PDF(Pubmed)
Abstract：
BACKGROUND: In 2018, the Mozambique Ministry of Health launched guidelines for implementing differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV-associated mortality. The models were fast-track, 3-month antiretrovirals dispensing, community antiretroviral therapy groups, adherence clubs, family approach and three one-stop shop models: adolescent-friendly health services, maternal and child health, and tuberculosis. We conducted a cost-effectiveness analysis and budget impact analysis to compare these models to conventional services.
METHODS: We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients\' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty.
RESULTS: After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care.
CONCLUSIONS: DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.
METHODS: We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients\' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty.
RESULTS: After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care.
CONCLUSIONS: DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.
摘要：
背景：2018年，莫桑比克卫生部启动了实施差异化服务提供模式（DSDM）以优化艾滋病毒服务提供的指南，提高护理保留率，并最终降低与艾滋病毒相关的死亡率。模型是快速跟踪的，3个月的抗逆转录病毒药物配药，社区抗逆转录病毒治疗小组，坚持俱乐部，家庭方式和三个一站式商店模式:青少年友好型健康服务，妇幼保健,和肺结核。我们进行了成本效益分析和预算影响分析，以将这些模型与传统服务进行比较。
方法：我们根据每个模型的入学率百分比和研究期间每年的结果概率（治疗保留12个月）构建了一个决策树模型，其中3个用于成本效益分析（2019-2021），3个用于预算影响分析（2022-2024）。从卫生系统的角度来看，这些分析的费用主要是按客户年估算的。从社会角度进行了二次成本效益分析。预算影响分析成本包括抗逆转录病毒药物，实验室测试和服务提供相互作用。成本效益分析还包括启动，培训和客户的机会成本。使用不受控制的中断时间序列分析来评估有效性，比较实施差异化模型前后的结果。进行了单向敏感性分析，以确定不确定性的驱动因素。
结果：实施DSDM后，12个月保留率平均增加14.9个百分点(95%CI:12.2,17.8)，从47.6%（95%CI，44.9-50.2）到62.5%（95%CI，60.9-64.1）。DSDM和常规护理的平均成本差异为-600万美元(173,391,277与179,461,668）和-3250万（394,705,618与433,232,289)从卫生系统和社会的角度来看，分别。因此,DSDM主导了常规护理。在单向敏感性分析中，结果对常规护理交互成本最敏感。对于150万人口来说，与DSDM相关的3年基本财务成本为5.5亿美元，与传统护理的5.64亿美元相比。
结论：在开始抗逆转录病毒治疗12个月后，DSDM更便宜，更有效地留住客户，估计从2022年到2024年为卫生系统节省约1400万美元。
方法：我们根据每个模型的入学率百分比和研究期间每年的结果概率（治疗保留12个月）构建了一个决策树模型，其中3个用于成本效益分析（2019-2021），3个用于预算影响分析（2022-2024）。从卫生系统的角度来看，这些分析的费用主要是按客户年估算的。从社会角度进行了二次成本效益分析。预算影响分析成本包括抗逆转录病毒药物，实验室测试和服务提供相互作用。成本效益分析还包括启动，培训和客户的机会成本。使用不受控制的中断时间序列分析来评估有效性，比较实施差异化模型前后的结果。进行了单向敏感性分析，以确定不确定性的驱动因素。
结果：实施DSDM后，12个月保留率平均增加14.9个百分点(95%CI:12.2,17.8)，从47.6%（95%CI，44.9-50.2）到62.5%（95%CI，60.9-64.1）。DSDM和常规护理的平均成本差异为-600万美元(173,391,277与179,461,668）和-3250万（394,705,618与433,232,289)从卫生系统和社会的角度来看，分别。因此,DSDM主导了常规护理。在单向敏感性分析中，结果对常规护理交互成本最敏感。对于150万人口来说，与DSDM相关的3年基本财务成本为5.5亿美元，与传统护理的5.64亿美元相比。
结论：在开始抗逆转录病毒治疗12个月后，DSDM更便宜，更有效地留住客户，估计从2022年到2024年为卫生系统节省约1400万美元。
