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

1. Cost Effective Care in Resource Limited Settings:Doing More With Less Stephen P. Merry, MD, MPH, DTM&H Assistant Professor of Family Medicine Mayo Clinic, Rochester

2. Disclosures • Financial Disclosures • None • Off label drug use • None 2

3. 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.

4. 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…

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

6. 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

7. 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

8. Disclaimer • I’m a clinician • Patient-centric, practice-based view on cost effectiveness analysis • Goal – practical concepts and tools • I’m not an economist

9. 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

10. 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

11. 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

12. What Is A Reasonable Cost? Options • How much are they willing to pay for the estimated value of the treatment? • What is 1 DALY worth • 3 x the per capita income (WHO) • The (income of the family / # in family) x 3 (my proposal)?

13. 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. • Recommend lifestyle changes, BP checks by a VHW, treat his tinea and return if consistently elevated above 160/100. • Do “a” but obviously start HCTZ daily now. • Do “b” but check a potassium, creatinine, fasting glucose, U/A, CBC, and ECG • Do “c” and also check his cholesterol level and initiate statin and ASA if elevated. • Do “d” and also begin Metformin if diabetic.

14. 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

15. Hypertension in Africa 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.

16. 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.

17. 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)

18. 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

19. 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

20. Rationing

21. 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).

22. Risk Stratification of hypertensive patients Adapted from WHO Guidelines

23. 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

24. Etiology of Heart Failure in a Urban Cardiology Practice in Africa(Ghana) Amoah AG. Cardiology 2000; 93(1-2):11-8

25. 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

26. Lifestyle Modifications in the Management of Hypertension Adapted from JNC 7

27. 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

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

29. 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

30. 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.

31. 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 • Become angry and give dad your “man up” pep talk • Find the funds for home monitoring and insulin admin. • Ask the chaplain to share the Gospel with father and son and d/c him per the father’s wishes • Keep him hospitalized and provide continued monitoring and insulin until stable and think about it later.

32. 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)

33. Less than 10% of DM1 is treated in LIC Geneva Health Forum

34. Pause • Brief debrief

35. 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 • Advise weight loss, exercise, and 1 aspirin per day • “a” and add Metformin 2000 mg daily • Check a creatinine and do “b” if < 1.5 • Do “c” and check his cholesterol and add a statin to control his LDL < 100 • Do “d” and also add an ACE in case and recommend home glucose monitoring

36. Risk Reduction of Various Interventions - 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

37. 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

38. Value of Intensive Glycemic Control3867 Type 2 DM followed 10 years Conclusion: Tight control of DM2 doesn’t affect mortality (or help much). UKPDS 33, Lancet 1998

39. 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

40. 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

41. 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.

42. 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

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

45. Cost Effective Care of DM2 in LIC • One medication decreases mortality = Metformin • Goal – Order of highest to lowest priority • Reduce cardiac risk (see prior slide) • Treat to reduce symptoms not A1C • Retinal monitoring if affordable/treatment available • Microalbuminuria -> ACE if affordable • Lower fasting glucose as income allows

46. 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 • Recommend monthly visits increasing to every 2 weeks at term with hospital delivery to be safest • Recommend she simply again deliver at home with the TBA • Recommend care at the maternity in town • 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.

47. 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.

48. per 100,000 live births

49. 69

50. 29