ABSTRACT
OBJECTIVES: Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity. METHODS: We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations. RESULTS: We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration. CONCLUSIONS: Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies.
ABSTRACT
Purpose/Background: Pelvic exenteration (PE), or “beyond-TME” surgery has become an established treatment for locally-advanced, or recurrent colorectal cancer, with the aim of achieving a complete (R0) resection and improve survival. We have established a regional centre for the management of advanced colorectal cancer and pelvic sarcoma. Methods/Interventions: This was a retrospective, observational study using electronic health records (EHR). Patients were identified from a prospectively managed database and from multi-disciplinary team minutes. Data was gathered for 47 patients operated on by our Advanced Cancer service between November 2016 and March 2021 by four surgeons. EHR were searched for tumour and operation characteristics, complications, survival, oncological and recurrence data. During the COVID-19 pandemic, some patients had their operations at a separate, private hospital. Eligible patients were those that had pelvic exenteration (defined as removal of colon/rectum with additional organs such as bladder, prostate, vagina, sacrum, kidney), or large pelvic dissection for sarcoma. Results/Outcomes: 47 patients (23 male, 24 female) underwent operation, with a median age of 64 and ASA II. 33 (70%) patients presented with a primary tumour and 14 with a recurrent tumour. 37 (79%) had a locally advanced rectal or sigmoid cancer, 2 (4%) anal cancers, 2 gastro-intestinal stromal tumours and 6 (13%) pelvic sarcomas. One patient with recurrent rectal cancer had inoperable disease found at time of surgery so proceeded with only a palliative resection. Resection type is presented in Table 1. 43 patients had recorded status for margins, of which 33 (77%) had R0 resection and 10 (23%) R1. Mean operating time was 499 minutes (range 130-1020). Median time in critical care post-op was 2.5 days (IQR 1-6) and length of stay 13 days (IQR 13-20.5). 30-day Clavien-Dindo complications were: none (15, 32%), Grade I/II (17, 36%), Grade III (6, 13%), Grade IV (8, 17%). One patient operated on in the independent sector could not have inpatient records assessed. 10 patients had a return to theatre, the majority (5) for wound washout, 1 for each of the following indications: replacement of ureteric stent, ureteric reimplantation, revision of ischaemic colostomy, revision of flap, planned return for removal of haemostatic packs. There was no 90 day mortality. At a median of 25.6 months follow-up, 32 (68%) patients remain alive. In the 15 patients who have died, the mean time to death from procedure was 16.7 months. Recurrence was seen in 11 (23%) patients, of which 6 (13%) were distant, 3 (6%) local and 2 (4%) both. Conclusion/Discussion: This data shows that it is possible to set up a new advanced cancer unit and achieve outcomes, in terms of mortality, margin status and recurrence that are comparable with those previously published by other centres during their set-up phase. (Table Presented).