Bubble continuous positive airway pressure in the treatment of severe paediatric pneumonia in Malawi: a cost-effectiveness analysis

Abstract

ObjectivesPneumonia is the largest infectious cause of death in children under 5 years globally, and limited resource settings bear an overwhelming proportion of this disease burden. Bubble continuous positive airway pressure (bCPAP), an accepted supportive therapy, is often thought of as cost-prohibitive in these settings. We hypothesise that bCPAP is a cost-effective intervention in a limited resource setting and this study aims to determine the cost-effectiveness of bCPAP, using Malawi as an example.DesignCost-effectiveness analysis.SettingDistrict and central hospitals in Malawi.ParticipantsChildren aged 1 month–5 years with severe pneumonia, as defined by WHO criteria.InterventionsUsing a decision tree analysis, we compared standard of care (including low-flow oxygen and antibiotics) to standard of care plus bCPAP.Primary and secondary outcome measuresFor each treatment arm, we determined the costs, clinical outcomes and averted disability-adjusted life years (DALYs). We assigned input values from a review of the literature, including applicable clinical trials, and calculated an incremental cost-effectiveness ratio (ICER).ResultsIn the base case analysis, the cost of bCPAP per patient was $15 per day and $41 per hospitalisation, with an incremental net cost of $64 per pneumonia episode. bCPAP averts 5.0 DALYs per child treated, with an ICER of $12.88 per DALY averted compared with standard of care. In one-way sensitivity analyses, the most influential uncertainties were case fatality rates (ICER range $9–32 per DALY averted). In a multi-way sensitivity analysis, the median ICER was $12.97 per DALY averted (90% CI, $12.77 to $12.99).ConclusionbCPAP is a cost-effective intervention for severe paediatric pneumonia in Malawi. These results may be used to inform policy decisions, including support for widespread use of bCPAP in similar settings.

Economic evaluation of community acquired pneumonia management strategies: A systematic review of literature

“…United States (n = 7), Germany (n = 4) or other European countries (n = 6). Only two studies were conducted in a low and middle income country context (Malawi and Malaysia) [25,26]. Studies were mainly conducted from a hospital/government, health system, or third party perspective (n = 14), while two studies reported a broader societal perspective [27,28].…”

“…The sample size of included studies ranged from 28 to 2,283 (median 337). Most studies considered adults (n = 15; mean age ranged from 48–72 years); two studies were based on under-five children [25,26] and one study considered all age groups [29]. Publication years ranged from 1998 to 2017, with 84% (n = 16) of the studies published before the publication of the CHEERs checklist in 2013.…”

“…), with associated costs (n = 12). Two studies evaluated other interventions along with recommended antibiotics; one described usual management of pneumonia with an intervention that combined staff education, visual reminder and manual [30] and the other compared usual care with the bubble continuous positive airway pressure (bCPAP) alongside other supportive care [26] (Table 2).…”

“…Multi-country trials presented cost data in a single currency [35–37]. Currency was reported in all studies, however, reporting year was not specified by four studies [26,32,34,38]. Due to the short time periods involved, most studies did not apply discounting for cost analysis (n = 17), five studies provided this justification [32,39–42].…”

“…Due to the short time periods involved, most studies did not apply discounting for cost analysis (n = 17), five studies provided this justification [32,39–42]. One study applied a 3% discount rate for cost and outcome without specifying the time horizon considered, another study discounted productivity loss at a rate of 3% if it was longer than a year but no discounting for cost was applied [26,28].…”