MENINGITIS MANAGEMENT COSTS IN MEXICO PART I:

Expert panel on the utilization of resources for a case of meningococcal

meningitis

PART II:Information obtained from researched

documentation

COST OF HANDLING MENINGITIS IN MEXICO PART I:

Results from a Delphi Panel: Utilization of resources for a case of meningococcal meningitis

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BACKGROUND

MENINGOCOCCAL INVASIVE DISEASE

Meningitis and bacterial sepsis are the inflammatory response of the leptomeninges cells and the subarachnoid space against aggressions of diverse nature such as: infectious, chemical (contrast, medication), tumorous (carcinomatose meningitis) or autoimmune (vasculitis).

Worldwide incidences and prevalence are unknown; however, we do know that 70 percent of cases occur in children under 5 years of age. 75-80 percent of meningitis occurring out of the neonatal period is produced by three pathogens: meningococcus, pneumococcus and Haemophilus influenzae. For this reason they are considered critical diseases that endanger the child’s life, or can leave irreversible sequelae.

BACKGROUND

MENINGOCOCCAL INVASIVE DISEASE

Meningitis and bacterial sepsis etiology in our environment have experienced important epidemiological changes in the last years. The incidence of etiological agents is basically influenced by external factors of sanitary policy.

Bacterial origin meningitis, caused mainly by Neisseriae meningitis and Streptococcus pneumoniae, represent the most lethal form of the disease, and its distribution, morbidity and mortality are determined by the social and economic conditions of the poorest communities and countries in the World, where preventive vaccination and medication for its control are very limited by the levels of economic development.

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OBJECTIVE

To identify a (cost) resource utilization pattern for a case of bacterial menigococcal meningitis within the Mexican health sector.

METHODS AND MATERIALS

DELPHI PANEL

The study was carried out by adapting Delphi methodology, in order to identify participant's response patterns through a series of sequenced questionnaires.

Some characteristics of this methodology (Delphi) include a very high minimization of influence between participants, equal opportunities for participation and a good performance with heterogeneous groups.

Verbal communication skills are not required, and even though they don’t guarantee representation of participants, written communication skills are necessary.

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METHODS AND MATERIALS

DELPHI PANEL (continued)

During the first stage, a questionnaire is used as a starting point for specialists to express their individual estimations. Then, the questionnaires are collected and the responses are statistically analyzed and integrated into a second questionnaire. Specialists know and evaluate these previously obtained responses to indicate agreement or disagreement with them and corroborate or rectify the primary responses.

Just as other methods of consensus, the Delphi is proposed for problems that need to be investigated quickly and inexpensively. Its alteration depends on the area of interest and context where it's being applied, which is why variations in practice are justified.

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METHODS AND MATERIALS

DELPHI PANEL (continued)

This analysis made use of the Delphi method in order to identify a resource utilization pattern for treatment of bacterial meningitis by meningococcus. The end result was to conduct a study of cost associated with this malady.

The study was conducted between august and october 2009

through the use of 2 questionnaires and two rounds of consultations.

METHODS AND MATERIALS

The following flow chart details the process that was followed.

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Source: Polytechnic University of Madrid http://www.gtic.ssr.upm.es/encuestas/delphi.htm

METHODS AND MATERIALS

PARTICIPANTS

Five infectology and pediatric infectology specialists belonging to highly specialized hospitals from the public and private sector. Participant selection was carefully controlled with criteria ranging from gender, age, research activities, position in their respective hospitals and experience in treating the disease.

EXCLUSION CRITERIA

Non-infectology specialists, infectology specialists with an administrative position at the time that the evaluation was conducted.

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METHODS AND MATERIALS

INSTRUMENTS

A questionnaire was designed and delivered to the participants via electronic format. It mainly dealt with resource utilization for the treatment of meningococcal meningitis.

Central tendency measures were obtained from the first stage of responses. The second, or validation, stage, was developed the following month. In this stage, participants were required to ratify or modify their original response.

The questionnaire, made up of fifty-two items, evaluated two sections: Acute Phase and Management of Sequelae.

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METHODS AND MATERIALS

ACUTE PHASE

First contact and follow-up

Hospitalization

Number of cases attended to in clinical practice

Laboratory studies

Cabinet studies

Invasive medical procedures

Pharmacological treatment

Blood transfusion and hemoderivatives

Relatives that were recommended for prophylaxis and medicine

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METHODS AND MATERIALS

SEQUELAE MANAGEMENT

Types of sequelae and patient percentage

Appointment follow-up (twelve month period by types of sequelae)

Laboratory studies (twelve month period by types of sequelae)

Cabinet studies (twelve month period by types of sequelae)

Medical devices by sequelae

Pharmacological treatment (twelve month period by types of sequelae)

Patient survival (percentage)

Diminhed quality of life (percentage)

Amputation costs

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ANALYSES AND RESULTS

DATA

The study was conducted in order to find out resource utilization when treating a typical or average case of a patient with bacterial meningitis by meningococcal.

The following results were obtained by a second questionnaire (validation); they were statistically processed and provided central tendency measures.

Results analysis and diagram presentation used the median, as it is less sensitive to variable oscillation values than the mean, therefore not affected by dispersion.

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ANALYSES AND RESULTS

MAIN FINDINGS

Average meningitis meningococcus cases that specialists have worked with: 7

Average of hospital stay, caused by meningococcal meningitis: 16 Percentage of patients that retain sequelae after disease was

presented: 50%. Survival percentage: 70%. Epilepsy, amputations, and mild hypoacusia are the most prevalent

sequelae, after the disease presents itself. Given the sequelae, rehabilitation appointments are a top priority for

patients that presented meningococcemia profiles. Cost of minor amputation: 20 thousand pesos; Cost of major

amputation: 50 thousand pesos. No information on medication use was found, even when this category

was explicitly researched.

ANALYSES AND RESULTS

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MAIN RESULTS

Type and number of consultations that intervened in a case of meningococcemia

Acute Phase1st Contact and Monitoring

Number of Specialty Consultations

1 1 1 13 4 4.5

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Neurology

Pediatrics or in

ternal medicine

Intensive care

Emergency

Neurosurgery

Consultation with Specialist (total)

Infectology

Rehabilitation

MAIN RESULTS

Average of hospital stay, caused by a case of meningococcal meningitis

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Acute PhaseAverage Hospital Stay

1

7

8

Emergency ICU Hospital f loor

ANALYSES AND RESULTS

ANALYSES AND RESULTS

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MAIN

RESULTS

Laboratory Studies that intervene with treating a case of

meningitis by meningococcus.

Acute PhaseLaboratory Test

0.5 0.51

1.5 1.52 2

2.5 2.5 2.5 2.75 3 3 3 3 33.5 3.53.75

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8

11

6.5

54.54.5

44444

ANALYSES AND RESULTS

MAIN RESULTS

Cabinet Studies used for treating a case of meningococcal meningitis

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Acute PhaseCabinet Studies

1 1 11.5

2 2 22.5

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Ultr

ason

ogra

phy

MR

IEc

hoca

rdio

gram

s

CT

scan

EEG

BAER VE

PEl

ectro

card

iogr

ams

X-R

ays

ANALYSES AND RESULTS

MAIN RESULTS

Invasive medical procedures used for treating a case of meningococcal meningitis

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Acute PhaseInvasive Medical Procedures

2.5

4.55

10.25

Lumbar punctures Endotracheal intubation(no. of days)

Arterioclisis (no. of days) Central catheters (no. ofdays)

ANALYSES AND RESULTS

MAIN RESULTS

Blood transfusions and hemoderivatives for treatment of meningitis meningococcal

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Acute PhaseBlood transfusions and hemoderivatives

22.25

4.5

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Gamma globulins Globular packages FFP Platelet count

ANALYSES AND RESULTS

MAIN RESULTS

Percentage of sequelae by meningitis meningococcal

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Sequelae ManagementSequelae (% of patients)

2% 4% 8%

8%

8%

8%

9%9%14%

30%

Loss of visual acuity

Sore / Grafts

Severe hearing loss

Mental retardation

Sensory-motor deficit

Hydrocephalus

Mediated hearing loss

Amputations

Epilepsy

No sequelae

ANALYSES AND RESULTS

MAIN RESULTS

Amputation costs

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Sequelae ManagementAmputation Costs

$20,000

$50,000

Minor amputation

Major amputation

ANALYSES AND RESULTS

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Cost per expert physician survey. 1st Round (Only medical attention costs are included)Cost Source: DOF 16 April 2007 updated for 2009

Item/ Physician Specialist

1 Specialist

2 Specialist

3 Specialist

4 Specialist

5 General medicine 1 Emergency room 2nd level 1 3rd level 1 Specialty 2nd level 32 3rd level 4 4 25 Hospitalization Days Hospitalized 2nd level 9 3rd level 11 8 5 11 Days in ICU 5 7 5 8 10 Clinical Analyses Applied 76 64 8 86 224 Radiodiagnostic 10 4 8 10 CAT 1 1 3 5 NMR 1 2 2 Electrodiagnostic 4 2 5 12 Ultrasonography 2 1 13 Costs Consultation Costs $2,184 $5,260 $5,260 $1,105 $32,875 Hospitalization Cost $192,844 $234,691 $164,230 $267,537 $333,229 Cost for applied analyses $20,902 $26,168 $736 $56,467 $93,408 Total $215,930 $266,119 $170,226 $325,109 $459,512

ANALYSES AND RESULTS

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Cost per expert physician survey. Concensus (only medical attention costs are included)Cost Source DOF 16 April 2007 updated to 2009

Item Consensus General medicine Emergency room 2nd level 1 3rd level Specialty 2nd level 3rd level 15 Hospitalization Days Hospitalized 2nd level 3rd level 8 Days in ICU 7 Clinical Analyses Applied 112 Radiodiagnostic 9 CAT 2 NMR 1 Electrodiagnostic 7 Ultrasonography 1 Costs Consultation Costs $20,830 Hospitalization Cost $234,691 Cost for applied analyses $42,149 Total $297,670

MENINGITIS TREATMENT COSTS IN MEXICOPART II:

Hospital Files Evaluated

ANALYSES AND RESULTS: Cost of Meningococcal Meningitis

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27Cost of medical files:2 patients detected with meningitis meningococcus: 1 at the “Hospital de Infectología CMN La Raza del IMSS” and 1 in the Private Sector (For this one, cost estimations were made through a public sector tabulator) Cost source: DOF 16 April 2007 updated to 2009

Patient with Meningococcal Meningitis

Item Public Sector

Private Sector

General medicine Emergency room 2nd level 3 3rd level 1 Specialty 2nd level 3rd level 42 3 Hospitalization Days Hospitalized 2nd level 3rd level 6 Days in ICU 10 1 Clinical Analyses Applied 4 35 Radiodiagnostic 1 3 CAT NMR Electrodiagnostic 2 Ultrasonography Costs Consultation Costs $58,545.00 $5,612 Hospitalization Cost $309,384.00 $28,077 Cost for applied analyses $738.00 $4,820 Cost for pharmacological treatment $496.31

Total $369,163.31 $38,509

ANALYSES AND RESULTS: Cost of Bacterial Meningitis (not meningococcus)

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Cost of medical records. (6 patients detected in the “Hospital de Infectología- CMN La Raza del IMSS” )-Cost source:DOF 16 April 2007 updated to 2009

Item/ Patient Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6

General medicine 1 2 Emergency room 2nd level 1 1 1 3rd level 1 2 1 Specialty 2nd level 1 3rd level 3 2 4 7 Hospitalization Days Hospitalized 2nd level 13 3rd level 17 10 45 1 Days in ICU 8 7 9 9 8 30 Clinical Analyses Applied 16 125 98 24 18 11 Radiodiagnostic 2 1 2 2 CAT 1 1 5 1 NMR 1 0 Electrodiagnostic 1 1 2 Ultrasonography 1 1 Costs Consultation Costs $6,129.00 $0.00 $5,964.00 $1,105.00 $7,399.00 $11,977.00 Hospitalization Cost $305,689.00 $306,226.00 $252,693.00 $252,693.00 $439,221.00 $847,079.00 Cost for applied analyses $10,702.00 $29,810.00 $9,261.00 $3,318.00 $44,351.00 $11,102.00 Cost for pharmacological treatment $5,087.61 $1,550.90 $4,310.54 $33,491.19 $40,716.33 $3,544.74 Total $327,607.61 $337,586.90 $272,228.54 $290,607.19 $531,687.33 $873,702.74

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Gráficas que se tienen que editar (Por número de diapositiva) Diapositiva 9:

Delphi Process Task Force, Technical Team, Expert Panel

Event definition, Expert panel selections Creation of first questionnaire, First questionnaires sent

out 1st Circulation (Dentro de la flecha) 1st questionnaire responses

Statistical analysis of group responses, Addition of statistical analysis to second questionnaire, sent out

2nd circulation (Dentro de la 2da flecha) Review group responses and compare to answers from

the first questionnaires, Answer 2nd questionnaire. Final statistical analysis of group responses, Results

are presented to the task force Conclusion

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Diapositiva 16: Acute Phase 1st Contact and Follow-up

Number of Specialist Consultations Neurology Pediatrics or internal medicine Intensivist Emergency Room Neurosurgery Specialist Consultations (total) Infectology Rehabilitation

Diapositiva 17: Number of Hospitalization Days: Acute Phase

Emergency Room Intensive Care Unit Main Floor

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Diapositiva 18 Number of Lab Studies: Acute Phase

HIV ELISA Western Blot Immunoglobulin Catheter Tip Uroculture Coproculture LCR Cultures Hepatic Function Panel Anticonvulsants Hemocultures Secretions Reactive Protein C Dimero D Fibrinogeno

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Cultures (total) Renal Function EGO PCR Blood Chemistry Electrolytes Vein Geometry VSG Arterial Geometry

Diapositiva 19: Acute Phase Procedures: Cabinet Studies

Ultrasonography RMIN Ecocardiogram CAT Electroencephalogram Auditory Potentials

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Electrocardiograms X-Rays

Diapositiva 20: Acute Phase: Invasive Medicine Procedures

Lumbar Puncture Arteriaclasis (number of days)

Diapositiva 21: Acute Phase: Blood and Hemoderivative

Transfusion Gamma Globulin Globular Package Fresh Concentrated Plasma Concentrated Platelets

Diapositiva 22: MM Sequelae Management (Patient Percentage)

Loss of visual acuteness Pressure Ulcer/Graft

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Severe Hypoacusia Mental Retardation Motor or Sensory Deficit Hydrocephalus Mild Hypoacusia Amputations Epilepsy No Sequelae

Diapositiva 23: MM Sequelae Management: Amputation Costs

Minor Amputation Major Amputation

Diapositiva 24: Specialist (1, 2, 3, 4, 5) Item/Physician General Medicine

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