Pre-Hospital Pulse-Oximetry and Supplemental Oxygen Utilization in Malawi: An Exploratory Cost-Effectiveness Analysis

Pneumonia is the leading cause of death globally in children aged 0-5 years. Early access to pulse-oximetry and supplemental oxygen in low-resource, pre-hospital settings may result in improved pediatric pneumonia outcomes. However, few data exist regarding their application in such settings.

We performed an exploratory cost-effectiveness analysis using a decision analytic model to examine use of pulse-oximetry and supplemental oxygen in pre-hospital environments of Malawi.

Our model yielded an Incremental Cost-Effectiveness Ratio (ICER) for pre-hospital pulse-oximetry use of $35 (USD) per disability-adjusted life-year (DALY) averted compared to no pulse-oximetry use. One-way sensitivity analysis showed highest sensitivity to the parameter of downstream hospitalization cost. Given that inpatient management is the standard of care for hypoxemic pneumonia, when only pre-hospital costs were considered the result was an ICER of $9.9/DALY averted. Both values were considered cost-effective according to a conservative willingness-to-pay (WTP) threshold set for 1x the average GDP per capita in Malawi ($588, 2018). When oxygen was analyzed in combination with pulse-oximetry, we found a baseline WTP threshold for pre-hospital oxygen of $71 per patient. For every 1% reduction in total pediatric pneumonia mortality consequent to pre-hospital oxygen use, we determined the recommended WTP allowance for oxygen would increase by approximately $4.53.

We conclude that pulse-oximetry is likely cost-effective in low-resource, pre-hospital environments. We acknowledge the need for further research on the effectiveness of pre-hospital oxygen in reducing pediatric pneumonia mortality and suggest ranges of cost and efficacy for which oxygen is likely to be found cost-effective in tandem with pulse-oximetry.