Economic evaluations of differentiated service delivery should include savings and ancillary benefits, not only health system costs

Abstract

Economic evaluations of differentiated service delivery should include savings and ancillary benefits, not only health system costs We write in reference to the study by Nichols et al.[1] that evaluated costs and outcomes of community-based differentiated service delivery (DSD) models for HIV treatment in Zambia. The authors compared conventional, facility-based care to mobile antiretroviral therapy (ART), community adherence groups (CAGs), urban adherence groups (UAGs), and home delivery of ART under the Community HIV Epidemic Control (CHEC) model. The authors found that conventional care was least expensive in terms of direct clinical service and medication costs, whereas mobile ART, CAGs, UAGs, and CHEC were more expensive, in that order.We appreciate this detailed costing analysis of DSD models in Zambia. At the University of Maryland Baltimore, we have nearly two decades of experience in the provision of medical/technical service delivery in Zambia [2]. Based on community-based approaches demonstrated to improve HIV case-finding and linkage [3], provide high-quality care [4], and improve retention in adult ART programs [5], we developed and implemented the CHEC model [6], which provides home delivery of ART and was one of the models evaluated in this analysis. CHEC was primarily implemented in the PEPFAR/CDC-funded Stop Mother and Child HIV Transmission (SMACHT) project, which was conducted in the Southern Province of Zambia from 2015 to 2020. Under SMACHT, CHEC significantly improved maternal/child HIVoutcomes [7] and achieved 90% linkage to ART and 91% viral suppression [8].We would like to discuss four key considerations that are relevant to the economic impacts: the models compared, the outcome selected, how retention is defined, and the ancillary benefits and savings that were not included.

Economic evaluations of differentiated service delivery should include savings and ancillary benefits, not only health system costs: authors’ reply

“…We chose retention in ART care as the primary outcome for our analysis for a similar reason. Although we agree with Claassen et al [1] that viral suppression is an excellent indicator of patient success on treatment, it is also true that only patients who are retained in care can have a viral load measurement. Given this limitation, the fact that many patients were missing viral load measurements and that retention in ART care as defined in our manuscript was available for all the patients included in our study, retention in care made more sense as a primary outcome.…”

“…We thank Claassen et al [1] for their thoughtful comments. The models of care included in our analysis [urban adherence groups, community adherence groups, home antiretroviral therapy (ART) delivery (through the Community HIV Epidemic Control; CHEC model), and mobile ART] were indeed more expensive than conventional care.…”

“…In their comments, Claassen et al [1] were critical of the exclusion of savings to patients and other benefits of differentiated service delivery models to offset their higher costs to providers. The guiding principle for our analysis, however, was to ensure that costs and outcomes were measured consistently between all models of care.…”

“…To that end, we decided to include only the aspects of each model that could be directly compared with all the other models of care described in our manuscript. For the CHEC model, about which Claassen et al [1] write, this was the ‘stable in care’ portion of model. We recognize that there may be other ancillary benefits to the CHEC model not captured in our analysis, and this may also be the case with other models of care.…”

Standardising Workforce Cost Estimates Across Australian Jurisdictions: Genomic Testing as a Use Case

“…Australia also shares a health workforce market with New Zealand (with many shared regulatory and quasi-regulatory aspects). This remuneration and landscape of worker conditions is complex and can be challenging to assess within the country, let alone in comparison to other countries (5, 6). Differences in workforce costs are important in assessing cost variance between jurisdictions and countries, in health policy decisions and in understanding the impact of labour costs on economic evaluation (7).…”