensive retinopathy

Very high Very high riskrisk

Adapted from WHO Guidelines

Who to Treat?Isolated Systolic HTN?

• Systolic > 160 (Diast < 95).• NNT 5 years to prevent a major CV event

• 18 men; 38 women• 19 elderly > 70; 39 < 70 yo• 16 people with prior CV disease• So, have to treat about 20 people for 5 years to

prevent one CV event or 100 people for 1 year• NNT/year = 100• Cost to prevent an event in Africa = US$50/year

(cheapest method of treatment!) x 100 = US$5,000 to prevent a fatal MI or stroke

Staessen JA. Lancet 2000; 355(9207): 865-72

Etiology of Heart Failure in a Urban Cardiology Practice in Africa(Ghana)

16% 10%10%

Hypertension

Rheumatic HeartDisease

Cardiomyopathy

Congenital HeartDisease

Ischemic

Amoah AG. Cardiology 2000; 93(1-2):11-8

How should we treat mild HTN or low risk patients?

• Depends… “Shared Decision Making”

• Diet• Low salt• High fruits and vegetables• Weight loss• Less alcohol

• Exercise

Lifestyle Modifications in the Management of Hypertension

ModificationModification RecommendationRecommendation Approximate systolic Approximate systolic BP reductionBP reduction

Weight reductionWeight reduction Maintain BMI 18.5 – Maintain BMI 18.5 – 2525

5-20 mm Hg per 10 lb 5-20 mm Hg per 10 lb lossloss

Adopt DASH eating Adopt DASH eating planplan

Diet rich in fruits, Diet rich in fruits, vegevege’’s, low fat dairy, s, low fat dairy, reduced sat. fatreduced sat. fat

8-14 mm Hg8-14 mm Hg

Dietary sodium Dietary sodium reductionreduction

Low salt diet – 2.4 gm Low salt diet – 2.4 gm sodiumsodium

2-8 mm Hg2-8 mm Hg

Physical activityPhysical activity 30 min per day brisk 30 min per day brisk activityactivity

4-9 mm Hg4-9 mm Hg

Limit alcoholLimit alcohol No more than 2/day No more than 2/day men and 1/day men and 1/day womenwomen

2-4 mm Hg2-4 mm Hg

Adapted from JNC 7

Second Rx:Choose Meds Wisely

• All meds ~ same benefit in large studies (ALLHAT).

• Start with Thiazide diuretics - cheap, few side effects, superior in CHD prevention

• CCB’s work best in Africans

Ha DA, Chisholm D Cost-effectiveness analysis of interventions to prevent cardiovascular disease in Vietnam. Health Policy and Planning 2011;26:210–222.

Cost-Effectiveness Analysis

• WHO-Choice ((CHOosing Interventions that are Cost-Effective): http://www.who.int/choice/cost-effectiveness/en/

• program in the World Health Organization that helps countries decide health system priorities based on considerations of costs and impacts.

• One Health Tool – software – released 2012 http://www.who.int/choice/onehealthtool/en/

• software tool designed to inform national strategic health planning in low- and middle-income countries

Conclusion

• I can’t practice “there” just like I practice here.

• Someone has thought about what should be screened, prevented, diagnosed and treated (the WHO and MOH)

• I should integrate with national practice standards.

Case 2: The Togolese Boy With DM1

A 7 year old boy presents with DKA to your rural mission hospital. He is from a village without electricity or running water in his home. His family lives on < $2/day per person. His father comes to you as medical director of the hospital & asks you to d/c his son home to die. You would

a)Become angry and give dad your “man up” pep talk

b)Find the funds for home monitoring and insulin admin.

c)Ask the chaplain to share the Gospel with father and son and d/c him per the father’s wishes

d)Keep him hospitalized and provide continued monitoring and insulin until stable and think about it later.

DM1 – The Present Reality in LIC

• Costs exceed household resources in LIC.

• It’s a fatal disease. Life expectancy < 1 yr

• If annual treatment costs are > 2/3 the country’s per capita income, treatment is not reasonable (without relief type aid).

• International attn focused on providing specifically for DM1 costs (c.f. http://www.un-ngls.org/IMG/pdf_MDGs_and_Diabetes_Factsheet.pdf)

27/05/2008

Geneva Health Forum

Less than 10% of DM1 is treated in LICSufficiency of diabetes medicines consumption per country

13,17%

16,95%

24,56%

14,37%

37,78%

19,35%

13,15%

10,86%

10,43%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Total Oral

Insulin

Total Oral

Insulin

Total Oral

Insulin

Total Oral

Insulin

Total Oral

Insulin

Total Oral

Insulin

Total Oral

Insulin

Total Oral

Insulin

Total Oral

Insulin

Total Oral

Insulin

Sufficiency (%)

• Brief debrief

Case 3:The 70 year old Togolese Diabetic

A 70 yo man presents with polyuria to your rural mission hospital. He is from a village without electricity or running water. His family lives on < $2/day. You find no percussed suprapubic fullness over his bladder and a random glucose is 354. His exam is otherwise normal. You would

a)Advise weight loss, exercise, and 1 aspirin per day

b)“a” and add Metformin 2000 mg daily

c)Check a creatinine and do “b” if < 1.5

d)Do “c” and check his cholesterol and add a statin to control his LDL < 100

e)Do “d” and also add an ACE in case and recommend home glucose monitoring

Risk Reduction of Various Interventions Risk Reduction of Various Interventions - 1993- 1993

Increased cardiovascular risk in type 2 diabetes

Calculated effects of different interventions on coronary and total deaths in 1000 normal and 1000 men with type 2 diabetes aged 35 to 57 years without a history of myocardial infarction. Yudkin, JS, BMJ 1993; 306:1313

Conclusion Errors…

• The residual risk of “MRFIT” is due to high sugars

• Lowering sugar will eliminate the risk

• We should focus on frequently testing glucose and treating hyperglycemia

Value of Intensive Glycemic ControlValue of Intensive Glycemic Control3867 Type 2 DM followed 10 years3867 Type 2 DM followed 10 years

UKPDS 33, Lancet 1998

Conventional Control•Diet alone•A1C 7.9%

Intensive Control•Diet + Sulfa or Insulin•A1C 7%

Less weight gain No difference in agent eff.

Less hypoglycemia 12% less laser photocoag of retinae

No sig difference in deaths

Conclusion: Tight control of DM2 doesn’t affect mortality (or help much).

ADVANCE:The End of Tight Control?

• 215 centers, 20 countries; U. of Sydney, AU

• 11,140 pts DM2 randomized to “tight” A1C 6.5% or standard A1C to 7.3%; f/u 5 years

• Age > 55, Vascular disease or risk

• No difference in CV death, nonfatal MI, stroke.

• Less macroalbuminuria (9.4% vs 10.9%)

• More hypoglycemia (2.7% vs 1.5%)

The ADVANCE Collaborative Group. INTENSIVE BLOOD GLUCOSE CONTROL AND VASCULAR OUTCOMES IN PATIENTS WITH TYPE 2 DIABETES. N Engl J Med 358(24):2560, June 12, 2008

ACCORD:The End of Tight Control?

• No significant different in MI or stroke

• Intensive treatment caused• Increased all-cause mortality 5% vs 4% (P=NS)• More Hypoglycemia 16.2% vs 5.1%• More Weight gain > 10 kg 27.8% vs 14.1%

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group . The EFFECTS OF INTENSIVE GLUCOSE LOWERING IN TYPE 2 DIABETES. N Engl J Med 358(24):2545, June 12, 2008

The Big Point

• Summary of 50 years of type 2 diabetes research:

• Glycemic control has only a little to do with morbidity and mortality

• Obesity, inactivity, and other bad behaviors mitigate risk

• Correcting the real problems reduce risk.

Rational CV Risk Reduction Method:

• Smoking Cessation

• Med Diet, weight loss, exercise

• ASA

• BP normalization

• Statin (not lipid lowering)

• Glycemic control of minor benefit – use for symptoms unless well resourced.

• Self testing wasteful unless on insulin

27/05/2008

Geneva Health Forum

World Health Organization/ Health Action International (VII) – Cost of Meds Expressed in Days of Wages

A ffordability of one months therapy with the LP G of glibenclamide (5 mg, 2 times a day) and the LP G of metformin (500 mg, 3 times a day) in the private sector

0 1 2 3 4 5 6 7 8 9

Ethiopia (2004)Ghana (2004)

India-Chennai (2004)India-Haryana (2004)

India-Karnataka (2004)India-M aharashtra 12 districts (2004)India-M aharashtra 4 regions (2005)

India-Rajasthan (2003) India-West Bengal (2004)

Kenya (2004)M ongolia (2004)

Nigeria (2004)P akistan (2004)Tanzania (2004)

Sudan-Gadarif (2006)Sudan-Khartoum (2005)Sudan-Kordofan (2006)

Uganda (2004)Yemen (2006)

F iji (2004)Indonesia (2004)

J ordan (2004)M orocco (2004)

P eru (2005)P hilippines (2005)

Syria (2003)

Lebanon (2004)M alaysia (2004)

Kuwait (2004)United A rab Emirates (2006)

Affordability in days wages

M etformin500 mg

Glibenclamide5 mg

Cost Effective Care of DM2 in LIC

• One medication decreases mortality = Metformin

• Goal – Order of highest to lowest priority1. Reduce cardiac risk (see prior slide)2. Treat to reduce symptoms not A1C3. Retinal monitoring if affordable/treatment

available4. Microalbuminuria -> ACE if affordable5. Lower fasting glucose as income allows

Case 4: The Pregnant Pakistani Woman

A healthy 30 yo G2P1 with an uncomplicated last pregnancy delivered by trained TBA in her home presents for prenatal care to your rural hospital at 12 weeks GA. You would

a)Recommend monthly visits increasing to every 2 weeks at term with hospital delivery to be safest

b)Recommend she simply again deliver at home with the TBA

c)Recommend care at the maternity in town

d)Recommend TT2, iron/folate, insecticide treated bednet use, IPTp, a prenatal visit in each trimester with a midwife or physician and delivery with the midwife.

Why Be Involved

Institute of Medicine. The U.S. Commitment to Global Health: Recommendations for the New Administration Committee on the U.S. Commitment to Global Health. 2009.

per 100,000

live births

Inadequate Prenatal Care

Prenatal Care

►Requires 1 visit per trimester

►Interventions• Iron/Folate• Fansidar malaria treatment/prophylaxis• IT Bed nets• Tetanus immunization - TT2 • Advise location of delivery

Highly Cost Effective: Prevention/Public Health

• Lifestyle/public health• Latrines• Hand washing• Clean water (vs pills for NTD’s)• Insecticide treated bed nets

Wilson IJE 2005

Actual Causes of Death2

Tobacco

Poor diet/lack of exercise3

Alcohol

Infectious agents

Pollutants/toxins

Firearms

Sexual behavior

Motor vehicles

Illicit drug use

Leading Causes of Death1

Percentage (of all deaths)

Heart Disease

Cancer

Chronic lower respiratory disease

Unintentional Injuries

Pneumonia/influenza

Diabetes

Alzheimer’s disease

Kidney Disease

Stroke

Percentage (of all deaths)

1 National Vital Statistics Reports, Vol. 53, No. 15, February 28, 2005.2 Adapted from McGinnis Foege, updated by Mokdad et. al., 2000.3 JAMA, April 20, 2005—Vol 293, No. 15, pg 1861.

Primary Health Care:Getting to the root of the problem

Cost Effectiveness: Prevention

• Lifestyle/public health• Latrines• Hand washing• Clean water (vs pills for NTD’s)• Insecticide treated bed nets• Smoking cessation• Weight loss• Exercise DM2, HTN• Med Diet • Aspirin CAD

Cost Effectiveness: Diagnosis

• Limited labs Choose 1 or 2

• Limited imaging Use rarely

• Careful exam Yet efficient

• Rare specialists Textbooks or Virtual Consults

Empiric Rx: WHO IMCI(Integrated Management of Childhood Illness) – Syndromic Diagnoses

• Cough (and fever)

• Increased respiratory rate• ≥60 if age < 2 mos.• ≥50 if age 2-12 mos.• ≥40 if age 12 mos. to 5 years

• Lower chest retractions

• (Hypoxia, crackles, percussed

dullness rather than CXR)

= Pneumonia= Pneumonia

• Lifestyle/public health Sustainable cheap

• Essential meds No fru-fru• Efficient treatment of chronic disease• Balance NNTB / NNTH Mental Math• Avoid futility End of

life care

Cost Effective Care: Treatment

• Treatment• Lifestyle/public health Sustainable

cheap• Essential meds and meds only when

essential• No treatment for URI’s, most OM,

conjunctivitis, sinusitis, acute bronchitis• I & D not antibiotic for abscess• No expensive junk

The Benefits of Responsible Use of Medicines. Setting Policies for Better and Cost-effective Healthcare. Ministers Summit, Amsterdam, the Netherlands.

3 October 2012,

WHO Essential Medication List

• WHO Department of Essential Medicines and Health Products

• Find updated list here: http://www.who.int/medicines/en/

• Buy essential meds from IDA:• http://www.ida.nl/

Cost Effective Care

cheap• Essential meds No fru-fru• Task Shifting - Increase access and lower

Surgical Task Shifting

Chu et al. PLoS Medicine 2009

Surgical Task Shifting

Merry, World J Surg, 2011

Cost Effective Care

cheap• Essential meds No fru-fru• Task Shifting Access• Efficient treatment of chronic disease

• Pills if treatment saves 1 year of disability adjusted life for < 3 x per capita GNP (3 x personal income)

Cost Effective Care

cheap• Essential meds No fru-fru• Efficient treatment of chronic disease• Task Shifting Access• Balance NNTB / NNTH Mental Math

Evidence BasedCancer Screening Recs for Thailand (MIC) 2014

Chalkidou, K., P. Marquez, et al. (2014). "Evidence-informed frameworks for cost-effective cancer care and prevention in low, middle, and high-income countries." The Lancet. Oncology 15(3): e119-131.

So, how should I decide?

• National treatment guidelines (http://apps.who.int/medicinedocs/en/cl/CL9.1/clmd,50.html )

• Oxford Handbook of TM

• Ask your national colleague (and accept their approach as best)

• Mental math – estimate ratio of benefit to cost/harm

Buy at www.talcuk.org

Cost Effective Care

cheap• Essential meds No fru-fru• Efficient treatment of chronic disease• Task Shifting Access

• Balance NNTB / NNTH Mental Math• Avoid futility End of

life care

Cost Effective Care

• Treatment• Avoid futility - intensive care of

terminal patients• Helping patients/families accept death

and place their trust in Jesus• Learning to die well – hospice, chaplains,

pastors, community

Cost Effective Care

• Treatment• Lifestyle/public health• Essential meds• Efficient treatment of chronic disease• Task Shifting • Balance NNTB / NNTH• Avoid futility

Case 5: The Anginal African Farmer

A 55 yo African small business owner presents with angina. He smokes a few cigarettes per day, eats a reasonable diet though high salt. BMI 33, BP 160/105, normal exam. Which of the following would you do?

a)Advise DASH/Med diet with nuts and weight loss

b)Control HTN with a B-blocker

c)Smoking cessation

d)Lipid lowering to LDL < 70

e)Low dose aspirin daily

f)Exercise daily

Select Bibliography• WHO and World Economic Forum, “From Burden to ‘Best Buys’”, 2009

• C. J. Murray’s bibliography…

• Rhatigan et al. Applying the Care Delivery Value Chain: HIV/AIDS Care in Resource Poor Setttings. Harvard Business School working paper, 2009

• Ha DA, Chisholm D Cost-effectiveness analysis of interventions to prevent cardiovascular disease in Vietnam. Health Policy and Planning 2011;26:210–222.

• Ministers Summit: The Benefits of Responsible Use of Medicines: Setting Priorities for Better and Cost-Effective Healthcare. Amsterdam, 3 Oct 2012.

• WHO-Choice ((CHOosing Interventions that are Cost-Effective): http://www.who.int/choice/cost-effectiveness/en/

• One Health Tool – software – released 2012 http://www.who.int/choice/onehealthtool/en/

Medical Missionaries Behaving Well

• Follow country MOH treatment protocols

• Focus on prevention

• Treat patients cost effectively

• Prepare before you go• Steve’s Essential Stuff for Global Health Preparation (Google

it)• Handbook of Tropical Medicine (see resources in above doc)• Read Certificate in Global Health Practice at Unite for Sight:

http://www.uniteforsight.org/global-health-university/global-health-practice-certificate

• Consider diploma course in Tropical Medicine & MPH in Global Health

Learning Objectives

• Treat chronic diseases in adults and children in resource limited settings in a rational, cost-effective way.

• Follow an income and country GNP based protocol for hypertension, type 1 and 2 diabetes, hyperlipidemia, and coronary artery disease diagnosis and care.

• Design treatment protocols based on guiding principles of cost-effectiveness.

Questions & Discussion

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