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Cost analysis of adult male circumcision with the prepex[TM] device versus surgery in Rwanda.

In this study from Rwanda, voluntary adult male circumcision costs 33% less with trained nurses using the PrePex[TM] device compared with physician-nurse teams performing dorsal-slit surgery. These cost savings and the documented safety, speed, and efficacy of the PrePex procedure, serve Rwanda's HIV prevention program.

Key Words: Cost, Rwanda, male circumcision, nurses, HIV prevention, PrePex.

Introduction

Male Circumcision to Reduce HIV Transmission

Three randomized controlled trials have shown that voluntary adult male circumcision (MC) reduces heterosexual acquisition of the human immunodeficiency virus (HIV) in men by up to 60% (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). In a long-term follow up to the large-scale MC trial in Uganda (Gray et al., 2007), HIV incidence was 73% lower in trial participants who had accepted MC than in those who had declined, and 67% lower in control-group participants who accepted MC after trial closure than in those who declined (Gray et al., 2012). Two meta-analyses (Byakika-Tusiime, 2008; Mills, Cooper, Anema, & Guyatt, 2008), a systematic review (Siegfried, Muller, Deeks, & Volmink, 2009), and a cost analysis (Uthman, Popoola, Yahaya, & Aremu, 2011) have confirmed that HIV risk can be substantially reduced through MC. The World Health Organization (WHO) and the United Nations Programme on HIV/ AIDS (UNAIDS) (2007) recommend that voluntary adult MC be considered as an option within a comprehensive prevention program in countries where HIV prevalence is epidemic and transmission is predominantly heterosexual.

Assessing the Cost of Adult Male Circumcision

Modeling performed in 2011 by the Ministry of Health in Rwanda, with support from the United States Agency for International Development Health Policy Initiative and UN AIDS, indicated that the cost in U.S. dollars of voluntary adult MC in 13 African nations ranged from $65.85 to $95.15 per procedure, and that scaling up adult MC programs to reach 80% of eligible males in these nations would require completion of 20.34 million procedures by 2015; completion of an additional 8.42 million procedures over the next 10 years could avert 3.36 million new HIV infections by 2025. Scale-up would cost an estimated $2 billion but would result in an anticipated net saving of $16.51 billion due to averted treatment and care costs (Njeuhmeli et al., 2011).

In their cost analysis based on a hypothetical cohort of 150,000 men, Binagwaho, Pegurri, Muita, and Bertozzi (2010) estimated the mean total cost (including HIV screening, medical tools and supplies, laboratory expenses, and staff time) of a single surgical MC procedure in an adult in Rwanda to be $59.

Male Circumcision Using The PrePex[TM] Device

As an alternative to conventional MC surgery, the government of Rwanda explored the feasibility of using the PrePex[TM] device (Circ MedTech Ltd.) in a scale-up program because the procedure is nonsurgical (i.e., does not require anesthesia, suturing, or sterile setting) and could be performed by trained nurses.

The PrePex device is disposable and has five elements (see Figure 1): inner ring, placement ring, and elastic ring, as well as a sizing plate (to determine the appropriate ring size) and a verification thread (to ensure proper placement). The rigid inner ring is positioned around the glans, under the foreskin; the placement ring is then used to deploy the elastic ring in position to compress the foreskin against the inner ring, initiating ischemia. Dermal anesthetic cream applied prior to placement, plus oral ibuprofen 400 mg (repeat once pm), minimizes post-placement discomfort. Seven days later, the necrotic distal foreskin is removed bloodlessly, using scissors; the elastic ring is cut with a scalpel and the inner ring is extracted (pain during extraction lasts just seconds). A sterile dressing is applied and subjects are seen weekly until complete healing occurs (within six weeks). No sexual activity is permitted during the healing period.

By comparison, surgical MC requires a sterile field for the procedure, anesthesia, sutures, and antibiotic prophylaxis. In addition, the PrePex procedure is significantly faster than surgical MC. A previously published study (Mutabazi et ah, 2012) compared procedure times for adult MC performed with the PrePex device versus standard surgical methodology, as recorded by a dedicated observer using a stopwatch to time every step of every procedure in every subject; mean procedure time was significantly shorter with the PrePex device than with surgery (in minutes and seconds, 3:06 versus 15:24; P< 0.0001).

The feasibility of performing nonsurgical MC using the PrePex device has been documented in a series of clinical trials (Bitega, Ngeruka, Hategekimana, Asiimwe, & Binagwaho, 2011; Mutabazi et al., 2012, 2013). These studies demonstrated that adult MC in Rwanda can be performed with equal efficacy, equal or greater safety, and notably greater speed using the PrePex device compared with standard surgical methodology, and that trained nurses can perform this procedure as well as physicians, without compromising safety or success rates.

Consequently, in Rwanda (where only an estimated 15% of men are circumcised), the government has implemented a nationwide voluntary MC program with the goal of reaching two million adult men in two years in an effort to decrease HIV incidence by 29% by the year 2025 (Mutabazi et al., 2013).

Objective

This study was undertaken to compare cost data from the study of procedure times for nonsurgical MC performed by nurses and surgical MC performed by physician-nurse teams (Mutabazi et al., 2012), and to estimate how the cost differential might affect Rwanda's national MC scale-up program to reduce the risk of sexual transmission of HIV.

Methods

This single-center non-blinded randomized controlled trial (clinicaltrials.gov NCT01284088) compared the costs associated with nonsurgical adult MC performed in a standard examination room by a team of two trained nurses using the PrePex device versus surgical MC performed in a sterile environment by a physician-nurse team using the WHOapproved dorsal-slit method.

The study was carried out over the course of nine weeks in the Nyamata District Hospital, located in a rural area 35 kilometers from Kigali City. The study was reviewed and approved by the Rwanda National Ethics Committee on January 13, 2011. All subjects were given complete information about the procedure and provided written informed consent for the procedure and follow-up care.

Cost categories included in the analysis reflect ongoing expenses that are specific to each method: supplies (tools, devices, and other consumables), laboratory tests, salaries for the clinicians performing the procedures, and treatment of procedure-related adverse events (AEs). Investments in training and infrastructure incurred at the outset and not ongoing were excluded because they are meaningful only in the context of the intended nationwide scale-up program.

With both methods, supplies accounted for the greatest portion of ongoing costs. The present study generated primary data on the cost of supplies for the PrePex procedure (in U.S. dollars, to the nearest $0.01). The cost of supplies for surgical MC (to the nearest $1.00) was taken from a previously published report by Binagwaho et al. (2010), which modeled the cost-effectiveness of surgical MC in Rwanda in a large hypothetical cohort of males in different age groups (adults, N = 150,000). These differences in data sources, population characteristics, and the precision of cost data precluded formal statistical comparisons.

Results

The study population was composed of 217 adult male Rwandan volunteers randomized in a 2:1 ratio to have either nonsurgical MC with the PrePex device performed by teams of two nurses (n = 144) or dorsal-slit surgical MC performed by teams of one physician and one nurse [n = 73). All subjects in both groups achieved successful circumcision (defined as full exposure of the glans) and healing (epithelialization with no drainage from the site). AEs requiring treatment were documented in six subjects from the surgical group (8%) but none from the PrePex group.

In the following cost summaries, all amounts are given in U.S. dollars.

Supplies

Supplies for MC include tools (where feasible, stainless steel and reusable), devices (the PrePex device itself), and materials, such as surgical dressings. For reusable tools, the estimated cost of loss through wear was based on experience using such tools in other procedures.

Table 1 summarizes the cost of supplies needed for a single PrePex MC procedure in the study, as obtained from local sources. The total cost of supplies was $22.38. The mean total cost of supplies for dorsal-slit surgical MC in an adult in Rwanda was assessed by Binagwaho et al. (2010) at $29 ($21 for consumables, $8 for the surgical kit including costs for sterilization and amortization); in addition, surgical MC incurred a $6 cost per procedure for laboratory testing (hematology profile) as a safety precaution, whereas such testing was not required with the PrePex procedure.

Salaries for Clinicians Performing MC

For both PrePex and surgical MC, ongoing costs for staff time reflect the combined time required for preparation and for the procedure itself, as previously reported (Mutabazi et al, 2012), and the mean hourly salaries for staff physicians and for professional nurses with six years of training in Rwanda. PrePex procedure time is the combined time required for device placement (from positioning of the placement ring over the penis to removal of the verification thread and patient standing up) and device removal (from the first cut of dry foreskin to detachment of the device). Surgical procedure time is measured from first cut to last suture.

Table 2 summarizes the mean total per-procedure costs for associated staff salaries for the time spent by clinical personnel involved in performing MC with the PrePex device or by dorsalslit surgery ($0.35 versus $4.36, respectively).

Treatment of Adverse Events

The cost of treating AEs was based on the time spent by clinicians, the materials and medications used (based on the type of AE), and the incidence of each type of AE reported. Among the 217 MC procedures performed by nurses using the PrePex procedure or by physicians using dorsal-slit surgery, there were no reported cases of infection following either type of procedure. However, a small number of cases of bleeding serious enough to require suturing (apart from routine suturing during the surgical procedure), edema, and exudate were reported among subjects who underwent surgical MC.

Table 3 summarizes the frequency and costs associated with each type of AE reported. Treatment of AEs added a mean of $1.49 per procedure to the cost of surgical MC; however, among subjects who had MC performed with the PrePex device, there were no AEs reported and therefore no additional costs in this category.

Mean Total Costs per Procedure

The mean total of ongoing costs specific to each method of performing MC was $22.73 ($22.38 for supplies, $0.00 for laboratory testing, $0.35 for salaries, $0.00 for treatment of AEs) for nonsurgical MC with the PrePex device performed in a standard examination room by nurse teams; and $40.85 ($29, $6", $4.36, $1.49) for dorsal-slit surgical MC performed in a sterile setting by physician-nurse teams. These differences are illustrated in Figure 2.

To provide additional perspective for these differences in ongoing costs specific to each method of performing MC, the expenditures common to both methods must also be considered. As previously reported by Binagwaho et al. (2010), these costs include approximately $3.50 for wide-scale promotion of the MC program and $9.20 for HIV counseling and testing. Thus, the total ongoing cost for adult MC in Rwanda would be approximately $35.50 with PrePex versus $53.50 with surgery (a difference of 33%). Figure 3 illustrates the ongoing method-specific costs combined with costs common to both methods to compare the total costs of MC with each method.

Discussion

This study analyzed the costs of voluntary adult MC performed as a nonsurgical procedure by nurse teams using the PrePex device or as a surgical procedure performed by physician-nurse teams. The feasibility of nurses performing MC using the PrePex device has been well documented (Mutabazi et al, 2013, 2014).

Ongoing Costs

In the present study, the mean total for ongoing costs (supplies, laboratory tests, salaries, treatment of AEs) was $22.73 with the PrePex procedure performed by nurses versus $40.85 with conventional surgery performed by physicians, a saving of approximately $18 per procedure. Among these costs, no AEs requiring treatment were reported in the PrePex group; however, even assuming a low incidence of AEs in a larger sample, consistent with previous reports (Bitega et al., 2011; Galukande et al, 2014; Mutabazi et al., 2012, 2013), and adding $1.49 per procedure (the amount equal to that allowed for AE treatment with surgical MC), the cost savings with PrePex versus surgery would still be substantial.

With both methods of performing MC, the ongoing cost per procedure might be lower in the context of a national scale-up program than the amounts reported in the current study. It is likely that unit costs for supplies would be lower with larger bulk purchases, and costs for clinicians' salaries and treatment of AEs would also be lower as personnel gain experience and skill, increasing the speed and safely of the procedure.

Initial Investments

Apart from the ongoing expenses reported here, there are at least two categories of initial (non-ongoing) expense that would also have to be considered in any assessment of the cost of a national scale-up program of voluntary MC. The initial investments in training and infrastructure required with each method are substantial, but these expenses are meaningful only in the context of a large-scale, long-term program involving a vastly greater number of participants than the 217 young men who had MC performed in the present study.

In this study, the total cost of the three-day PrePex training course for 10 nurses (five teams of two nurses) was approximately $3,700. This amount covered salaries for the trainers and the nurses, PrePex kits and other supplies to practice the procedures, printed instructional materials, and administrative costs. To allow comparison with the costs of surgical MC as modeled by Binagwaho et al. (2010), this initial investment in training can be extrapolated to a hypothetical cohort of 150,000 men undergoing the PrePex procedure in a year, for which it was estimated that 50 teams of nurses would be needed. The total cost of training 50 teams of nurses would be approximately $37,000, which would add $0.25 to the cost per procedure. By comparison, Binagwaho et al. (2010) calculated that training a sufficient number of physicians to perform surgical MC in 150,000 adults in a year would add $1.30 to the cost per procedure. However, these estimates must be interpreted cautiously because a national scale-up program would not be limited to 150,000 MC procedures in a year and because there is no way to predict the need to train new personnel to replace previously trained personnel who discontinue participation.

There was no actual investment in infrastructure in preparation for this study. Binagwaho et al (2010] estimated that performing 150,000 surgical MC procedures in a year would require 94 small surgery rooms (each accommodating 8 procedures per day for 200 days). By comparison, it is estimated that performing 150,000 nonsurgical MC procedures in a year using the PrePex device would require 25 standard examination rooms (each accommodating 30 procedures per day for 200 days). Although construction costs would be higher for 94 sterile environments than for 25 standard examination rooms, the actual cost impact of investing in infrastructure would be very difficult to calculate for several reasons: 1) an MC scale-up program is not limited to 150,000 procedures in a year, 2) standard examination rooms could be either rented or constructed as deemed appropriate, 3) minor surgical procedures might sometimes be performed in non-sterile facilities, and 4) new sterile and non-sterile facilities would also be used for other clinical purposes unrelated to MC.

Circumcision in Men With Phimosis

One factor that could potentially reduce the cost-effectiveness of the PrePex procedure is that it cannot be used in men with phimosis because they would require either a surgical slit in the foreskin to allow placement of the PrePex device or referral for conventional surgical MC. The prevalence of phimosis declines from 100% at birth to 10% at three years of age (Morris et al., 2012). The prevalence in adult males appears to be low, but it is difficult to determine with accuracy due to differences in demographics and reporting criteria. Primary studies have reported rates of 0.5% among men over age 40 in Brazil (Romero, Romero, Almeida, Oliveira, & Filho, 2013) and 5% among men over age 18 in Rwanda (Bitega et al., 2011). A comprehensive review suggests that the prevalence in adult males is approximately 2% (Shahid, 2012). If these estimated low prevalence rates in men are valid, phimosis should not seriously compromise the cost effectiveness of an MC scale-up program utilizing the PrePex device.

Contrasting Reports On Cost Effectiveness

The cost savings reported here with PrePex versus surgical MC reflects three main factors: the PrePex procedure is significantly faster (Mutabazi et al., 2012); it was performed by nurses instead of physicians without compromising outcome (Mutabazi et al., 2013, 2014); and it incurred lower costs for supplies according to the comparative data. However, in contrast to these positive findings, two published reports cast doubt on the potential savings that could be achieved with use of the PrePex device in scale-up MC programs in Africa.

A study from Uganda (Duffy, Galukande, Wooding, Dea, & Coutinho, 2013) presented primary data on costs with PrePex using a model based on 625 procedures. It showed the per-procedure cost of supplies as $23.40, which is consistent with the primary data in the present study showing this cost as $22.38. In both studies, the device itself accounts for most of this cost. However, using secondary data on surgical MC in a model based on 10,000 previously performed procedures, the authors reported that the corresponding cost with forceps-guided surgery was $10.83, whereas a secondary-data estimate of $29 with dorsal-slit surgery (Binagwaho et al., 2010) was utilized in this study. Due mainly to this discrepancy (which probably reflects methodological differences in accounting rather than actual differences in the supplies needed for forceps-guided surgery versus dorsal-slit surgery), Duffy et al. (2013) concluded that overall per-procedure costs are higher with PrePex. However, they also noted the logistical advantages of the PrePex procedure, including the possibility of lowering costs by using nonphysician personnel to perform it. They further acknowledged that the greater number of MC procedures possible with PrePex could prevent more cases of HIV infection, resulting in slightly lower long-term costs with PrePex than with surgery.

A study from Kenya (Obiero, Young, & Bailey, 2013) utilized a WHO/UNAIDS planning tool to analyze data from 48,265 forceps-guided surgical MC procedures and projected costs for MC performed with the PrePex device. The model assumed the use of non-physician teams to perform the PrePex procedure, which is consistent with the design of the present study. However, there are large discrepancies in the direct-cost categories of supplies and salaries, including treatment of AEs. For surgical MC, the authors' summation of these direct costs was lower than the present study's estimate (approximately $26 to $27 versus $41); and for PrePex MC, their projection of costs including the price of the device itself was higher than the present study's directly measured costs even after adding an amount equal to that allowed for treatment of AEs with surgical MC ($39 to $40 versus $24). The authors also included per-procedure estimates for the initial investments in training and infrastructure, which were extrapolated to a large cohort of subjects. In comparison with the present study, their estimates for training were higher for the PrePex device and lower for surgery, but the absolute amounts for both methods in both reports still represent only a minor contribution to overall costs. Their estimate of necessary capital investment was similar for both methods. Considering the cost categories in which there are major discrepancies, data reported by Obiero et al. (2013) suggest that the overall per-procedure cost would be approximately $13 higher with PrePex than with surgery, whereas data from the present study suggest the cost would be approximately $17 lower with PrePex. Again, it seems likely that major methodological differences account for much of these conflicting outcomes. Also, it must not be assumed that findings in one African nation are automatically applicable in another. (According to information provided by the manufacturer, the PrePex device is currently being used or studied in several other African nations and in Indonesia.)

The Role of Nurses

Because the PrePex procedure is notably faster than surgery, a greater number of MC procedures can be performed in a given time. The fact that Rwandan candidates have found PrePex more acceptable than surgery, regardless of whether the procedure is performed by physicians or nurses, may also contribute to the attainment of national goals for scale-up MC programs. The anticipated result is a reduced incidence of heterosexual transmission of HIV, which in turn can have an important long-term impact in reducing medical expenditures.

As reported in this study, the positive experience with nurses performing MC suggests the potential for cost saving in other clinical areas. Certainly, nurses can be trained to perform other procedures that have traditionally been reserved for physicians. The authors believe that allowing nurses to assume greater responsibility in handling many routine tasks can reduce costs without compromising clinical outcomes while allowing physicians more time to handle complex and demanding tasks. These benefits are especially important in providing vital clinical care in resource-poor areas. While the idea of training nurses or other non-physician personnel to perform surgical MC is not addressed here and is not currently approved in Rwanda, it is an option that may have practical advantages in Africa (Ford, Chu, & Mills, 2012).

Study Limitations

First, the quantity of tools and materials purchased for the PrePex wing of the present study (mainly, the device itself) were just sufficient to carry out this study whereas surgical tools and materials were purchased large quantities for diverse uses. Secondly, in this study the PrePex procedure was compared with WHO-approved dorsal-slit surgery, but other surgical methods, such as forceps-guided surgery (Duffy et al., 2013; Obiero et al., 2013), may prove to be more cost-effective. Finally, the design of this study (primary data on costs incurred with the PrePex procedure compared with data from a previously published model of surgical MC) did not permit rigorous statistical analysis. Large-scale randomized parallel-group prospective trials are necessary to obtain the data needed for formal statistical comparison of costs and also to examine the assumption that the positive results achieved on the present scale in a district hospital will be matched when procedures are performed on a far larger scale in rural clinics.

Conclusions

This study suggests that meaningful cost-savings can be achieved in Rwanda with nonsurgical MC performed by nurses using the PrePex device in place of surgical MC performed by physicians. The speed, safety, and acceptability of the PrePex nonsurgical method may also contribute to the attainment of Rwanda's national goals for scale-up voluntary MC programs designed to reduce the heterosexual transmission of HIV.

doi: 10.7257/1053-816X.2014.34.6.303

Research Summary

Background

Adult male circumcision (MC) can substantially reduce heterosexual HIV acquisition in men. Previous research by these authors reported that MC procedure time was significantly shorter with the PrePex[TM] device than with surgery in Rwanda. Nurses were trained to perform MC using the PrePex device, and the procedure proved to be safe and successful in achieving complete circumcision and complete healing.

Objectives

This study was undertaken to compare cost data from the study of procedure times for nonsurgical MC performed by nurses and surgical MC performed by physician-nurse teams (Mutabazi et al., 2012), and estimate how the cost differential might affect Rwanda's national MC scale-up program to reduce the risk of sexual transmission of HIV.

Methods

A prospective, randomized (2:1), non-blinded study in healthy volunteers aged 21 to 54 years compared ongoing cost elements that differed between PrePex MC and dorsal slit surgical MC: supplies, salaries, and treatment of adverse events.

Results

Mean total procedure-specific costs for ongoing expenses were U.S. $22.73 per MC procedure with the PrePex device (n = 144) versus U.S. $40.85 with surgery (n = 73). Savings were seen in all three cost categories.

Conclusions

In this study in Rwanda, nonsurgical MC performed by nurses using the PrePex device offered meaningful cost savings compared with surgical MC performed by physiciannurse teams.

Level of Evidence--II

(Polit & Beck, 2012)

References

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Vincent Mutabazi, MD, is the Acting Head of the Clinical Research Center and Director of Research Grants, Ministry of Health, Kigali, Rwanda.

Jean Paul Bitega, MD, is a Surgeon and Head of Clinical Affairs, Rwanda Military Hospital, Kigali, Rwanda.

Leon Muyenzi Ngeruka, MD, is a Surgeon, Rwanda Military Hospital, Kigali, Rwanda.

Jean Pierre Nyemazi, MD, is Head of Planning and Monitoring and Evaluation Division, Ministry of Health, Kigali, Rwanda.

Mary Dain, BSc, is a Senior Program Manager, Clinton Health Access Initiative, New York, NY.

Steven A. Kaplan, MD, is a Professor of Urology, Weill Cornell Medical College, New York, NY.

Corine Karema, MD, is a Physician, Ministry of Health, Kigali, Rwanda.

Agnes Binagwaho, MD, PhD, is Minister of Health, Ministry of Health, Kigali, Rwanda.

Authors' Note: This study was funded by the government of the Republic of Rwanda. Aside from the authors, no one associated with the government of Rwanda participated in the preparation and review of this article or in the decision to submit it for publication. The manufacturer of the PrePex[TM] device played no role in the design, performance, interpretation, or reporting of this study. None of the authors has any relevant financial or non-financial relationships or interests to declare. The authors wish to thank Steven Tiger, PA, who worked on a pro bono basis with no outside funding to help with the preparation of this manuscript.

Table 1.

Cost in U.S. Dollars ($) per Procedure for Tools and
Materials Used in Performing MC with the PrePex Device

                                                  Device Placement

                               Defined    Cost per   Units
Tools and Materials              Unit       Unit     Used     Cost

Antiseptic solution            1 mL       0.004      16.9     0.07
Plain gauze swabs              1          0.016        3      0.05
PrePex device                  1          20.00        1     20.00
Reusable skin marker *         1/5        0.114        1      0.11
Lidocaine 5% cream             1 gr       0.096      0.76     0.07
Gloves                         1 pair     0.20         2      0.40
Ibuprofen 400 mg               1 tablet   0.38         2      0.76
Reusable sterile spatula *     1/100      0.021        0         0
Reusable sterile forceps *     1/100      0.024        0         0
Reusable sterile scissors *    1/100      0.023        0         0
Sterilization pouch            1          0.083        0         0
Single-use surgical blade      1          0.09         0         0
Povidone iodine solution       1 mL       0.01         0         0
MC wound dressing              1          0.014        0         0
Micropor tape                  10 cm      0.06         0         0
Cutter *                       1/1000     0.007        0         0

Total per-procedure cost for supplies                        21.46

                                    Device Removal

                               Units          Overall
Tools and Materials            Used    Cost    Cost

Antiseptic solution            16.1    0.06    0.13
Plain gauze swabs                4     0.06    0.11
PrePex device                    0     0       20.00
Reusable skin marker *           0     0       0.11
Lidocaine 5% cream               0     0       0.07
Gloves                           2     0.40    0.80
Ibuprofen 400 mg                 0     0       0.76
Reusable sterile spatula *       1     0.02    0.02
Reusable sterile forceps *       1     0.02    0.02
Reusable sterile scissors *      1     0.02    0.02
Sterilization pouch              1     0.08    0.08
Single-use surgical blade        1     0.09    0.09
Povidone iodine solution        7.1    0.07    0.07
MC wound dressing                2     0.03    0.03
Micropor tape                    1     0.06    0.06
Cutter *                         1     0.01    0.01

Total per-procedure cost for supplies  0.92    22.38

* For reusable items, the defined unit is the estimated
fraction of total potential use lost through wear in
performing one procedure.

Note: MC = male circumcision in adult volunteers.

Table 2.

Cost in U.S. Dollars ($) per Procedure for Salaries of
Clinical Personnel Performing MC with the PrePex Device or
Dorsal-Slit Surgery

                                             PrePex Nonsurgical MC
                                             (n= 144)
Personnel
(mean hourly                      Time *        Required    Salary
salary)         Phase of MC      (min:sec)      Personnel    Cost

Physician       Preparation          0              0         0
(U.S.
$9.22)          Procedure            0              0         0

                Total                0             --         0

Professional    Preparation        3:24             2        0.18
nurse (U.S.
$1.60)          Procedure     3:06 ([dagger])       2        0.17

                Total              6:30            --        0.35

Total per-                                                   0.35
procedure
cost for
salaries

                            Dorsal-Slit Surgical MC
                             (n= 73)
Personnel
(mean hourly     Time *     Required    Salary
salary)         (min:sec)   Personnel    Cost

Physician         8:48          1        1.35
(U.S.
$9.22)            15:24         1        2.37

                  24:12        --        3.72

Professional      8:48          1        0.23
nurse (U.S.
$1.60)            15:24         1        0.41

                  24:12        --        0.64

Total per-                               4.36
procedure
cost for
salaries

* Mean times as previously published (Mutabazi et al., 2012).

([dagger]) Combined procedure time includes device placement
and device removal.

Note: MC = male circumcision in adult volunteers.

Table 3.

Cost in U.S. Dollars ($) per Procedure for Treatment of AEs
Related to MC Performed with the PrePex Device or Dorsal-

                                              PrePex Nonsurgical MC
Slit Surgery                                  (n = 144)

                        Cost per   Incidence,     Cost per
Type of AE               Event        n(%)       Procedure *

Abnormal bleeding        25.00          0           0.00
  requiring suturing
  ([dagger])
Diffuse edema             3.00          0           0.00
Productive exudate        3.00          0           0.00
Infection                  --           0           0.00

Total per-procedure                                 0.00
  cost for treatment
  of AEs

                                   Dorsal-Slit Surgical
Slit Surgery                       MC (n = 73)

                        Incidence,     Cost per
Type of AE                 n(%)       Procedure *

Abnormal bleeding         4 (5.5)        1.37
  requiring suturing
  ([dagger])
Diffuse edema             2 (2.7)        0.08
Productive exudate        1 (1-4)        0.04
Infection                    0           0.00

Total per-procedure                      1.49
  cost for treatment
  of AEs

* (Cost per event x number of events) divided by number of
procedures performed.

([dagger]) This AE does not refer to routine surgical
suturing.

Notes: AE = adverse event, MC = male circumcision in adult
volunteers.
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Article Details
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Title Annotation:Research
Author:Mutabazi, Vincent; Bitega, Jean Paul; Ngeruka, Leon Muyenzi; Nyemazi, Jean Pierre; Dain, Mary; Kapla
Publication:Urologic Nursing
Article Type:Report
Geographic Code:6RWAN
Date:Nov 1, 2014
Words:5892
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