Drummond's check-list for assessing economic evaluations

(Drummond M et al. Methods for the economic evaluation of health care

programmes. 2nd ed. Oxford. Oxford University Press. 1997)
1. Was a well-defined question posed in answerable form?
Malaria is one of the leading causes of morbidity in endemic countries. Between 350
and 660 million clinical episodes of the disease occur per year among African
children,1,2 and roughly 1.2 million deaths (representing 2% of all premature deaths
in the world) are caused annually by malaria in lowand middle-income countries,3
although estimates range from 700 000 to 2.7 million deaths per year.4 Of all global
deaths due to malaria, around 75% are estimated to occur in African children.4
Current WHO recommendations for malaria control in children in endemic areas rely
on case management, use of insecticide-treated nets and vector control,5,6 none of
which has proved fully efficacious for controlling the infection.711 Hence, there is a
need to test new strategies that, combined with existing interventions, can
effectively reduce the burden of malaria among children in endemic areas.5
The delivery of intermittent preventive treatment in infants (IPTi) during routine
contacts through the Expanded Programme on Immunization (EPI)1214 is a
promising malaria control strategy whose efficacy rates in the prevention of malaria
episodes1521 range from 22.6%16 to 63.2%.

The research question is clearly stated by the author as an cost effective analysis of
IPTi that can provide

1.1. Did the study examine both costs and effects of the service(s) or
programme(s)?
The study examine both the financial and non-financial cost.
1.2.

Did the study involve a comparison of alternatives?

They compared the intervention with do-nothing

1.3. Was a viewpoint for the analysis stated and was the study placed in any
particular decision-making context?
It was not explicitly saying about the government or health service perspective but
the writer says that the purpose of the study is to provide an information for
government about what will the government get if they applied the intervention
strategy.

2. Was a comprehensive description of the competing alternatives given

(i.e. can you tell who did what to whom, where, and how often)?
Description of area and population on both Tanzania and Mozambique was well
explained. Additional explanation is located in estimation of health impact section
(which can make the reader confuse). However, further detail of both trials was not
stated in the essay. The Author need to describe how much sample, inclusion and
exclusion criteria, and how they administer the drugs. We found that the method of
both trial is similar using RCT and comparing SP with Placebo, however there is
slightly different in time to administer the SP drugs, study in Tanzania assigned SP
on children age 2,3 and 9 months while in Mozambique is 3,4 and 9 months.
The list of competing alternatives appears complete, and as the authors stated the
option is do-nothing alternative
2.1.

Were there any important alternatives omitted?

2.2.

Was (should) a do-nothing alternative be considered?

The author decided to do the standard CEA where the Malaria IPTi is compared with
do-nothing strategy.

3.

Was the effectiveness of the programme or services established?

The author have addressed the evidence about the IPTi (p.123 col.1). All of the
evidence is come from RCT study, moreover some of the study is a double blind RCT
which is the strongest form of evidence. The settings of the evidence is the same as
the study of IPTi trials that been used in this CEA. The other evidence showing that
there is no effective strategies to control Malaria infection is also identified on the
essay.
The primary outcome of economic evaluation is Malaria case averted and DALY
averted.
3.1. Was this done through a randomised, controlled clinical trial? If so, did the
trial protocol reflect what would happen in regular practice?
3.2.

Was effectiveness established through an overview of clinical studies?

3.3. Were observational data or assumptions used to establish effectiveness? If so,

what are the potential biases in results?

Multivariate sensitivity analysis was performed using Monte-Carlo simulations

generated by @Risk (version 4.5) addin tool to Microsoft Excel (Palisade
Corporation, Ithaca, NY, USA) to
explore the robustness of the results in the face of simultaneous variation in
selected assumptions and data input

4. Were all the important and relevant costs and consequences for each
alternative identified?
The author not explicitly said what perspectives do they use, however, on page
stated that the study will count the non-financial cost, such as .. which is make
the study is based on social perspectives. Atau the author discussed about the cost
that will spent in implementing the intervention, which is make an employer
perspective???
IPTi was part of the routine vaccination of EPI, if we assume that the cost of direct
non-medical such as transportation is already counted in EPI program, therefore
there is no cost for direct non-medical.

4.1. Was the range wide enough for the research question at hand?
4.2. Did it cover all relevant viewpoints? (Possible viewpoints include the
community or social viewpoint, and those of patients and third-party payers. Other
viewpoints may also be relevant depending upon the particular analysis.)
4.3. Were the capital costs, as well as operating costs, included?
5. Were costs and consequences measured accurately in appropriate
physical units (e.g. hours of nursing time, number of physician visits, lost
work-days, gained life years)?

Hutton et al. (2009) define clearly all of the resources that will be needed to
implement IPTi and it is translated to $US. However, by converting it to the
currency, it is not clear that how many hours take to do the sensitization to stake
holder or training the health worker.
There are 3 cost effective ratios that is malaria case averted, DALYs averted (By
combining Malaria morbidity and mortality averted), and Death averted
The trials is delivered through EPI which is another health programme, the author
did not explain about the joint resources, such as time for mother to seek the drug,
or transportation cost that spent to go to health center.
5.1. Were any of the identified items omitted from measurement? If so, does this
mean that they carried no weight in the subsequent analysis?
5.2. Were there any special circumstances (e.g., joint use of resources) that made
measurement difficult? Were these circumstances handled appropriately?

6.

Were the cost and consequences valued credibly?

Cost-effectiveness ratios are presented in United States dollars (US$) for the year
2006.
Penggunaan harga berdasarkan penelitian lain yang menurut author lebih sesuai
6.1. Were the sources of all values clearly identified? (Possible sources include
market values, patient or client preferences and views, policy-makers views and
health professionals judgements)
6.2. Were market values employed for changes involving resources gained or
depleted?
6.3. Where market values were absent (e.g. volunteer labour), or market values
did not reflect actual values (such as clinic space donated at a reduced rate), were
adjustments made to approximate market values?
6.4. Was the valuation of consequences appropriate for the question posed (i.e.
has the appropriate type or types of analysis cost-effectiveness, cost-benefit, costutility been selected)?
7.

Were costs and consequences adjusted for differential timing?

Cost and consequences are not discounted to present values.

7.1. Were costs and consequences that occur in the future discounted to their
present values?
7.2. Was there any justification given for the discount rate used?

8. Was an incremental analysis of costs and consequences of

alternatives performed?

The Authors report two types of incremental cost effectiveness ratio, first using
Individual efficacy Cost per DALY averted is 3.7 and 11.2 in Ifakara and Manhica
respectively, cost per malaria episode averted 1.6 in Ifakara and 4.7 in Manhica and
cost per malaria death averted 100.2 and 301.1 in Ifakara and Manhica respectively.
Second, by using pooled efficacy result that taken from Apote et al (2009) cost per
DALY averted 7.9 and 8.3 in Ifakara and Manhica respectively, cost per Malaria
episode averted 3.3 and 3.5 in Ifakara and Manhica respectively, last is cost per
malaria death averted 211 in Ifakara and 222.8 in manhica.
In the discussion part, Author mention about cost saving

8.1. Were the additional (incremental) costs generated by one alternative over
another compared to the additional effects, benefits, or utilities generated?
9. Was allowance made for uncertainty in the estimates of costs and
consequences?
9.1. If data on costs and consequences were stochastic (randomly determined
sequence of observations), were appropriate statistical analyses performed?
9.2. If a sensitivity analysis was employed, was justification provided for the range
of values (or for key study parameters)?
9.3. Were the study results sensitive to changes in the values (within the assumed
range for sensitivity analysis, or within the confidence interval around the ratio of
costs to consequences)?
Four key input parameter that is IPTi efficacy, casefatality rate, malaria attack rate
and cost per dose of IPTi delivered in 10.000 simulations is generated
stochastically and analyzed using multivariate sensitivity analysis was performed
using Monte-Carlo simulations generated by @Risk (version 4.5) addin tool to

Microsoft Excel (Palisade Corporation, Ithaca, NY, USA). The Monte-Carlo

simulation is widely use to account for risk in quantitative analysis and decision
making, it will shows every possible outcome, even it is an extreme one. Therefore,
the authors has conducted an appropriate sensitivity analysis and the result of the
analysis is provided in table 4.
In the discussion the Authors stated that the sensitivity analysis generated a wide
confidence interval because of the large number of uncertainty is allowed in
analysis. Hutton et al. conclude that even using the highest limit of CI in DALY
averted in both country, IPTi still an appealing health plan.

10. Did the presentation and discussion of study results include all
issues of concern to users?
10.1. Were the conclusions of the analysis based on some overall index or ratio of
costs to consequences (e.g. cost-effectiveness ratio)? If so, was the index
interpreted intelligently or in a mechanistic fashion?
Conclusion of the analysis is based on the ratio of cost effectiveness, the DALY
averted
10.2. Were the results compared with those of others who have investigated the
same question? If so, were allowances made for potential differences in study
methodology?

ALY averted: case management with artemisinin-based combination therapy, US$ 1012;
insecticide-treated
nets, US$ 2940; and indoor residual spraying, US$ 3241.45 In a review of malaria
prevention strategies in childhood, the cost per DALY averted using insecticide-treated nets
was found to be above US$ 9, including cost savings.23 Thus IPTi, at a cost of less than US$
12 per DALY averted and with the likelihood of additional cost savings to the health system
and patient, is found to be at least as cost-effective as other options for malaria control
among infants

10.3. Did the study discuss the generalisability of the results to other settings and
patient/client groups?
Hutton et al. does state that this study will be likely to hold in other setting with
high endemic of Malaria especially sub sahara Africa
10.4.

Did the study allude to, or take account of, other important factors in the

choice or decision under consideration (e.g. distribution of costs and consequences,

or relevant ethical issues)?
The author mention some consideration regarding the to safety, efficacy and potential
interactions between
IPTi and EPI vaccines and also about Acceptability, immunological effects and impact on
drug resistance. However existing research found that SP is unlikely to have effect on drug
resistance.

10.5. Did the study discuss issues of implementation, such as the feasibility of
adopting the preferred programme given existing financial or other constraints,
and whether any freed resources could be redeployed to other worthwhile
programmes?
Although the authors presenting the detail of implementing cost of the IPTi program
there is no expression about the problem that likely to happen to implement it in
other setting which is crucial information for the health stakeholder to know.

The Author providing fairly complete discussion.

IPTi offers an excellent value for the money when judged by a standard of under US$ 50 per
DALY averted for a very cost-effective intervention.22 There are two further benefits of the
IPTi intervention that are not reflected
in these findings: anaemia prevention and cost savings
This study is beset by several uncertainties. The multivariate sensitivity analysis yielded
wide confidence intervals resulting from the ranges of four key input parameters However,
these wide ranges were generated because
a considerable degree of uncertainty in the selected parameters was allowed for, as shown
in Table 4. Furthermore, even with an upper confidence limit of US$ 12.2 per DALY averted in
the United Republic of Tanzania and an
upper confidence limit of US$ 92.0 per DALY averted in Mozambique, IPTi is still an attractive
health intervention