key: cord-0309620-ifkszijc
authors: Klarman, M.; Flaherty, K. E.; Cajusma, Y.; Schon, J.; Exantus, L.; Beau de Rochars, V. M.; Baril, C.; Becker, T. K.; Nelson, E. J.
title: A nighttime telemedicine and medication delivery service to avert pediatric emergencies: An exploratory cost-effectiveness analysis
date: 2021-09-28
journal: nan
DOI: 10.1101/2021.09.26.21264144
sha: f8453df8a5749faa80a84ee79a3a44324121cba8
doc_id: 309620
cord_uid: ifkszijc

Objective: We sought to compare the costs of a nighttime pre-emergency pediatric telemedicine and medication delivery service (TMDS) per disability-adjusted life year (DALY) averted to the costs of hospital emergency medicine (HEM) per DALY averted from a societal perspective. Methods: We studied a nighttime pediatric TMDS and HEM in a semi-urban and rural region of Haiti. Costs of the 2 services were enumerated to represent the financial investments of both providers and patients. DALYs averted were calculated to represent the years lives lost (YLL) and years lost to disability (YLD) from diarrheal, respiratory, and skin (bacterial and scabies etiologies) disease among children from zero to 9 years old. The incremental cost-effectiveness ratio (ICER) was estimated and compared to the per-capita gross domestic product (GDP) of Haiti ($1,177). Cost-effectiveness was defined as an ICER less than 3 times the per-capita GDP of Haiti ($3,531). Univariate sensitivity analysis was performed to evaluate how uncertainty of individual parameter estimates (utilization rates, costs, lost wages, discounting factor) affected the ICER. Results: The total costs of the nighttime TMDS and HEM to society were $285,931.72 per year and $89,335.41 per year, respectively. The DALYs averted by the TMDS and HEM were 199.76 and 22.37, respectively. Through sensitivity analyses, the ICER of the TMDS ranged from $791.43 to $1,593.35. Conclusion: A nighttime pediatric TMDS is a cost-effective alternative to HEM for pre-emergency pediatric care in semi-urban and rural regions in Haiti, and possibly in similar lower-middle income countries.

Respiratory infections and diarrheal disease are the leading causes of pediatric mortality for children between one month to 5 years of age globally and resulted in 560,000 deaths in 2018. 1, 2 Under 5 mortality (U5M) disproportionately burdens those living in low-and middle-income countries (LMIC). 3 LMIC endure U5M rates 14 times higher than high income countries (HIC), and within LMIC, the U5M rate among the lowest wealth quintile is 2 times that of the highest quintile. 4 The COVID-19 pandemic has increased this disparity. 5, 6 Well-established low-cost treatments exist for both acute respiratory infections and diarrheal diseases. 7, 8 Oral amoxicillin for bacterial pneumonia can reduce mortality by 32% 9 and treatment of diarrhea with oral rehydration solution and zinc can reduce mortality by 93% 10 and 23%, 11 respectively. However, these treatments are most effective when administered soon after symptoms start, which is difficult when healthcare access is limited, especially at night. Delayed treatment, especially in children, can result in rapid progression to an emergent state. 12 In these settings, emergency care is considerably more difficult to access and expensive than preemergency care. 13, 14 More than half of the 5.3 million early childhood deaths in 2018 were considered preventable with basic healthcare. 15 Improving access to healthcare is one of the highest global health priorities set by the Sustainable Development Goals (SDG). 16 , 17 SDG 3.8 seeks to "achieve universal health coverage", however progress is insufficient to reach this target by 2030. 17, 18 LMIC are the furthest off this target. 19 Innovative, cost-effective approaches are needed to overcome persistent as well as emerging barriers to improve and sustain healthcare access in LMIC. In Haiti, only 23% of the total population and 5% of the rural population have access to quality primary care. 20 Access to emergency services is low with 51% of the population living within 50 km of a tertiary care facility. 13 Child health and wellness is substandard, with Haiti ranking 151 out of 180 countries on the Flourishing Index. 21 The U5M rate is 65 per 1,000 live births compared to 39 per 1,000 live births globally. 1 Respiratory infection and diarrheal disease are major contributors to this burden, accounting for over half of hospitalizations and over a third of deaths of hospitalized children. 22 To better understand barriers to pediatric healthcare in Haiti, we conducted a needs assessment to identify differences in household healthcare seeking intention ('would do') and behavior ('did do'); 23 this initiative was part of the Improving Nighttime Access to Care and Treatment Study . In this needs assessment, households expressed an intention to seek care from a provider within conventional networks, but because of cost, distance, and nighttime hours, in practice sought care from disconnected providers near to the household. INACT-1 revealed that a pediatric telemedicine and medication delivery service (TMDS), known as MotoMeds, might provide an innovative solution to one aspect of the crisis of limited access to pediatric healthcare.

The TMDS was launched in Gressier, Haiti as a pre-pilot (INACT-2) in September 2019. Families with children experiencing pre-emergent medical problems at night called the call center. A nurse with physician oversight used a clinical decisionsupport tool adapted from the World Health Organization (WHO) Integrated Management of Childhood Illness guidelines 24, 25 to triage, conduct an assessment and generate a plan and logistics system to enable household medication delivery. Patients identified with life-threatening conditions were referred for emergency care. During INACT-2, call-center nurses were dispatched to all households to confirm that callcenter findings matched in-person findings ( Figure 1 ). Respiratory illness, diarrhea and skin problems (bacterial infections, scabies) were common, and the median time to delivery was 1h 20 min. At 10-days, 94% of parents reported the problem resolved/had improved.

The objective of the study herein was to conduct a cost-effectiveness analysis of a scaled TDMS model. We determined and compared the cost of the nighttime preemergency pediatric TMDS per DALY averted to HEM per DALY averted. infections, and HIV/AIDS. Among children less than 5 years of age, the leading causes of death are acute respiratory infections, prematurity, and diarrhea. 13 About 62% of the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 28, 2021. ; https://doi.org/10.1101/2021.09.26.21264144 doi: medRxiv preprint population lives below the international poverty level of $1.25/day. 14 Government healthcare spending per capita is $8, below the low income average of $9. 27 Over one third of this funding is spent at the hospital level, leading to an over reliance on emergency services. 28 In 2019, the MotoMeds TMDS was launched in Gressier, Haiti 30, 31 Population and Utilization Estimations. Delivery zones were delineated in each location based on distance and terrain. Inhabitants within these zones were referred to . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. DHS data were used to determine the proportion of the accessible population ages under 1 year (2.2%), from one to 4 years (7.5%), and 5 to 9 years (11.3%). 33 The age distribution was assumed to be geographically uniform across Haiti.

Cost Estimation. All costs were converted from Haitian gourdes to US dollars ($) at a rate of 1 US dollar to 90.15 Haitian gourdes (24-month average July 2019 to June 2021). 34 Telemedicine and Delivery Service. Fixed, variable, and family costs were summed to determine the societal cost of the TMDS. Costs represented the operational budget and . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 28, 2021. ; https://doi.org/10.1101/2021.09.26.21264144 doi: medRxiv preprint did not include start-up expenses. Primary data were obtained from 16 months of MotoMeds operations, the TMDS service in Gressier (INACT-2). Fixed costs refer to costs that did not vary according to patient volume while variable costs refer to costs that did vary according to patient volume. Family costs refer to the amount paid by the family for the service (Figure 3 ).

Fixed costs: The supervisor, study physician(s), and on-call physician(s) were assumed to be paid a fixed monthly rate. The call center nurses were assumed to be compensated per shift worked. In INACT-2, Gressier drivers were paid a daily retainer; however, this was not included in the compensation scheme for Jacmel and Leogane.

For the pre-pilot, the TMDS employed 2 call center nurses and 2 drivers per night. In order to serve Gressier, Leogane and Jacmel, the TMDS at scale was expected to employ 4 call center nurses, 5 on-call nurses and 14 drivers per night. Human resource administrative fees were estimated to be between 8-10%. Fixed costs also captured monthly operational costs (e.g. office rent, internet, and phone plans); drivers and oncall nurses were determined to receive a set amount of cellular phone credits monthly.

Variable costs: Variable costs included driver delivery payment, medications, and fluids. They were calculated per patient and multiplied by the expected number of patients per year. Half of deliveries were estimated to require 2 drivers and 20% of deliveries were estimated to require a nurse visit due to driver safety and patient severity respectively. Variable costs also captured software technologies utilized by TMDS for call intake (Twilio) 35 23 We conservatively assumed the same ratio for these analyses. Daily wages were estimated from the mean per capita gross national income. We were not able to obtain provider/institutional costs, likely due to the absence of specific . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 28, 2021. ; https://doi.org/10.1101/2021.09.26.21264144 doi: medRxiv preprint costing data at local hospitals. 38 As a result, provider costs were conservatively assumed to be equal to or greater than the direct healthcare patient costs for HEM.

Telemedicine Delivery Service. The key outcome indicator was the disability-adjusted life years (DALYs) averted by treatment of pediatric pre-emergency conditions. The total . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint assumed that diarrheal disease, respiratory infections, bacterial skin infections, and scabies skin infestation will remain the conditions most commonly treated by future iterations of the TMDS. Additionally, it was assumed that TMDS will serve similar population proportions in Gressier, Leogane, and Jacmel. Furthermore, it was assumed that the exchange rate will remain relatively stable at the 24-month average. 34 Given 35% of families with a sick child seek care and 8% of care-seekers seek hospital care, it is estimated that 2.8% of the accessible population will utilize HEM, 47.2% less than TMDS, for a total of 296 cases per year (Supplement 1).

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint (Table 1) .

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. In the TMDS and HEM DALY calculations, treatment of respiratory infections was found to avert the most YLL in all age groups. Treatment of diarrheal disease was found to avert the most YLD in all age groups.

Cost-Effectiveness Estimation. The TMDS is estimated to cost society $196,596.31 more than HEM yet averts an additional 177.39 DALYs. Correspondingly, the ICER is estimated at $1,108.27 signifying the TMDS costs an additional $1,108.27 to avert one additional DALY. This value is under the per capita GDP of Haiti, $1,177 in 2019, 31 therefore the TMDS is considered highly cost effective by WHO standards. 30 Sensitivity Analysis. Through sensitivity analysis the ICER ranged from $791.43 to $1,593 ( Figure 5 ). When the following parameters were increased, TMDS utilization, HEM utilization, cost of HEM care, cost of hospital transport and daily wages, the ICER . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 28, 2021. ; https://doi.org/10.1101/2021.09.26.21264144 doi: medRxiv preprint decreased, signifying a higher degree of cost-effectiveness. A decreased discounting factor was likewise associated with a lower ICER signifying a higher degree of costeffectiveness. Through all parameter variations the ICER remained within 2x the per capita GDP of Haiti and thus signified cost-effectiveness.

Here, we demonstrated the cost-effectiveness of a nighttime TMDS compared to hospital emergency services in Haiti. TMDS has the potential to avert additional years of life lost and years lost to disability among children under 10 for a relatively low cost to society. TMDS greatest costs relate to compensation of drivers and nurses. In this way, finances ideally are funneled directly back into society.

The results were robust to all input variables. Sensitivity analyses showed that the proportion of the population utilizing TMDS and the proportion of the population utilizing HEM were the key parameters influencing the ICER ( Figure 5 ). Increased TMDS utilization and increased HEM utilization are positively associated with the ICER.

While alternative TMDS operational modes and scales were not considered, it is important to note that increased TMDS utilization was found to be positively associated with cost-effectiveness. Therefore, a positive feedback loop where professionalism, reasonable payment structure and word-of-mouth might perpetuate TMDS usage and has the potential to further increase the cost-effectiveness of the service.

This cost-effectiveness analysis may stimulate interest in innovative solutions to improve access to care like the TMDS evaluated herein. Other TMDSs have been largely limited to HIC 45 ; however there is likely an underappreciated need for both . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 28, 2021. ;  telemedicine and medication delivery in LMIC. Successful telemedicine use cases include the Aponjon remote consultation service for maternal, neonatal, and infants in Bangladesh that provided valuable medical advice and support but lacked a referral system 46 Limitations in data availability likely contributed to a conservatively low ICER. The estimate of HEM usage is based on the INACT-1 study where families were asked to recall illnesses from the past month but did not specifically ask about illnesses requiring pediatric hospital level care, with the true HEM usage likely to be higher. MotoMeds TMDS cares for patients 10 years and under but DALYs in this analysis were calculated . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 28, 2021. ; https://doi.org/10.1101/2021.09.26.21264144 doi: medRxiv preprint for children 0-9 years. Additionally, TMDS averts DALYs caused by other illnesses not included in this analysis.

A TDMS for nighttime pre-emergency pediatric care is cost-effective compared to HEM in semi-urban and rural Haiti. This form of TDMS may represent an innovative option to extend access to care to isolated families at night across Haiti and possibly in other LMIC with similar challenges.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 28, 2021. ; . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted September 28, 2021. ; https://doi.org/10.1101/2021.09.26.21264144 doi: medRxiv preprint

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We thank the team who collected the data for this study. We are grateful to Randy Autrey and Krista Berquist for their administrative support, as well as Glenn Morris at the Emerging Pathogens Institute, Desmond Schatz in the Department of Pediatrics at the University of Florida for their ongoing support and guidance from the Ministry of