Cost Analysis Interim Results for MITS Implementation in LMIC Settings
Building the evidence base for Minimally Invasive Tissue Sampling (MITS) adoption in Low- and Middle-Income Countries (LMICs) can enhance cause of death data quality and inform effective interventions to prevent mortality. This study aims to understand cost implications associated with MITS implementation, focusing on operational costs from the health care provider perspective in LMIC settings. Interim results from a cost survey conducted at four geographically dispersed MITS sites reveal insights into the costs and cost drivers involved. The study seeks to characterize costs and identify factors influencing MITS implementation costs in LMICs.
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MITS Cost Analysis Interim Results Laura Morrison, Elizabeth Brown, Tia Paganelli, and Norman Goco September 17, 2020 1
Building the evidence base for MITS Adoption of MITS in LMICs can improve the amount of and quality of COD data, thus improving the epidemiological knowledge base, and informing effective interventions for preventing mortality. To promote expansion of MITS, must evaluate validity, acceptability, feasibility, and cost- effectiveness. (Byass 2016) This study is an initial step towards understanding cost implications. Cost studies of novel practices (1) advocate for widespread adoption and (2) inform realistic implementation.
Building the evidence base for MITS What is agreed upon related to costs of MITS? That they must be better understood. (Byass 2016) MITS and MIA cost documentation and comparison studies in high-income countries exist, but may not be relevant for LMIC contexts. (Weustink et al, 2009; Breeze et al, 2010) Cost of specific supplies (biopsy needles), requirement of complex and costly microbiology platforms and microbiology specialists/pathologists are limitations to MIA in Mozambique (Castillo et al, 2015) Perceived high cost of MITS among HCWs in Pakistan (Feroz et al, 2019) May require public investment Operational expenses < initial investment cost
Study Objective Characterize the costs and cost drivers associated with MITS implementation in LMIC settings from the health care provider perspective. Implementation costs estimate MITS operational requirements only (no research costs). The provider s perspective represents costs that clinics/hospitals or health care systems would face in expanding/mainstreaming the use of MITS.
Cost Data Collection Interim results draw from a cost survey of four sites conducted between Feb - June 2020. Sites are geographically dispersed Sites are recipients of MITS Alliance grant funding Sites must have conducted MITS outside of training Cost survey delivered during in-person site visits, by e-mail; follow ups via phone interview. Pilots identified all relevant resources used (in-person site visits) Data collected from sites include: context-specific site information financial and economic data related to resources used in MITS implementation
Cost estimation RECURRING COST INITIAL INVESTMENT COST
Cost estimation RECURRING COST INCREMENTAL COST (PER CASE) Sampling Community collection (if applicable) Testing Test transport (if applicable) Materials (e.g. reagents, office + lab supplies) MITS kits (materials, labor, shipping) Labor (staff compensation) Screening and enrollment Sample collection Cause of death determination Processing Analysis Reporting PROGRAM ADMINISTRATION COST (ANNUAL) Labor (staff compensation) Materials (e.g. office supplies, meetings, internet) not included in interim results
Cost estimation INITIAL INVESTMENT COST CAPITAL COSTS Lab equipment Office furniture Technology Renovation expenses cost * quantity * utilization by MITS program START-UP COSTS initial training + training additional staff (labor, materials, space, MITS kits) ethics approval process protocol development data management system set-up community sensitization activities other misc. expenses (e.g. launching expenses, implementation visits)
MITS Sites included in Cost Study Site 1 Site 2 Site 3 Site 4 Country classification (World Bank) Lower-middle income Low income Low income Low income Setting Rural Rural Urban Urban University Hospital University Hospital University Hospital University Hospital 5% Neonates 5% Stillbirths 15% Infants 75% Adults MITS case population 6% Infants 94% Adults 100% Adults 100% Neonates
MITS Sampling by Site Site 1 Site 2 Site 3 Site 4 Needle Only (95%) Needle + Ultrasound (5%) Sampling methods used (% used) Needle Only (100%) Needle Only (100%) Needle Only (100%) Sample collection location (facility or community) Facility Facility Facility Facility 7 samples / case 9 samples / case 9 samples / case 6 samples / case Brain, lung, liver, blood, CSF, marrow, lesions Brain, lung, liver, blood, csf, skin, pleural effusion, lesions, cancerous masses Brain, lung, liver, blood, csf, placenta, skin, lesions, cancerous masses Brain, lung, liver, placenta, lesions, abdominal organs Samples collected (quantity + type)
MITS Sites included in Cost Study Site 1 Site 2 Site 3 Site 4 Quantity of tests conducted per case (average) 27 22.2 12.2 1.1 Histology (5) Microbiology (5) Special stains (17) Histology (5) Microbiology (6) Biochemistry/Serology (9) Hematology (2) Special stains (.2) Histology (4) Microbiology (4) IHC (1.2) Special stains (3) Histology (1) Special stains (.1) Type of tests conducted per case (average)
Incremental cost to conduct MITS (cost per case) $1,200 $1,028 $906 $889 $858 $1,000 $800 $609 $600 $400 $200 $- Site 1 $398 $19 $211 $- $261 $- Site 2 $398 $17 $386 $0 $228 $- Site 3 $398 $28 $314 $5 $161 $- Site 4 $398 $35 $165 $- $11 $- Average $398 $24 $269 $1 $165 $- SITE 1 SITE 2 SITE 3 SITE 4 AVERAGE MITS kits Materials Labor Test transport Testing Sample collection * * * MITS kits, Labor, and Testing costs drive the marginal cost of conducting MITS. MITS kits cost may be reduced if produced at scale or sourced locally.
Average cost per test $75.03 Biochemistry/Serology $58.80 IHC $53.54 Special stains $48.55 Histology $37.23 Microbiology $6.67 Hematology Test costs vary little by site. Tests not performed at sites include molecular, cytology, TAC PCR, Traditional PCR. 14
Testing cost per case 27 1.1 15.6 tests/case 22.2 tests/case 12.2 tests/case tests/case tests/case $261 $228 $165 $161 $11 SITE 1 SITE 2 SITE 3 SITE 4 AVERAGE SITE 1 SITE 2 SITE 3 SITE 4 AVERAGE While calculated costs per test are similar, the number of tests performed per case is the most important determinant of testing cost. More tests are run for middle and low-cost tests (e.g. special stains, histology). 15
Labor cost per case Staff compensation (per case) $211 $386 $314 $165 $269 SITE 1 SITE 2 SITE 3 SITE 4 AVERAGE Considerable variation in staff positions by site, suggesting flexibility in support roles to pathologists/ specialists. Total Staff 11 9 6 8 8.5 Pathologists 3 Lab Techs 1.8 Social Scientists Microbiologists Compensation may include incentives (hourly or per case). Site supervisor, Pediatrician Other staff Clinical specialist, Nurse counselor, MITS specialist, MITS assistant, Accountant, Security, Logistician Data enumerator, Physician Cause of death determination Screening and enrollment Sample collection Processing Analysis Reporting 16
Initial Investment Costs: Start-up and Capital Great variation in both start-up and costs across site depends on existing infrastructure and investment in start-up activities. $48,818 $40,772 CAPITAL $22,551 $29,302 $20,962 $36,505 $16,910 $6,535 $26,268 START-UP $6,657 $14,427 $12,392 $2,050 $4,607 $4,267 SITE 3 SITE 1 SITE 2 SITE 3 SITE 4 AVERAGE SITE 1 SITE 2 SITE 4 AVERAGE 17
Capital Costs $36,505 Renovation Office furniture Technology Lab equipment $22,551 $16,910 $6,535 $2,505 SITE 1 SITE 1 SITE 2 SITE 2 SITE 3 SITE 3 SITE 4 SITE 4 AVERAGE AVERAGE Where required, renovation drives capital expenses. Specific costly and necessary lab equipment and technology needs drive cost: e.g. autopsy table, embedding machine, cameras, laptops, and computers. 18
Start-up Costs $26,267 Training Other misc expenses and activities Community sensitization Data management system $14,427 $12,392 $4,606 $4,267 1 2 3 4 5 SITE 1 SITE 2 SITE 3 SITE 4 AVERAGE Training costs (initial and additional staff) make up, on average, 38% of start-up costs. Other start-up costs may depend on site-specific investment in certain activities, as hours and staff mix vary by site. 19
Implications The cost of MITS expansion depends greatly on the existing infrastructure of sites. Capital-heavy investments drive costs (other start-up costs may not be as site-dependent). Labor allocation demonstrates the need for highly trained staff who are costly to employ. What can we learn about support staffing mix and implications for cost? This study is a first step towards additional necessary examinations of cost considerations, including cost-comparison and cost-effectiveness studies, which further provide needed economic justification for the expansion of MITS. 20
Acknowledgements Thank you to the MITS Alliance grantees who generously contributed their efforts to facilitating our data collection. 21
Questions? 22
