Peri-operative pulse oximetry in low-income countries: a cost-effectiveness analysis

Samantha L Burn, Peter J Chilton, Atul A Gawande, Richard J Lilford, Samantha L Burn, Peter J Chilton, Atul A Gawande, Richard J Lilford

Abstract

Objective: To evaluate the cost-effectiveness of pulse oximetry--compared with no peri-operative monitoring--during surgery in low-income countries.

Methods: We considered the use of tabletop and portable, hand-held pulse oximeters among patients of any age undergoing major surgery in low-income countries. From earlier studies we obtained baseline mortality and the effectiveness of pulse oximeters to reduce mortality. We considered the direct costs of purchasing and maintaining pulse oximeters as well as the cost of supplementary oxygen used to treat hypoxic episodes identified by oximetry. Health benefits were measured in disability-adjusted life-years (DALYs) averted and benefits and costs were both discounted at 3% per year. We used recommended cost-effectiveness thresholds--both absolute and relative to gross domestic product (GDP) per capita--to assess if pulse oximetry is a cost-effective health intervention. To test the robustness of our results we performed sensitivity analyses.

Findings: In 2013 prices, tabletop and hand-held oximeters were found to have annual costs of 310 and 95 United States dollars (US$), respectively. Assuming the two types of oximeter have identical effectiveness, a single oximeter used for 22 procedures per week averted 0.83 DALYs per annum. The tabletop and hand-held oximeters cost US$ 374 and US$ 115 per DALY averted, respectively. For any country with a GDP per capita above US$ 677 the hand-held oximeter was found to be cost-effective if it prevented just 1.7% of anaesthetic-related deaths or 0.3% of peri-operative mortality.

Conclusion: Pulse oximetry is a cost-effective intervention for low-income settings.

Figures

Fig. 1
Fig. 1
Cost–effectiveness of pulse oximetry as a function of the proportion of anaesthetic-related deaths averted
Fig. 2
Fig. 2
Cost–effectiveness of pulse oximetry as a function of baseline anaesthetic-related mortality
Fig. 3
Fig. 3
Cost–effectiveness acceptability curve for pulse oximetry

References

    1. Merry AF, Eichhorn JH, Wilson IH. Extending the WHO ‘Safe Surgery Saves Lives’ project through global oximetry. Anaesthesia. 2009;64(10):1045–8. 10.1111/j.1365-2044.2009.06104.x
    1. Enright A, Merry A. The WFSA and patient safety in the perioperative setting. Can J Anaesth. 2009;56(1):8–13. 10.1007/s12630-008-9001-x
    1. Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC, et al.Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet. 2010;376(9746):1055–61. 10.1016/S0140-6736(10)60392-3
    1. Our product. Lifebox: saving lives through safer surgery [Internet]. London: Lifebox Foundation; 2013. Available from: [cited 2013 Jul 17].
    1. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al.Disease control priorities in developing countries. Washington: World Bank; 2006.
    1. Pulse oximeter: technology opportunity assessment. Seattle: Program for Appropriate Technology in Health; 2013. Available from: [cited 2014 Aug 18].
    1. Edejer TT-T, Baltussen R, Adam T, Hutubessy R, Acharya A, Evans DB, et al.Making choices in health: WHO guide to cost effectiveness analysis. Geneva: World Health Organization; 2003.
    1. Hutubessy R, Chisholm D, Edejer TT-T. Generalized cost–effectiveness analysis for national-level priority-setting in the health sector. Cost Eff Resour Alloc. 2003;1(1):8. 10.1186/1478-7547-1-8
    1. Howie SR, Hill S, Ebonyi A, Krishnan G, Njie O, Sanneh M, et al.Meeting oxygen needs in Africa: an options analysis from the Gambia. Bull World Health Organ. 2009;87(10):763–71. 10.2471/BLT.08.058370
    1. Moller JT, Johannessen NW, Espersen K, Ravlo O, Pedersen BD, Jensen PF, et al.Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications. Anesthesiology. 1993;78(3):445–53. 10.1097/00000542-199303000-00007
    1. Dubowitz G, Breyer K, Lipnick M, Sall JW, Feiner J, Ikeda K, et al.Accuracy of the Lifebox pulse oximeter during hypoxia in healthy volunteers. Anaesthesia. 2013;68(12):1220–3. 10.1111/anae.12382
    1. Lifebox annual review. London: Lifebox Foundation; 2011. Available from: [cited 2014 July 25].
    1. Lee E, Dobbins M, Decorby K, McRae L, Tirilis D, Husson H. An optimal search filter for retrieving systematic reviews and meta-analyses. BMC Med Res Methodol. 2012;12(1):51. 10.1186/1471-2288-12-51
    1. Bainbridge D, Martin J, Arango M, Cheng D; Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012;380(9847):1075–81. 10.1016/S0140-6736(12)60990-8
    1. Braz LG, Braz DG, da Cruz DS, Fernandes LA, Módolo NSP, Braz JRC. Mortality in anesthesia: a systematic review. Clinics (Sao Paulo). 2009;64(10):999–1006.
    1. Hansen D, Gausi SC, Merikebu M. Anaesthesia in Malawi: complications and deaths. Trop Doct. 2000;30(3):146–9.
    1. Ouro-Bang’na Maman AF, Tomta K, Ahouangbévi S, Chobli M. Deaths associated with anaesthesia in Togo, West Africa. Trop Doct. 2005;35(4):220–2. 10.1258/004947505774938666
    1. Fenton PM, Whitty CJM, Reynolds F. Caesarean section in Malawi: prospective study of early maternal and perinatal mortality. BMJ. 2003;327(7415):587. 10.1136/bmj.327.7415.587
    1. Enohumah KO, Imarengiaye CO. Factors associated with anaesthesia-related maternal mortality in a tertiary hospital in Nigeria. Acta Anaesthesiol Scand. 2006;50(2):206–10. 10.1111/j.1399-6576.2006.00945.x
    1. Walker IA, Obua AD, Mouton F, Ttendo S, Wilson IH. Paediatric surgery and anaesthesia in south-western Uganda: a cross-sectional survey. Bull World Health Organ. 2010;88(12):897–906. 10.2471/BLT.10.076703
    1. Zoumenou E, Gbenou S, Assouto P, Ouro Bang’na Maman AF, Lokossou T, Hounnou G, et al.Pediatric anesthesia in developing countries: experience in the two main university hospitals of Benin in West Africa. Paediatr Anaesth. 2010;20(8):741–7. 10.1111/j.1460-9592.2010.03348.x
    1. Pedersen T, Nicholson A, Hovhannisyan K, Møller AM, Smith AF, Lewis SR. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev. 2014;3:CD002013.
    1. Sacks H, Chalmers TC, Smith H Jr. Randomized versus historical controls for clinical trials. Am J Med. 1982;72(2):233–40. 10.1016/0002-9343(82)90815-4
    1. Kunz R, Oxman AD. The unpredictability paradox: review of empirical comparisons of randomised and non-randomised clinical trials. BMJ. 1998;317(7167):1185–90. 10.1136/bmj.317.7167.1185
    1. Mateer JR, Olson DW, Stueven HA, Aufderheide TP. Continuous pulse oximetry during emergency endotracheal intubation. Ann Emerg Med. 1993;22(4):675–9. 10.1016/S0196-0644(05)81846-3
    1. Coté CJ, Goldstein EA, Coté MA, Hoaglin DC, Ryan JF. A single-blind study of pulse oximetry in children. Anesthesiology. 1988;68(2):184–8. 10.1097/00000542-198802000-00002
    1. Coté CJ, Rolf N, Liu LMP, Goudsouzian NG, Ryan JF, Zaslavsky A, et al.A single-blind study of combined pulse oximetry and capnography in children. Anesthesiology. 1991;74(6):980–7. PMID 1904206.
    1. Gibbs N, Rodoreda P. Anaesthetic mortality rates in Western Australia 1980–2002. Anaesth Intensive Care. 2005;33(5):616–22.
    1. Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology. 1989;70(4):572–7. 10.1097/00000542-198904000-00002
    1. Kwok AC, Funk LM, Baltaga R, Lipsitz SR, Merry AF, Dziekan G, et al.Implementation of the World Health Organization surgical safety checklist, including introduction of pulse oximetry, in a resource-limited setting. Ann Surg. 2013;257(4):633–9. 10.1097/SLA.0b013e3182777fa4
    1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9. 10.1056/NEJMsa0810119
    1. Ciani O, Buyse M, Garside R, Pavey T, Stein K, Sterne JA, et al.Comparison of treatment effect sizes associated with surrogate and final patient relevant outcomes in randomised controlled trials: meta-epidemiological study. BMJ. 2013;346:f457. 10.1136/bmj.f457
    1. Moynihan R. Surrogates under scrutiny: fallible correlations, fatal consequences. BMJ. 2011;343:d5160. 10.1136/bmj.d5160
    1. Yudkin JS, Lipska KJ, Montori VM. The idolatry of the surrogate. BMJ. 2011;343:d7995. 10.1136/bmj.d7995
    1. Salomon JA, Wang H, Freeman MK, Vos T, Flaxman AD, Lopez AD, et al.Healthy life expectancy for 187 countries, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2144–62. 10.1016/S0140-6736(12)61690-0
    1. Galukande M, von Schreeb J, Wladis A, Mbembati N, de Miranda H, Kruk ME, et al.Essential surgery at the district hospital: a retrospective descriptive analysis in three African countries. PLoS Med. 2010;7(3):e1000243. 10.1371/journal.pmed.1000243
    1. Shillcutt SD, Walker DG, Goodman CA, Mills AJ. Cost effectiveness in low- and middle-income countries: a review of the debates surrounding decision rules. Pharmacoeconomics. 2009;27(11):903–17. 10.2165/10899580-000000000-00000
    1. World development report 1993: investing in health [Internet]. Washington: Oxford University Press; 1993. Available from: [cited 2014 Jul 25].
    1. World development indicators. Washington: World Bank; 2014.
    1. Reardon S. Frugal science gets DIY diagnostics to world’s poorest. New Sci. 2013;219(2933):20–1 10.1016/S0262-4079(13)62184-3
    1. McKenzie AG. Mortality associated with anaesthesia at Zimbabwean teaching hospitals. S Afr Med J. 1996;86(4):338–42.
    1. Duke T, Wandi F, Jonathan M, Matai S, Kaupa M, Saavu M, et al.Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea. Lancet. 2008;372(9646):1328–33. 10.1016/S0140-6736(08)61164-2
    1. Matai S, Peel D, Wandi F, Jonathan M, Subhi R, Duke T. Implementing an oxygen programme in hospitals in Papua New Guinea. Ann Trop Paediatr. 2008;28(1):71–8. 10.1179/146532808X270716
    1. Savage A. Why are the chosen pulse oximeters so expensive? BMJ. 2012;344:e210–, discussion e219.. 10.1136/bmj.e210
    1. Core medical equipment. Geneva: World Health Organization; 2011. Available from: [cited 2014 Jul 25].
    1. Medical devices: managing the mismatch. An outcome of the priority medical devices project. Geneva: World Health Organization; 2010. Available from: [cited 2014 Jul 25].
    1. Compendium of innovative health technologies for low-resource settings 2011–2013. Geneva: World Health Organization; 2014. Available from: [cited 2014 Jul 25].

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe