Evaluation of the 2018–2019 vaccine effectiveness against medically attended influenza-like illness using medical records and claims data

BackgroundHealthcare administrative databases are a rich source of information that could be leveraged to estimate real-world influenza vaccine effectiveness (VE). We aimed to evaluate the VE of standard egg-based influenza vaccines and determine if administrative healthcare data provide accurate VE estimates compared to the US CDC data.MethodsThis retrospective cohort study was conducted during the 2018–2019 influenza season. Individuals who had at least one relevant record per year between 2015 and 2019 in their electronic medical record were included. Individuals were considered protected 14 days after receiving an influenza vaccine. The outcome was the occurrence of medically attended influenza-like illness (MA-ILI) defined by clinical diagnostic codes. Adjusted odds ratios (aORs) were derived from multivariate logistic regression and adjusted VE (aVEs) were calculated using 100 × (1-aORs).ResultsA total of 5,066,980 individuals were included in the analysis with 1,307,702 (25.8%) considered vaccinated. Overall, the median age was 54 (IQR, 32–66) and 58.1% were female. Vaccine protection against MA-ILI was moderate in children and low in adults. All estimates were lower than VEs reported by the CDC for the 2018–2019 influenza season. Our results were robust to potential loss to follow up, but misclassification bias and residual confounding led to underestimation of the 2018–2019 aVE. When stratified by the number of primary care visits, aVE estimates and vaccination coverage increased with the number of primary care visits, reaching estimates similar to those obtained by the US CDC and US national vaccination coverage among those with ≥ 6 primary care visits, resulting in significant positive vaccine protection in frequent healthcare users.ConclusionsModerate and low aVEs were observed during the 2018–2019 season using administrative healthcare data, which was likely due to detection and misclassification biases, correlated with healthcare seeking behaviour, leading to an underestimation of the 2018–2019 influenza VE.     

A Cost Analysis of a Community Health Worker Program in Rural Vermont

Studies have shown that community health workers (CHWs) can improve the effectiveness of health care systems; however, little has been reported about CHW program costs. We examined the costs of a program staffed by three CHWs associated with a small, rural hospital in Vermont. We used a standardized data collection tool to compile cost information from administrative data and personal interviews. We analyzed personnel and operational costs from October 2010 to September 2011. The estimated total program cost was $420,348, a figure comprised of $281,063 (67 %) for personnel and $139,285 (33 %) for operations. CHW salaries and office space were the major cost components. Our cost analysis approach may be adapted by others to conduct cost analyses of their CHW program. Our cost estimates can help inform future economic studies of CHW programs and resource allocation decisions.     

Complex care and contradictions of choice in the safety net

This article explores the complicated and often‐contradictory notions of choice at play in complex care management (CCM) programmes in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety‐net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilisers into ‘active’ patients who will reduce their service utilisation and thereby contribute to a more rational, cost‐effective healthcare system. By considering our data alongside philosopher Annemarie Mol's (2008) conceptualisation of the competing logics of choice and care, we argue that these premises often undermine CCM teams' efforts to support patients and provide the care they need – not only to prevent medical crises, but to overcome socio‐economic barriers as well. We assert that while safety‐net CCM programmes are held accountable for the degree to which their patients successfully transform into self‐managing, cost‐effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programmes thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA ).     

Financial cost analysis of a strategy to improve the quality of administrative vaccination data in Uganda

BackgroundHigh-quality vaccination data are critical to planning, implementation and evaluation of immunization programs. However, sub-optimal administrative vaccination data quality in low- and middle-income countries persist for heterogeneous reasons, though most relate to organizational factors and human behavior. The nationwide Data Improvement Team (DIT) strategy in Uganda aimed to strengthen human resource capacity to generate quality administrative vaccination data at the health facility.MethodsA financial cost analysis of the Uganda DIT strategy (2014–2016) was conducted from the program funder perspective. Activity-based micro-costing from funder financial and program monitoring records was used to estimate total and unit costs by program area (in 2016 US dollars). Hypothetical scenarios were developed to illustrate potential approaches to reducing costs.ResultsOver 25 months the DIT strategy was implemented in all 116 operational districts and 3443 (89%) health facilities in Uganda at a total financial cost of US $575 275. Training and deployment of DITs accounted for the highest proportion of expenditure across program areas (69%). Transport, per diems, lodging, and honoraria for DIT members and national supervisors were the main cost drivers of the strategy. Deployment of 557 DIT members cost US $839 per DIT member, US $4 030 per district, and US $136 per health facility. The estimated opportunity cost of government staff time wasn’t a major cost driver (2.5%) of total cost.ConclusionThe results provide the first estimates of the magnitude and drivers of cost to implement a national workforce capacity building strategy to improve administrative vaccination data quality in a low- or middle-income country. Financial costs are a critical input to combine with future outcome data to describe the cost of strategies relative to performance outcomes. The operational costs of the strategy were modest (0.5–1.6%) relative to the estimated operational costs of Uganda’s national immunization program.     

The Development of a Tool to Assess Quality of Cost Estimates

Objective: To develop and implement a quality assessment instrument to evaluate cost estimates in economic evaluation studies. Design and setting: The assessment instrument was devised through a consensus process. The instrument was developed in the process of estimating a national set of provincial standard costs for healthcare services in Canada. Participants: All healthcare providers for a variety of services including public health, inpatient acute care, ambulatory care, physicians, pharmaceuticals, blood and ambulance services, and workers’ lost productivity. Main outcome measures: An assessment form which evaluated estimates for the full cost of resources; the appropriate inclusion of resources and resource prices; the degree of detail in the unit of measurement; basis of evidence; and the sample of providers from which cost estimates were generated. Results: When applied to existing cost estimates, a wide variation in quality was observed between service categories and provinces. Inpatient hospital, physician services, and drugs had high quality estimates; public health, nursing home, and home care had lower quality estimates. Conclusions: This quality assessment instrument can be used to target deficiencies in cost estimates and to identify administrative units which are leaders in the field, and hence which can serve as role models for further development of these data.     

Initiatives and Barriers to Adopting Health Information Technology

In recent years, US healthcare experts have increasingly agreed that the effective application of information technology (IT) can enable the industry to address its three most pressing concerns: an increase in medical errors, rising costs, and the fragmentation of care delivery. While other industries have fully adopted and capitalized on IT to optimize operational efficiencies and customer service delivery, healthcare systems in the US have generally been slow to make a full transition.Presently, one of the quickest and most efficient ways health systems can begin to benefit from IT is through the implementation of the electronic health record (EHR). This dynamic resource provides key healthcare stakeholders (patients, payers, and providers) with a comprehensive view of current and historical patient data compiled from various sources. It holds tremendous potential for better management of chronic diseases, improving outcomes, and streamlining expenses.While the EHR has been shown to generate positive results in its limited use so far, its widespread implementation faces several hurdles, most notably cost. Additionally, primary EHR users (payers and providers) often experience initial infrastructure and personnel burdens, along with potential workflow disruptions. Despite this, considerable support for the EHR as an entry point for full-scale IT adoption is mounting in the US with a number of high-level government initiatives.This article examines the current state of health IT efforts in the US, the barriers to further adoption, and how technology can be, and is being, used to meet major challenges in the US healthcare industry. Although this article exclusively examines the US healthcare system, the author believes that many of the issues and scenarios described herein are universal among healthcare systems worldwide. At the same time, the author acknowledges that, to a great degree, each nation’s healthcare system faces its own unique considerations that may or may not be reflected in or relevant to the information in this article.     

Income and Technology as Drivers of Australian Healthcare Expenditures

The roles of income and technology as the major determinants of aggregate healthcare expenditure (HEXP) continue to interest economists and health policy researchers. Concepts and measures of medical technologies remain complex; however, income (on the demand side) and technology (on the supply side) are important drivers of HEXP. This paper presents analysis of Australia's HEXP, using time‐series econometrics modeling techniques applied to 1971–2011 annual aggregate data. Our work fills two important gaps in the literature. First, we model the determinants of Australia's HEXP using the latest and longest available data series. Second, this novel study investigates several alternative technology proxies (input and output measures), including economy‐wide research and development expenditures, hospital research expenditures, mortality rate, and two technology indexes based on medical devices. We then apply the residual component method and the technology proxy approach to quantify the technology effects on HEXP. Our empirical results suggest that Australian aggregate healthcare is a normal good and a technical necessity with the income elasticity estimates ranging from 0.51 to 0.97, depending on the model. The estimated technology effects on HEXP falling in the 0.30–0.35 range and mimicking those in the literature using the US data, reinforce the global spread of healthcare technology. Copyright © 2016 John Wiley & Sons, Ltd.     

Kosten Intimer Partnergewalt gegen Frauen

About one in four women in Germany have experienced intimate partner violence at some point in their lives. Intimate partner violence against women is associated with a wide range of acute and long-term physical and psychological health problems. Partner violence also incurs huge costs to healthcare services, social care and the legal system with a subsequent loss in economic productivity. This systematic review will present existing studies on cost estimations with a particular focus on the types of costs and methodological problems in the studies which will provide information for the development of future surveys estimating the costs of partner violence. Electronic databases were searched in addition to manual searches. The database search for identification of such studies was only partially successful because administrative reports predominated. A total of nine cost estimates were identified which fulfilled the inclusion criteria and three studies considered direct, indirect and intangible costs. Due to the fragmentary data there is considerable heterogeneity in the cost categories and it can be assumed that the real costs are higher than those found in the studies. For reasons of international comparability, future data collection should be based on standard indicators which still need to be formulated.     

Emergency Department Services Use Among Immigrant and Non-immigrant Groups in the United States

Immigrants have disproportionate lack of access to healthcare and insurance. Emergency departments could serve as a healthcare substitute and increased demand can negatively affect the US emergency services system. Medical Expenditures Panel Survey (2000–2008) data was modeled to compare emergency departments (ED) use between non-citizens, foreign-born (naturalized), and US-born citizens. Group differences were assessed using non-linear decomposition techniques. Non-citizens were less likely to use ED services (8.7 %) compared to naturalized immigrants (10.6 %) and US-born Americans (14.7 %). Differences in ED use persisted after adjusting for the Behavioral Model covariates. Healthcare need and insurance partially explained the differences in ED use between the groups. Between 2000 and 2008 non-citizen immigrants used markedly less ED services compared to US citizens, regardless of their nation of origin. We also found that demographic and healthcare need profiles contributed to the divergence in use patterns between groups. A less restrictive healthcare policy environment can potentially contribute to lower population disease burden and greater efficiencies in the US health care system.     

Measuring operational efficiency in a health care system: a case study from Thailand

This paper investigates the economic relationship among medical resources and efficiency of the health care system in a developing Asian country. The rapid growth in the use of limited resources and the escalating national health expenditure, raise the critical economic question of whether the use of health care resources are efficient. We estimated a four-factor production system, based on 1982-1997 annual operational data comprising five cross-sectional regions per year. The translog production function and three derived demand for factor input equations were jointly estimated using systems regression method. Results show that different types of medical care workers (doctors, nurses, pharmacists) influenced efficiency differently. The marginal products (MPs) of nurses and capital are the highest and they varied across the regions. Third, the estimates of factor substitution possibilities indicate difficult factor adjustments; these estimates differ in magnitudes and significance across regions but they similarly classify all but one (different) input pair as economic substitutes. Fourth, the regional variations in returns to scale estimates in live births tend to converge to that of the Bangkok metropolis. Finally, technical change is physician and pharmacist labor using, but capital and nursing labor saving. Policy implications of these findings touch on Article 78 of the Thailand Constitution.     

Understanding wellness and barriers to care among Iraqi refugee women in the United States

Iraqi refugees in the US experience a high prevalence of non‐communicable diseases. In this article, we explore how cultural and structural realities intersect to influence utilisation of preventative healthcare and cancer screening with the aim of understanding health disparities in this population. We conducted three focus group discussions with a total of 14 Iraqi refugee women living in a northeastern US city in 2016 and analysed the qualitative data using a thematic analysis. Eight themes emerged from our data: (a) ‘prevention is better than cure:' Iraqi refugee women maintain wellness; (b) physical and mental health are interrelated in causing and curing ill‐health; (c) Iraqi refugee women embrace both biomedical and other healing practices; (d) God contributes to healing; (e) cancer is caused by dangerous environments. Three of the eight themes related to barriers to care; (f) multi‐level problems within hospitals and clinics prevent the delivery of care; (g) financial barriers prevent access to care and good health; (h) competing priorities are a barrier to good health. We argue that understanding refugee health requires critical analysis of both culturally informed understandings of health and illness as well as the structural aspects of health disparities that result in limited access to life opportunities, racism and inequality for refugees and their communities.     

Cost‐effectiveness of Occupational Therapy in Older People: Systematic Review of Randomized Controlled Trials

A systematic review of the cost‐effectiveness of occupational therapy for older people was conducted. MEDLINE, CINAHL, Web of Science, PsycINFO, Cochrane Library, OT seeker and unpublished trials registers were searched. Reference lists of all potentially eligible studies were searched with no language restrictions. We included trial‐based full economic evaluations that considered both costs and outcomes in occupational therapy for older people compared with standard care (i.e. other therapy) or no intervention. We reviewed each trial for methodological quality using the Cochrane risk of bias tool and assessed the quality of economic evaluations using a Drummond checklist. In the results of this review, we included five eligible studies (1–5) that were randomized controlled trials with high‐quality economic evaluation. Two studies were full economic evaluations of interventions for fall prevention (1 and 2); two studies were full economic evaluations of preventive occupational therapy interventions (3 and 4; one was a comparison of an occupational therapy group with a social work group); one study was a full economic evaluation of occupational therapy for individuals with dementia (5). Two of the studies (one was preventive occupational therapy [3] and the other was occupational therapy for dementia [5]) found a significant effect and confirmed the cost‐effectiveness of occupational therapy for older people compared with the control group. These studies found that occupational therapy for older people was clinically effective and cost‐effective in comparison with standard care or other therapies. With reference to their clinical implication, these intervention studies (using a client‐centred approach) suggested potentially cost‐effective means to motivate clients to maintain their own health. However, this review has limitations because of the high heterogeneity of the reviewed studies on full economic evaluations of occupational therapy for older people. Future studies on the cost‐effectiveness of occupational therapy in older people are strongly warranted. Copyright © 2015 John Wiley & Sons, Ltd.     

Potential cost-effectiveness of vaccination for rotavirus gastroenteritis in eight Latin American and Caribbean countries.

OBJECTIVES: To estimate the costs, benefits and cost-effectiveness of vaccination for rotavirus gastroenteritis in eight Latin American and Caribbean countries: Argentina, Brazil, Chile, the Dominican Republic, Honduras, Mexico, Panama, and Venezuela. METHODS: An economic model was constructed to estimate the cost-effectiveness of vaccination from the health care system perspective, using national administrative and published epidemiological evidence, country-specific cost estimates, and vaccine efficacy data. The model was applied to the first five years of life for the 2003 birth cohort in each country. The main health outcome was the disability-adjusted life year (DALY), and the main summary measure was the incremental cost per DALY averted. A 3% discount rate was used for all predicted costs and benefits. Sensitivity analyses evaluated the impact of uncertainty regarding key variables on cost-effectiveness estimates. RESULTS: According to the estimates obtained with the economic model, vaccination would prevent more than 65% of the medical visits, deaths, and treatment costs associated with rotavirus gastroenteritis in the eight countries analyzed here. At a cost of US$ 24 per course (for a two-dose vaccine), the incremental cost-effectiveness ratio ranged from 269 US dollars/DALY in Honduras to 10,656 US dollars/DALY in Chile. Cost-effectiveness ratios were sensitive to assumptions about vaccine price, mortality, and vaccine efficacy. CONCLUSIONS: Vaccination would effectively reduce the disease burden and health care costs of rotavirus gastroenteritis in the Latin American and Caribbean countries analyzed here. From the health care system perspective, universal vaccination of infants is predicted to be cost-effective, based on current standards.     

Cost-Effectiveness of Propofol (Diprivan) Versus Inhalational Anesthetics to Maintain General Anesthesia in Noncardiac Surgery in the United States

ObjectivesIt is not known whether using propofol total intravenous anaesthesia (TIVA) to reduce incidence of postoperative nausea and vomiting (PONV) is cost-effective. We assessed the economic impact of propofol TIVA versus inhalational anesthesia in adult patients for ambulatory and inpatient procedures relevant to the US healthcare system.MethodsTwo models simulate individual patient pathways through inpatient and ambulatory surgery with propofol TIVA or inhalational anesthesia with economic inputs from studies on adult surgical US patients. Efficacy inputs were obtained from a meta-analysis of randomized controlled trials. Probabilistic and deterministic sensitivity analyses assessed the robustness of the model estimates.ResultsLower PONV rate, shorter stay in the post-anesthesia care unit, and reduced need for rescue antiemetics offset the higher costs for anesthetics, analgesics, and muscle relaxants with propofol TIVA and reduced cost by 11.41 ± 10.73 USD per patient in the inpatient model and 11.25 ± 9.81 USD in the ambulatory patient model. Sensitivity analyses demonstrated strong robustness of the results.ConclusionsMaintenance of general anesthesia with propofol was cost-saving compared to inhalational anesthesia in both inpatient and ambulatory surgical settings in the United States. These economic results support current guideline recommendations, which endorse propofol TIVA to reduce PONV risk and enhance postoperative recovery.     

American Health Information Management Association. Position Statement. Issue: roles of health information managers and coders in patient-focused care

Patient-focused care is a new model of care delivery organized around the patient instead of the hospital structure. Care is provided by multi-disciplinary teams of healthcare workers on the patient care unit. As many services as possible are brought to the patient, rather than taking the patient to a decentralized department. Successful models have demonstrated increased operational efficiency and greater levels of satisfaction among patients, physicians, and staff members. Administrative tasks done in a variety of departments may be assigned to a member of the care team. Such tasks may include patient registration; insurance verification and financial arrangements; and medical record assembly, analysis, abstracting, and coding. Given the different educational levels and prior training administrative team members may have, careful consideration must be given to assignment of the medical record abstracting and coding functions. The quality of clinical data submitted by all providers in the US is critically important to the future of the nation's healthcare system. Under prospective payment systems, the accuracy of clinical data abstracting and coding has a significant impact on healthcare facilities. But the need for accurate clinical data goes beyond payment systems. As more and more clinical data are being captured and maintained in databases across the country, for uses that may be yet unknown, it is essential that such data be collected consistently and accurately. To assure the quality and validity of health information, only trained, experienced coders should abstract and code the data.(ABSTRACT TRUNCATED AT 250 WORDS)     

Catalog of Age- and Medical Condition—Specific Healthcare Costs in the United States to Inform Future Costs Calculations in Cost-Effectiveness Analysis

ObjectivesThis study aims to develop a catalog of annual age- and medical condition—specific healthcare costs per capita among those who are living at a certain age (survivors) and the costs attributable to death itself for those who die at that age (decedents) in the United States. These estimates can be used to inform future cost calculations in cost-effectiveness analysis (CEA).MethodsWe discussed a theoretical framework to incorporate futures costs in CEA. We used the nationally representative Medical Expenditure Panel Survey data to estimate costs among survivors and death costs. For survivors, we obtained cost estimates nonparametrically using kernel-based regression and locally weighted scatterplot smoothing. We estimated costs attributable to death using inverse probability weights comparing decedents with appropriately weighted survivors at a given age after controlling for more than 270 clinical condition classifications, demographics, and interactions. Cost estimates were expressed in 2019 US dollar and also separately by sex and specific clinical conditions.ResultsAverage healthcare costs per capita among survivors, expectedly, rose over age from $2062 (95% confidence interval [CI] $1553–$2478) during the first year of life to $14 307 (95% CI $13 706–$14 956) at 85 years or older. Average costs of death were $44 569 (95% CI $14 304–$67 369) during the first year of life and declined by –$321 (95% CI –$620 to –$22) per 1 year older.ConclusionsThe US catalog of healthcare costs among survivors and decedents can facilitate calculations of future costs in CEA as recommended by the Second Panel on Cost-Effectiveness in Health and Medicine.     

Analysis of Health Care Costs in Elderly Patients with Multiple Chronic Conditions Using a Finite Mixture of Generalized Linear Models

In this paper we analysed healthcare costs in a sample of elderly patients suffering from multimorbidity. On the one hand, multimorbid individuals consume a disproportionally large share of healthcare resources. On the other hand, the patient specific number and combination of co‐occurring single diseases result in inhomogeneous data leading to biased estimates when using traditional regression techniques. Therefore, we applied a mixture of regressions in order to control for unobserved heterogeneity focussing on the identification of multimorbidity patterns. We used a subsample of N = 1050 patients from a multicentre prospective cohort study of randomly selected multimorbid primary care patients aged 65 to 85 years in Germany (ISRCTN 89818205) who completed a detailed questionnaire on healthcare utilization during the 6‐month period preceding the interview. Disease combinations of 1047 were included. We detected four different groups of patients with regard to total costs. These groups corresponded largely to findings from the epidemiological literature. The effect of the presence of an additional disease on costs differed between groups. Moreover, two diametrically opposed cost trends were detected with respect to the number of co‐occurring diseases. While in one group costs increased with the number of co‐occurring diseases, in a second group cost tended to decrease. Copyright © 2016 John Wiley & Sons, Ltd.     

Importance of health system context for evaluating utilization patterns across systems

Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out‐of‐system health‐care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data‐generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross‐system assessments of health‐care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary‐care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations. Published in 2010 by John Wiley & Sons, Ltd.     

Measuring costs in cost-utility analyses. Variations in the literature

OBJECTIVES: Although cost-utility analysis (CUA) has been recommended by some experts as the preferred technique for economic evaluation, there is controversy regarding what costs should be included and how they should be measured. The purpose of this study was to: a) identify the cost components that have been included in published CUAs; b) catalogue the sources of valuation used; c) examine the methods employed for estimating costs; and d) explore whether methods have changed over time. METHODS: We conducted a comprehensive search of the published literature and systematically collected data on the cost estimation of CUAs. We audited the cost estimates in 228 CUAs. RESULTS: In most studies (99%), analysts included some direct healthcare costs. However, the inclusion of direct non-healthcare and time costs (17%) was generally lacking, as was productivity costs (8%). Only 6% of studies considered future costs in added life-years. In general, we found little evidence of change in methods over time. The most frequently used source for valuation of healthcare services was published estimates (73%). Few studies obtained utilization data from RCTs (10%) or relied on other primary data (23%). About two-thirds of studies conducted sensitivity analyses on cost estimates. CONCLUSIONS: We found wide variations in the estimation of costs in published CUAs. The study underscores the need for more uniformity and transparency in the field, and continued vigilance over cost estimates in CUAs on the part of analysts, reviewers, and journal editors.