1. 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

2. COST OF HANDLING MENINGITIS IN MEXICO PART I: Results from a Delphi Panel: Utilization of resources for a case of meningococcal meningitis

3. 3 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.

4. 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. 4

5. 5 OBJECTIVE To identify a (cost) resource utilization pattern for a case of bacterial menigococcal meningitis within the Mexican health sector.

6. 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. 6

7. 7 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.

8. 8 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.

9. METHODS AND MATERIALS The following flow chart details the process that was followed. 9 Source: Polytechnic University of Madrid http://www.gtic.ssr.upm.es/encuestas/delphi.htm http://www.gtic.ssr.upm.es/encuestas/delphi.htm

10. 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. 10

11. 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. 11

12. 12 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

13. 13 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

14. 14 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.

15. 15 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.

16. ANALYSES AND RESULTS 16 MAIN RESULTS Type and number of consultations that intervened in a case of meningococcemia

17. MAIN RESULTS Average of hospital stay, caused by a case of meningococcal meningitis 17 ANALYSES AND RESULTS

18. 18 MAIN RESULTS Laboratory Studies that intervene with treating a case of meningitis by meningococcus.

19. ANALYSES AND RESULTS MAIN RESULTS Cabinet Studies used for treating a case of meningococcal meningitis 19

20. ANALYSES AND RESULTS MAIN RESULTS Invasive medical procedures used for treating a case of meningococcal meningitis 20

21. ANALYSES AND RESULTS MAIN RESULTS Blood transfusions and hemoderivatives for treatment of meningitis meningococcal 21

22. ANALYSES AND RESULTS MAIN RESULTS Percentage of sequelae by meningitis meningococcal 22

23. ANALYSES AND RESULTS MAIN RESULTS Amputation costs 23

24. ANALYSES AND RESULTS 24 Cost per expert physician survey. 1st Round (Only medical attention costs are included) Cost Source: DOF 16 April 2007 updated for 2009

25. ANALYSES AND RESULTS 25 Cost per expert physician survey. Concensus (only medical attention costs are included) Cost Source DOF 16 April 2007 updated to 2009

26. MENINGITIS TREATMENT COSTS IN MEXICO PART II: Hospital Files Evaluated

27. ANALYSES AND RESULTS: Cost of Meningococcal Meningitis 27 Cost 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

28. ANALYSES AND RESULTS: Cost of Bacterial Meningitis (not meningococcus) 28 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

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30. 30 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 30

31. 31  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 31

32. 32  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 32

33. 33 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 33

34. 34 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 34

35. 35 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 35