Person: Alkire, Blake
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Alkire
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Blake
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Alkire, Blake
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Publication Health-system-adapted data envelopment analysis for decision-making in universal health coverage(World Health Organization, 2018) Shrime, Mark; Mukhopadhyay, Swagoto; Alkire, BlakeAbstract Objective: To develop and test a method that allows an objective assessment of the value of any health policy in multiple domains. Methods: We developed a method to assist decision-makers with constrained resources and insufficient knowledge about a society’s preferences to choose between policies with unequal, and at times opposing, effects on multiple outcomes. Our method extends standard data envelopment analysis to address the realities of health policy, such as multiple and adverse outcomes and a lack of information about the population’s preferences over those outcomes. We made four modifications to the standard analysis: (i) treating the policy itself as the object of analysis, (ii) allowing the method to produce a rank-ordering of policies; (iii) allowing any outcome to serve as both an output and input; and (iv) allowing variable return to scale. We tested the method against three previously published analyses of health policies in low-income settings. Results: When applied to previous analyses, our new method performed better than traditional cost–effectiveness analysis and standard data envelopment analysis. The adapted analysis could identify the most efficient policy interventions from among any set of evaluated policies and was able to provide a rank ordering of all interventions. Conclusion: Health-system-adapted data envelopment analysis allows any quantifiable attribute or determinant of health to be included in a calculation. It is easy to perform and, in the absence of evidence about a society’s preferences among multiple policy outcomes, can provide a comprehensive method for health-policy decision-making in the era of sustainable development.Publication Economic valuation of the impact of a large surgical charity using the value of lost welfare approach(BMJ Publishing Group, 2016) Corlew, Daniel Scott; Alkire, Blake; Poenaru, Dan; Meara, John G; Shrime, MarkBackground: The assessment of the economic burden of surgical disease is integral to determining allocation of resources for health globally. We estimate the economic gain realised over an 11-year period resulting from a vertical surgical programme addressing cleft lip (CL) and cleft palate (CP). Methods: The database from a large non-governmental organisation (Smile Train) over an 11-year period was analysed. Incidence-based disability-adjusted life years (DALYs) averted through the programme were calculated, discounted 3%, using disability weights from the Global Burden of Disease (GBD) study and an effectiveness factor for each surgical intervention. The effectiveness factor allowed for the lack of 100% resolution of the disability from the operation. We used the value of lost welfare approach, based on the concept of the value of a statistical life (VSL), to assess the economic gain associated with each operation. Using income elasticities (IEs) tailored to the income level of each country, a country-specific VSL was calculated and the VSL-year (VSLY) was determined. The VSLY is the economic value of a DALY, and the DALYs averted were converted to economic gain per patient and aggregated to give a total value and an average per patient. Sensitivity analyses were performed based on the variations of IE applied for each country. Results: Each CL operation averted 2.2 DALYs on average and each CP operation 3.3. Total averted DALYs were 1 325 678 (CP 686 577 and CL 639 102). The economic benefit from the programme was between US$7.9 and US$20.7 billion. Per patient, the average benefit was between US$16 133 and US$42 351. Expense per DALY averted was estimated to be $149. Conclusions: Addressing basic surgical needs in developing countries provides a massive economic boost through improved health. Expansion of surgical capacity in the developing world is of significant economic and health value and should be a priority in global health efforts.Publication The Impact of Natural Disaster on Pediatric Surgical Delivery: A Review of Haiti Six Months Before and After the 2010 Earthquake(Johns Hopkins University Press, 2012) Hughes, Christopher; Nash, Katherine; Alkire, Blake; McClain, Craig; Hagander, Lars; Smithers, Charles; Raymonville, Maxi; Sullivan, Stephen R.; Riviello, Robert; Rogers, Selwyn O.; Meara, JohnLittle is known about pediatric surgical disease in resource-poor countries. This study documents the surgical care of children in central Haiti and demonstrates the influence of the 2010 earthquake on pediatric surgical delivery. Methods. We conducted a retrospective review of operations performed at Partners in Health/Zanmi Lasante hospitals in central Haiti. Results. Of 2,057 operations performed prior to the earthquake, 423 were pediatric (20.6%). Congenital anomalies were the most common operative indication (159/423 opera- tions; 33.5%). Pediatric surgical volume increased signi cantly a er the earthquake, with524 Pediatric surgical care in Haiti 670 operations performed (23.0% post-earthquake v. 20.6% pre-earthquake, p5.03). Trauma and burns became the most common surgical diagnoses a er the disaster, and operations for non-traumatic conditions decreased signi cantly (p,.01). Conclusion. Congenital anomalies represent a signi cant proportion of baseline surgical need in Haiti. A natural disaster can change the nature of pediatric surgical practice by signi cantly increasing demand for operative trauma care for months afterward.Publication Aseptic Meningitis with Craniopharyngioma Resection: Consideration after Endoscopic Surgery(Georg Thieme Verlag KG, 2016) Chen, Jenny X.; Alkire, Blake; Lam, Allen; Curry, William; Holbrook, EricObjectives: While bacterial meningitis is a concerning complication after endoscopic skull base surgery, the diagnosis can be made without consideration for aseptic meningitis. This article aims to (1) present a patient with recurrent craniopharyngioma and multiple postoperative episodes of aseptic meningitis and (2) discuss the diagnosis and management of aseptic meningitis. Design: Case report and literature review. Results: A 65-year-old female patient with a symptomatic craniopharyngioma underwent transsphenoidal resection. She returned postoperatively with symptoms concerning for cerebrospinal fluid (CSF) leak and bacterial meningitis. Lumbar puncture demonstrated mildly elevated leukocytes with normal glucose levels. Cultures were sterile and she was discharged on antibiotics. She returned 18 days postoperatively with altered mental status and fever. Again, negative CSF cultures suggested aseptic meningitis. Radiological and intraoperative findings were now concerning for widespread cerebrovascular vasospasm due to leaked craniopharyngioma fluids. In the following months, her craniopharyngioma recurred and required multiple surgical resections. Days after her last operation, she returned with mental status changes and a sterile CSF culture. She was diagnosed with recurrent aseptic meningitis and antibiotics were discontinued. The patient experienced near complete resolution of symptoms. Conclusions: Consideration of aseptic meningitis following craniopharyngioma resection is critical to avoid unnecessary surgical re-exploration and prolonged courses of antibiotics.Publication Global economic consequences of selected surgical diseases: a modelling study(Elsevier BV, 2015) Alkire, Blake; Shrime, Mark; Dare, Anna J; Vincent, Jeffrey R; Meara, JohnBackground The surgical burden of disease is substantial, but little is known about the associated economic consequences. We estimate the global macroeconomic impact of the surgical burden of disease due to injury, neoplasm, digestive diseases, and maternal and neonatal disorders from two distinct economic perspectives. Methods The value of lost output (VLO) approach projects annual market economy losses during 2015-2030 by relating disease mortality to changes in the labor force and gross domestic product (GDP). The value of lost welfare (VLW) approach uses a broader measure of nonmarket losses based on a concept termed the value of a statistical life and estimates the present value of long-run welfare losses resulting from mortality and short-run welfare losses resulting from morbidity incurred during 2010. Sensitivity analyses are performed for both approaches. Findings During 2015-2030, the VLO approach projects surgical conditions to result in losses of 1·25%of potential GDP, or $20·7 trillion (2010 USD, PPP). When expressed as a proportion of potential GDP, annual GDP losses are greatest in low- and middle-income countries, with up to a 2·5% loss in output by 2030. When nonmarket losses are assessed (VLW), the present value of economic welfare losses is estimated to be equivalent to 17% of 2010 GDP, or $14.5 trillion (2010 USD, PPP). Neoplasm and injury account for greater than 95% of total economic losses in each approach, but maternal, digestive, and neonatal disorders, which represent only 4% of losses in high-income countries in the VLW approach, contribute to 26% of losses in low-income countries. Interpretation The macroeconomic impact of surgical disease is substantial and inequitably distributed. When paired with the growing number of favorable cost-effectiveness analyses of surgical interventions in low- and middle-income countries, our results suggest that building surgical capacity should be a global health priority.Publication The Economic Consequences Of Mortality Amenable To High-Quality Health Care In Low- And Middle-Income Countries(Health Affairs (Project Hope), 2018-06) Meara, John G.; Alkire, Blake; Peters, Alexander; Shrime, MarkWe estimated deaths amenable to high-quality health care globally and then modeled the macroeconomic impact in low- and middle-income countries using two macroeconomic perspectives: a value-of-lost-output approach to project gross domestic product (GDP) losses annually for the period 2015-30, and a value-of-lost-welfare approach to estimate the present value of total economic welfare losses in 2015. We estimated that eight million amenable deaths occurred in 2015, 96 percent of them in low- and middle-income countries. The value of lost output resulted in a projected cumulative loss of $11.2 trillion in these countries during 2015-30, with a potential economic output loss of up to 2.6 percent of GDP in low-income countries by 2030, compared to 0.9 percent in upper-middle-income countries. The value-of-lost-welfare approach estimated welfare losses of $6.0 trillion in 2015. Inadequate access to high-quality health care results in significant mortality and imposes a macroeconomic burden that is inequitably distributed, with the largest relative burden falling on low-income countries. Given that these deaths are unnecessary and the projected GDP losses are avoidable, there is a strong ethical and economic case for promoting high-quality health care as an essential component of universal health coverage.Publication Obstructed Labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention(Public Library of Science, 2012) Alkire, Blake; Vincent, Jeffrey R.; Burns, Christy Turlington; Metzler, Ian Scott; Farmer, Paul; Meara, JohnBackground: Although advances in the reduction of maternal mortality have been made, up to 273,000 women will die this year from obstetric etiologies. Obstructed labor (OL), most commonly treated with Caesarean delivery, has been identified as a major contributor to global maternal morbidity and mortality. We used economic and epidemiological modeling to estimate the cost per disability-adjusted life-year (DALY) averted and benefit-cost ratio of treating OL with Caesarean delivery for 49 countries identified as providing an insufficient number of Caesarean deliveries to meet demand. Methods and Findings Using publicly available data and explicit economic assumptions, we estimated that the cost per DALY (3,0,0) averted for providing Caesarean delivery for OL ranged widely, from $251 per DALY averted in Madagascar to $3,462 in Oman. The median cost per DALY averted was $304. Benefit-cost ratios also varied, from 0.6 in Zimbabwe to 69.9 in Gabon. The median benefit-cost ratio calculated was 6.0. The main limitation of this study is an assumption that lack of surgical capacity is the main factor responsible for DALYs from OL. Conclusions: Using the World Health Organization's cost-effectiveness standards, investing in Caesarean delivery can be considered “highly cost-effective” for 48 of the 49 countries included in this study. Furthermore, in 46 of the 49 included countries, the benefit-cost ratio was greater than 1.0, implying that investment in Caesarean delivery is a viable economic proposition. While Caesarean delivery alone is not sufficient for combating OL, it is necessary, cost-effective by WHO standards, and ultimately economically favorable in the vast majority of countries included in this study.