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 costeffectiveness. (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 Processing Analysis PROGRAM ADMINISTRATION COST (ANNUAL) • Labor (staff compensation) • Materials (e.g. office supplies, meetings, internet) Reporting Cause of death determination not included in interim results Cost estimation CAPITAL COSTS • • • • Lab equipment Office furniture Technology Renovation expenses START-UP COSTS • • • • • • INITIAL INVESTMENT COST cost * quantity * utilization by MITS program 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 Country classification Site 1 Site 2 Site 3 Site 4 Low income Lower-middle income Low income Low income Rural Rural Urban Urban University Hospital University Hospital University Hospital University Hospital 100% Adults 5% Neonates 5% Stillbirths 15% Infants 75% Adults 100% Neonates (World Bank) Setting MITS case population 6% Infants 94% Adults MITS Sampling by Site Site 1 Sampling methods used (% used) Sample collection location (facility or community) Samples collected (quantity + type) Site 2 Site 3 Site 4 Needle Only (100%) Needle Only (100%) Needle Only (100%) Needle Only (95%) Needle + Ultrasound (5%) 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 MITS Sites included in Cost Study Quantity of tests conducted per case Site 1 Site 2 Site 3 Site 4 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) (average) Type of tests conducted per case (average) Interim Results 12 Incremental cost to conduct MITS (cost per case) $1 200 $1 000 $889 $1,028 $906 $800 $858 $609 $600 $400 $200 $- * * * MITS kits Materials Labor Test transport Testing Sample collection S Site I T E 11 $398 $19 $211 $$261 $- S Site I T E 22 $398 $17 $386 $0 $228 $- S Site I T E 33 $398 $28 $314 $5 $161 $- S Site I T E 44 $398 $35 $165 $$11 $- • 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 AV ERAGE $398 $24 $269 $1 $165 $- Average cost per test $75,03 Biochemistry/Serology $58,80 IHC $53,54 Special stains $48,55 Histology $37,23 Microbiology Hematology $6,67 • Test costs vary little by site. • Tests not performed at sites include molecular, cytology, TAC PCR, Traditional PCR. 14 Testing cost per case 27 tests/case $261 22.2 tests/case 12.2 tests/case 1.1 tests/case $228 15.6 tests/case $165 $161 $11 SITE 1 SITE 1 SITE 2 SITE 2 SITE 3 SITE 3 SITE 4 SITE 4 AVERAGE 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) Total Staff $211 $386 $314 $165 $269 SITE 1 SITE 2 SITE 3 SITE 4 AVERAGE 11 9 6 8 8.5 Pathologists 3 Lab Techs 1.8 Social Scientists • Considerable variation in staff positions by site, suggesting flexibility in support roles to pathologists/ specialists. Microbiologists Other staff •Screening and enrollment 16 Clinical specialist, Nurse counselor, MITS specialist, MITS assistant, Accountant, Security, Logistician Sample collection Processing • Compensation may include incentives (hourly or per case). Site supervisor, Pediatrician Data enumerator, Physician Analysis Reporting Cause of death determination Initial Investment Costs: Start-up and Capital $48,818 $40,772 CAPITAL $22 551 $29,302 $20,962 $36 505 $16 910 $6 535 START-UP $26 268 $6,657 $14 427 $4 267 SITE 1 SITE 1 17 SITE 2 SITE 2 SITE 3 SITE 3 $2 050 $4 607 $12 392 SITE 4 AVERAGE SITE 4 AVERAGE • Great variation in both start-up and costs across site depends on existing infrastructure and investment in start-up activities. Capital Costs Renovation Technology Office furniture Lab equipment $36,505 $22,551 $16,910 $6,535 SS IITTE 1E 1 SSII TTE E2 2 $2,505 SSII TTE E3 3 S SI ITT EE4 4 • 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 A VA EV ERR AAG EG E Start-up Costs $26,267 $14,427 Training Other misc expenses and activities Community sensitization Data management system $4,267 S I T 1E 1 S I T 2E 2 S I T3E 3 $12,392 $4,606 S I T4E 4 A V E R5 A G E • 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