Achieving self-sustainability of service delivery in an eye care program in Madagascar using time-driven activity based costing.

BACKGROUND: In the absence of adequate and reliable external funding, eye care programs in developing countries need a high level of financial self-sustainability for maintenance and growth. To cope with these cost pressures, an eye care program in Sava, Madagascar adopted a Time-Driven Activity Based Costing (TDABC) methodology to better manage the cost of, and to improve revenue associated with, their three principle activities: consultation visits, cataract operations, and sale of glasses. METHODS: Direct (variable) and indirect (fixed) cost estimates and revenue sources were gathered by activity (consultation, cataract operation, sale of glasses) and location (hospital or outreach) and TDABC models were established. Estimates were made of the proportion of the ophthalmologist's time (by far the scarcest and most expensive resource) dedicated to consultation, cataract operation, or sale of glasses. These proportions were used to attribute costs by activity. The hospital manager and medical director modified staff roles, program activities, and infrastructure investments to reduce costs and expand revenue sources by activity while monitoring activity specific efficiency and profit. RESULTS: The TDABC model for patient consultations showed that they were time consuming for the ophthalmologist and only resulted in net profit for the institution if the ophthalmologist converted most cataract patients into accepting surgery and refractive error patients into purchasing glasses from the hospital optical shop. The TDABC model for cataract surgery showed the programs needed to reduce the cost of imported consumable surgical products, reduce operation time, and, most importantly, reduce the number of very costly surgical camps providing essentially free surgery. In addition the model pushed the hospital to train staff in marketing skills so that a higher proportion of cataract cases come directly to the hospital willing to pay for surgery. The TDABC model provided the optical shop manager, for the first time, data on both the cost of supplies (frames and lenses) and the price of glasses sold resulting in strategies to maximize profit through preferential product presentation and customer experience. The eye program in the Sava region in northern Madagascar improved its cost recovery from 68 to 102% through patient revenue. CONCLUSIONS: TDABC models helped the Sava eye care program develop more efficient service delivery and increase revenue in excess of steadily increasing costs.

Pediatric Case Finding in Madagascar: A Controlled, Prospective Population-based Assessment of Key Informant Productivity and Cost.

Purpose: The Key Informant (KI) case finding method, which trains community members to screen children for eye problems and refer them to eye services, is a common strategy to identify and refer children with blindness and visual impairment. However, studies to date have not determined the benefit and cost of adding KIs to routine outreach activities.Methods: Four eye programs in Madagascar with established outreach camps added KIs to a portion of their camps distributed equally throughout their service region over a one year period. KIs recorded children screened and their attendance at an outreach camp. Outreach personnel used standardized registration forms to gather age, sex, visual acuity, diagnosis and treatment data. Costs were gathered for the KI program and outreach camps.Results: In one year, the 4 eye programs held 138 outreach camps, 43 with KIs. The KI camps were more productive than regular camps seeing an average of 61 and 24 children and 50 and 19 children with an eye problem, for KI and regular camps, respectively. The KI camps also saw more children with moderate or severe visual impairment or blindness with 21 and 8 children (per 10 camps) for KI and regular camps, respectively. A KI camp cost $463 ($642 vs. $179) more than a regular camp and $3 ($8 vs. $11) more per child seen.Conclusion: The KI method significantly increased the number of children attending outreach camps, at all levels of visual impairment and blindness, at a modest increase in costs.

Interventions to improve utilization of cataract surgical services by girls: Case studies from Asia and Africa.

PURPOSE: Gender and blindness initiatives continue to make eye care personnel aware of the service utilization inequity strongly favouring men, yet interventions to reduce that inequity, particularly for girls, are under developed. METHODS: This descriptive study gathered quantitative data on the degree of gender equity at five Child Eye Health Tertiary Facilities (CEHTFs) in Asia and Africa and conducted in-depth interviews with eye care personnel to assess their strategies and capacity to reduce gender inequity. Cataract surgery was utilized to assess the degree of inequity and success of interventions to reduce inequity in case finding, service utilization, and follow-up. RESULTS: CEHTF administrative data showed significant gender inequity in cataract surgical services favouring boys in all settings. CEHTFs actively seek children through community and school-based outreach, yet do not have initiatives to reduce gender inequity. Little gender inequity was found among children receiving surgical and follow-up care, although two out of three children were boys. CEHTF staff, despite being aware, offered no effective means to reduce gender inequity involving cataract surgical services. Interventions that successfully increased service utilization by girls came from individual cases, involving extraordinary effort by a single eye care programme person. CONCLUSION: Community-based case finders such as Anganwadi workers in India, Female Community Health Volunteers (FCHVs) in Nepal, and Key Informants (KIs) in Africa are necessary to identify children in need of cataract services, but insufficient to increase service utilization by girls. Secondary, often extra-ordinary community-based interventions by eye care personnel are needed in all settings.

Survey of US obstetrician opinions regarding NIPT use in general practice: implementation and barriers.

OBJECTIVE: To evaluate the knowledge and opinions of US obstetric providers who use noninvasive prenatal testing (NIPT) to understand current utilization and guide future best practices. METHODS: A questionnaire was designed to assess the level of knowledge and attitudes of OBGYNs toward screening options for aneuploidy, with a focus on NIPT. Initial questions evaluated obstetrician demographics, practice type, and NIPT familiarity. Subsequent questions were designed to solicit current practices regarding aneuploidy screening as well as opinions, experiences, and implications of NIPT. RESULTS: Survey respondents identified NIPT as clinically superior to traditional screening methods and indicated that they would like ACOG to formally recommend NIPT for any pregnant woman. Insurance coverage, and therefore cost, was noted as the biggest barrier, and over 81% of surveyed providers would utilize NIPT as a first-line screening test if patients' insurance offered full coverage. The majority of providers who have implemented NIPT into clinical practice indicated improved patient care. While most providers demonstrated accurate understanding of the technology and its application, nearly 15% misunderstood NIPT as being a diagnostic test for fetal aneuploidy. CONCLUSION: The results of the survey suggest that there is a desire for changes to current practice guidelines and insurance coverage. Additionally, provider education remains paramount.