Cost-effectiveness analysis of Smart Triage, a data-driven pediatric sepsis triage platform in Eastern Uganda

Abstract

Background: Sepsis, characterized by organ dysfunction due to presumed or proven infection, has a case-fatality over 20% in severe cases in low-and-middle income countries. Early diagnosis and treatment have proven benefits, prompting our implementation of Smart Triage at Jinja Regional Referral Hospital in Uganda, a program that expedites treatment through a data-driven triage platform. We conducted a cost-effectiveness analysis of Smart Triage to explore its impact on patients and inform multicenter scale up.

Methods: The parent clinical trial for Smart Triage was pre-post in design, using the proportion of children receiving sepsis treatment within one hour as the primary outcome, a measure linked to mortality benefit in existing literature. We used a decision-analytic model with Monte Carlo simulation to calculate the cost per year-of-life-lost (YLL) averted of Smart Triage from societal, government, and patient perspectives. Healthcare utilization and lost work for seven days post-discharge were translated into costs and productivity losses via secondary linkage data.

Results: In 2021 United States dollars, Smart Triage requires an annuitized program cost of only $0.05 per child, but results in $15.32 saved per YLL averted. At a willingness-to-pay threshold of only $3 per YLL averted, well below published cost-effectiveness threshold estimates for Uganda, Smart Triage approaches 100% probability of cost-effectiveness over the baseline manual triage system. This cost-effectiveness was observed from societal, government, and patient perspectives. The cost-effectiveness observed was driven by a reduction in admission that, while explainable by an improved triage mechanism, may also be partially attributable to changes in healthcare utilization influenced by the coronavirus pandemic. However, Smart Triage remains cost-effective in sensitivity analyses introducing a penalty factor of up to 50% in the reduction in admission.

Conclusion: Smart Triage's ability to both save costs and avert YLLs indicates that patients benefit both economically and clinically, while its high probability of cost-effectiveness strongly supports multicenter scale up. Areas for further research include the incorporation of years lived with disability when sepsis disability weights in low-resource settings become available and analyzing budget impact during multicenter scale up.

Trial registration: NCT04304235 (registered on 11/03/2020, clinicaltrials.gov).

Keywords: Cost-effectiveness analysis; Economic evaluation; Low-middle income country; Pediatric sepsis; Sepsis; Triage.

Fig. 1

Decision analytic model for patient care pathway before and after Smart Triage implementation. USD = United States dollars, HOC = Health opportunity cost, WHO = World Health Organization, GDP = Gross domestic product

Fig. 2

Cost effectiveness of Smart Triage relative to the baseline triage infrastructure at JRRH, societal perspective. USD = United States dollars, YLL averted = years of life lost averted, JRRH = Jinja Regional Referral Hospital

Fig. 3

Cost effectiveness acceptability curve of Smart Triage relative to the baseline triage infrastructure at JRRH. USD = United States dollars, HOC = Health opportunity cost, WHO = World Health Organization, GDP = Gross domestic product

Fig. 4

Tornado diagram showing variations in 95% confidence interval for ICER for various one-way sensitivity analyses. ICER = Incremental cost effectiveness ratio, YLL averted = Years of life lost averted, USD = United States dollars

Fig. 5

Cost effectiveness acceptability curve of Smart Triage, applying different penalty factors for admission rate reduction. USD = United States dollars, HOC = Health opportunity cost, WHO = World Health Organization, GDP = Gross domestic product