Akashdeep Singh Chauhan

Background: Hypertension, a leading cause of cardiovascular disease, is a significant public health challenge, with urban India reporting prevalence rates up to 40%. Excessive salt intake, averaging 8 to 11 g/day in India, far exceeds the World Health Organization–recommended limit of 5 g/day and is a key modifiable risk factor. While 24-hour urine collection is the gold standard for measuring 24-hour urinary excreted salt levels, its practicality in large-scale studies is limited, necessitating alternative methods such as spot urine sampling and dietary recall. Objective: This study aimed to address current knowledge gaps by evaluating 24-hour urinary excretory salt levels across age groups and comparing the gold standard of 24-hour urinary salt excretion with estimates from spot urine samples and 24-hour dietary recalls among adolescents and their parents in Chandigarh, India. Methods: A cross-sectional survey was conducted among 462 adolescents and 395 parents from public schools in Chandigarh, part of a cluster randomized controlled trial focused on reducing chronic disease risk factors. Twenty-four–hour urinary excreted salt levels were measured via 24-hour urine collection, spot urine samples were analyzed with the Kawasaki, Tanaka, and INTERSALT equations, and 2 nonconsecutive 24-hour dietary recalls using a correction factor of 0.9. Bland-Altman plots were used to assess agreement between methods. Results: The mean 24-hour urinary excreted salt levels measured via 24-hour urine samples were 6.95 g/day (SD 0.24; 95% CI 6.48‐7.42) for adolescents and 7.73 g/day (SD 0.3; 95% CI 7.18‐8.28) for parents. Spot urine estimates showed variability, with the INTERSALT equation with potassium yielding the closest results to 24-hour measurements for parents (mean 8.12, SD 0.4 g/d; 95% CI 7.36‐8.95) and adolescents (mean 7.97, SD 0.4 g/day; 95% CI 7.16‐8.77). Dietary recall underestimated 24-hour urinary excreted salt levels for both groups (mean 4.15, SD 0.08 g/day for adolescents and mean 3.62, SD 0.08 g/day for parents). Conclusions: Spot urine sampling, particularly the INTERSALT with potassium equation, offers a feasible alternative to 24-hour urine collection for estimating population-level 24-hour urinary excreted salt levels among adolescents and adults in resource-limited settings. Dietary recall alone significantly underestimates intake and should be supplemented with objective measures. These findings support the use of tailored estimation methods based on age for improved hypertension management strategies in India.

Objectives: This multicentre real-world evaluation, commissioned by NHS England, evaluated the impact of AI-assisted contouring of organs at risk on contour acceptability, workflows, and staffing. Methods: Data from 626 patients were collected from eight NHS radiotherapy departments. Time metrics from the date of planning CT scan to the start of first treatment were compared between manual and AI-enabled pathways. Acceptability scores for AI-generated contours were also collected. Results: AI-assisted contouring increased potential efficiency in treatment planning compared to manual methods, reducing time for contouring and redistributing workload across different staff types. 100% of manual contour reviews involved clinical oncologists compared to 38% reviewing AI-generated contours. However, workflow design meant that time saving was not observed across the whole treatment planning pathway. AI contours were generally well accepted, with 15.9% requiring no edits and 64.4% only minor edits. This varied by anatomy, with breast having the best acceptability and prostate and head and neck contours requiring more editing. Conclusions: AI contouring tools have the potential to enhance efficiency in radiotherapy treatment planning, creating operational flexibility. Pathway review and revision could unlock further benefits, for example, involving different staff types to address local bottlenecks. Workflow, capacity, and staffing review pre- and post-implementation could increase efficiency gains with AI-assisted contouring. Advances in knowledge: This study evaluated AI contouring tools in complex, real-world systems which differ between departments for generalizable conclusions. It describes the changes in time across the whole treatment planning pathway and the system-level impact of using AI tools to help inform holistic planning.

Introduction: Women living with HIV (WLHIV) face a higher risk of developing cervical cancer. India carries a significant burden of HIV, with an estimated 2.5 million people living with HIV in 2023. While the introduction of more effective antiretroviral therapy has improved the life expectancy of WLHIV, it has also extended the risk window for persistent human papillomavirus (HPV) infection and cervical disease progression. Cervical cancer prevention through HPV vaccination and regular screening remains the cornerstone of public health efforts. This study specifically aims to evaluate the cost-effectiveness of various cervical cancer screening strategies (at different intervals) among WLHIV in India. Methods and analysis: The study will be conducted in three interlinked components. First, a meta-analysis will be undertaken to evaluate the diagnostic accuracy of different screening strategies in detecting cervical lesions in WLHIV. Second, primary data collection will be carried out to estimate the treatment costs of cervical cancer and HIV among WLHIV. This phase will also include the collection of health-related quality of life (HRQoL) data, to inform utility estimates for the modelling component. A total of 135 participants will be enrolled for cost data assessment. Of these, a subset of 71 participants will also be included for HRQoL assessment. This data collection will be undertaken in four tertiary public sector hospitals located across four Indian states, that is, Mizoram, Maharashtra, Tamil Nadu and Karnataka. Lastly, a decision analytical model will be developed to simulate the process of screening, diagnosis and treatment for cervical cancer in a hypothetical cohort of WLHIV. A structured comprehensive review of literature will be undertaken to inform model input parameters related to the natural history of cervical disease, progression and mortality among WLHIV. Model calibration will be performed using a likelihood-based approach to ensure consistency with empirical epidemiological data. Probabilistic sensitivity analysis will also be conducted to assess the impact of joint parameter uncertainty on model outcomes. Ethics and dissemination: Ethical approval has been obtained from Ethics Committees of Indian Council of Medical Research–National AIDS Research Institute (NARI), Pune (Protocol No. NARI/EC/Approval/2024/716); B. J. Medical College and Sassoon General Hospitals, Pune (Ref. No. BJGMC/IEC/Pharmac/ND-0824297-297); Cancer Institute (WIA), Adyar, Chennai (Ref. No. IEC/2024/Nov-07); the Mizoram State Cancer Institute, Zemabawk, Aizawl (Ref. No. D.12016/2/2013-MSCI/IEC) and the KLE Academy of Higher Education and Research, Belagavi, Karnataka. The study findings will be disseminated through publications in peer-reviewed journals.

Introduction Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world’s largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions. Methods A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes. Results Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives. Conclusion While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes.

Background: Duchenne muscular dystrophy (DMD) is a rare progressive muscular disease that primarily affects boys. A lack of comprehensive care for patients living with DMD is directly associated with a compromised quality of life (QoL) for those affected and their caregivers. This disease also has a huge economic impact on families as its treatment requires substantial direct, indirect, and informal care costs. Objective: This study presents a protocol developed to evaluate the feasibility and efficacy of a patient-centered care (PCC) model for children with DMD. The care model was designed with the aim to empower families, improve QoL, and reduce economic burden on their families. Methods: This study is planned as a quasi-experimental study that will enroll 70 consecutive families with boys (aged 5-15 years) with DMD visiting a tertiary care center. The study is being conducted in 2 phases (preintervention and postintervention phases, referred to as phase 1 and phase 2, respectively). During phase 1, the patients received routine care. The study is now in phase 2, with the intervention currently being administered. The intervention is based on the PCC model individualized by the intervention team. The model has a comprehensive DMD telecare component that includes teleconsultation as one of its key components to reduce in-person physician visits at the health facility. Teleconsultation is especially beneficial for late-ambulatory and nonambulatory patients. Data on economic burden are being collected for out-of-pocket expenses for both phases during in-person visits via telephone or messaging apps on a monthly basis. QoL data for patients and their primary caregivers are being collected at 3 time points (ie, time of enrollment, end of phase 1, and end of phase 2). Outcome measures are being assessed as changes in economic burden on families and changes in QoL scores. Results: Participant recruitment began in July 2021. The study is ongoing and expected to be completed by March 2023. The findings based on baseline data are expected to be submitted for publication in 2023. Conclusions: This paper outlines a research proposal developed to study the impact of a PCC model for patients with DMD in low- and middle-income countries (LMICs). This study is expected to provide evidence of whether a multicomponent, patient-centric intervention could reduce economic burdens on families and improve their QoL. The results of this study could guide policy makers and health professionals in India and other LMICs to facilitate a comprehensive care program for patients living with DMD. The economic impact of a rare disease is an important consideration to formulate or evaluate any health policy or intervention related to new treatments and financial support schemes. Trial Registration: Clinical Trials Registry India (ICMR-NIMS) CTRI/2021/06/034274; https://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=56650 International Registered Report Identifier (IRRID): PRR1-10.2196/42491

BACKGROUND Duchenne muscular dystrophy (DMD) is a rare progressive muscular disease that primarily affects boys. A lack of comprehensive care for patients living with DMD is directly associated with a compromised quality of life (QoL) for those affected and their caregivers. This disease also has a huge economic impact on families as its treatment requires substantial direct, indirect, and informal care costs. OBJECTIVE This study presents a protocol developed to evaluate the feasibility and efficacy of a patient-centered care (PCC) model for children with DMD. The care model was designed with the aim to empower families, improve QoL, and reduce economic burden on their families. METHODS This study is planned as a quasi-experimental study that will enroll 70 consecutive families with boys (aged 5-15 years) with DMD visiting a tertiary care center. The study is being conducted in 2 phases (preintervention and postintervention phases, referred to as phase 1 and phase 2, respectively). During phase 1, the patients received routine care. The study is now in phase 2, with the intervention currently being administered. The intervention is based on the PCC model individualized by the intervention team. The model has a comprehensive DMD telecare component that includes teleconsultation as one of its key components to reduce in-person physician visits at the health facility. Teleconsultation is especially beneficial for late-ambulatory and nonambulatory patients. Data on economic burden are being collected for out-of-pocket expenses for both phases during in-person visits via telephone or messaging apps on a monthly basis. QoL data for patients and their primary caregivers are being collected at 3 time points (ie, time of enrollment, end of phase 1, and end of phase 2). Outcome measures are being assessed as changes in economic burden on families and changes in QoL scores. RESULTS Participant recruitment began in July 2021. The study is ongoing and expected to be completed by March 2023. The findings based on baseline data are expected to be submitted for publication in 2023. CONCLUSIONS This paper outlines a research proposal developed to study the impact of a PCC model for patients with DMD in low- and middle-income countries (LMICs). This study is expected to provide evidence of whether a multicomponent, patient-centric intervention could reduce economic burdens on families and improve their QoL. The results of this study could guide policy makers and health professionals in India and other LMICs to facilitate a comprehensive care program for patients living with DMD. The economic impact of a rare disease is an important consideration to formulate or evaluate any health policy or intervention related to new treatments and financial support schemes. CLINICALTRIAL Clinical Trials Registry India (ICMR-NIMS) CTRI/2021/06/034274; https://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=56650 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/42491

The establishment of link between high-risk human papillomavirus (HPV) infection and occurrence of cervical cancer has resulted in development of various HPV related control strategies for the prevention of cervical cancer. The objective of the present study was to assess the cost effectiveness of various screening strategies for cervical cancer and human papilloma virus (HPV) vaccination in India. A Markov model based on societal perspective was designed to estimate the lifetime costs and consequences of screening (with either visual inspect with acetic acid (VIA), Papanicolaou test or HPV DNA test at various time intervals) in a hypothetical cohort of 30–65 years age women or vaccination among adolescent girls. Diagnostic accuracy of the screening strategies, efficacy of HPV vaccination and data on transition probabilities was based on the results of the existing meta-analyses. Primary data was collected for assessing per person cost of screening, cost of treating cervical cancer and quality of life. We found that introduction of different screening strategies leads to reduction in lifetime occurrence of cervical cancer cases caused by HPV 16/18 from 20% to 61%, and cervical cancer deaths from 28% to 70%, as compared to no screening. Among various screening strategies, screening with both VIA 5 yearly and VIA 10 yearly came out to be cost effective at 1-time per capita GDP, with VIA every 5 years providing greater health benefits as compared to VIA 10 years. Hence, screening with VIA 5 years at an incremental cost of US$ 829 (INR 54,881) per QALY gained is the recommended strategy for India. Further, with regards to HPV vaccination, it leads to 60% reduction in cancer cases and mortality caused by HPV 16/18 as compared to no vaccination. Moreover, when this vaccinated cohort of adolescent girls is also screened later in their life (with VIA every 10 years and VIA 5 years), it leads to 69%-76% reduction in cancer cases and 71%-81% reduction in cancer deaths. As compared to no vaccination and no screening, both HPV vaccination alone and vaccination plus screening (with VIA every 5 yearly and VIA 10 yearly) appears to be cost effective with ICERs in the range of US$ 86 (INR 5,693) to US$ 476 (INR 31,511) per QALY gained. In the long run, when the cohort of adolescent girls, who were immunized for HPV, reach the age of 30 years, the screening frequency using VIA should be determined based on the coverage of HPV vaccination in that cohort.

Background India’s flagship National Health insurance programme (AB-PMJAY) requires accurate cost information for evidence-based decision-making, strategic purchasing of health services and setting reimbursement rates. To address the challenge of limited health service cost data, this study used econometric methods to identify determinants of cost and estimate unit costs for each Indian state. Methods Using data from 81 facilities in six states, models were developed for inpatient and outpatient services at primary and secondary level public health facilities. A best-fit unit cost function was identified using guided stepwise regression and combined with data on health service infrastructure and utilisation to predict state-level unit costs. Results Health service utilisation had the greatest influence on unit cost, while number of beds, facility level and the state were also good predictors. For district hospitals, predicted cost per inpatient admission ranged from 1028 (313–3429) Indian Rupees (INR) to 4499 (1451–14,159) INR and cost per outpatient visit ranged from 91 (44–196) INR to 657 (339–1337) INR, across the states. For community healthcare centres and primary healthcare centres, cost per admission ranged from 412 (148–1151) INR to 3677 (1359–10,055) INR and cost per outpatient visit ranged from 96 (50–187) INR to 429 (217–844) INR. Conclusion This is the first time cost estimates for inpatient admissions and outpatient visits for all states have been estimated using standardised data. The model demonstrates the usefulness of such an approach in the Indian context to help inform health technology assessment, budgeting and forecasting, as well as differential pricing, and could be applied to similar country contexts where cost data are limited.