Downing Janelle, El Ayadi Alison, Miller Suellen, Butrick Elizabeth, Mkumba Gricelia, Magwali Thulani, Kaseba-Sata Christine, Kahn James G
Health Services and Policy Analysis, University of California, Berkeley, CA, USA.
Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy, University of California, San Francisco, CA, USA.
BMC Health Serv Res. 2015 Jan 28;15:37. doi: 10.1186/s12913-015-0694-6.
Obstetric hemorrhage is the leading cause of maternal mortality, particularly in low resource settings where delays in obtaining definitive care contribute to high rates of death. The non-pneumatic anti-shock garment (NASG) first-aid device has been demonstrated to be highly cost-effective when applied at the referral hospital (RH) level. In this analysis we evaluate the incremental cost-effectiveness of early NASG application at the Primary Health Center (PHC) compared to later application at the RH in Zambia and Zimbabwe.
We obtained data on health outcomes and costs from a cluster-randomized clinical trial (CRCT) and participating study hospitals. We translated health outcomes into disability-adjusted life years (DALYs) using standard methods. Econometric regressions estimated the contribution of earlier PHC NASG application to DALYs and costs, varying geographic covariates (country, referral hospital) to yield regression models best fit to the data. We calculated cost-effectiveness as the ratio of added costs to averted DALYs for earlier PHC NASG application compared to later RH NASG application.
Overall, the cost-effectiveness of early application of the NASG at the primary health care level compared to waiting until arrival at the referral hospital was $21.78 per DALY averted ($15.51 in added costs divided by 0.712 DALYs averted per woman, both statistically significant). By country, the results were very similar in Zambia, though not statistically significant in Zimbabwe. Sensitivity analysis suggests that results are robust to a per-protocol outcome analysis and are sensitive to the cost of blood transfusions.
Early NASG application at the PHC for women in hypovolemic shock has the potential to be cost-effective across many clinical settings. The NASG is designed to reverse shock and decrease further bleeding for women with obstetric hemorrhage; therefore, women who have received the NASG earlier may be better able to survive delays in reaching definitive care at the RH and recover more quickly from shock, all at a cost that is highly acceptable.
产科出血是孕产妇死亡的主要原因，尤其是在资源匮乏地区，获得确定性治疗的延迟导致了高死亡率。非气动抗休克服（NASG）急救设备已被证明在转诊医院（RH）层面应用时具有很高的成本效益。在本分析中，我们评估了在赞比亚和津巴布韦，与在RH较晚应用NASG相比，在初级卫生保健中心（PHC）早期应用NASG的增量成本效益。
我们从一项整群随机临床试验（CRCT）和参与研究的医院获取了健康结局和成本数据。我们使用标准方法将健康结局转化为伤残调整生命年（DALYs）。计量经济学回归估计了早期在PHC应用NASG对DALYs和成本的贡献，通过改变地理协变量（国家、转诊医院）来生成最适合数据的回归模型。我们将早期在PHC应用NASG与后期在RH应用NASG相比的成本效益计算为新增成本与避免的DALYs之比。
总体而言，与等到转诊医院时再应用相比，在初级卫生保健层面早期应用NASG的成本效益为每避免一个DALY 21.78美元（新增成本15.51美元除以每位女性避免的0.712个DALYs，两者均具有统计学意义）。按国家来看，赞比亚的结果非常相似，不过在津巴布韦没有统计学意义。敏感性分析表明，结果对符合方案的结局分析具有稳健性，并且对输血成本敏感。
对于低血容量休克的女性，在PHC早期应用NASG在许多临床环境中可能具有成本效益。NASG旨在逆转休克并减少产科出血女性的进一步出血；因此，更早接受NASG的女性可能更有能力在到达RH接受确定性治疗时的延迟中存活下来，并更快地从休克中恢复，而且成本是高度可接受的。
