Observed costs and health care use of children in a randomized controlled trial of pneumococcal conjugate vaccine

High-Deductible Health Plans: Implications for Substance Use Treatment

OBJECTIVE

To examine whether high-deductible health plans are related to patient complexity, health services use, and medical care costs among substance use treatment patients.

DATA SOURCE/STUDY SETTING

Electronic health record data from Kaiser Permanente Northern California; 2007-2011.

STUDY DESIGN

Retrospective analysis of electronic health record data of substance use treatment patients (N = 31,001). We examined relationship of patient demographics, health comorbidities, and services use and cost to deductible level: none, low ($1-$999), and high (≥$1,000).

METHODS

Demographic, membership, diagnostic, and utilization data were merged with cost data. Utilization and costs were summarized into 6-month intervals. Generalized estimation methods for repeated measures with logistic, Poisson, and linear regression were used.

PRINCIPAL FINDINGS

Substance use patients with deductible plans were younger and had less comorbidity than those without deductibles. Patients with high deductibles had lower emergency room and hospital use 12- to 6-month pretreatment, but rates became similar to other groups in the 6 months immediately prior to treatment; treatment costs were similar.

CONCLUSION

Immediately prior to entering treatment, substance use patients with and without high deductibles have similar patterns of health services utilization. We discuss implications for health policy and treatment, particularly in an era of health reform.

The 5-year direct medical cost of neonatal and childhood stroke in a population-based cohort

BACKGROUND

Despite increasing awareness of the long-term impact of pediatric stroke, there are few estimates of the costs of care. We examined acute and 5-year direct costs of neonatal and childhood stroke in a population-based cohort in Northern California.

METHODS

We obtained electronic cost data for 266 children with neurologist-confirmed strokes, and 786 age-matched stroke-free controls, within the population of all children (<20 years) enrolled in a large managed care plan from 1996 through 2003. Cost data included all inpatient and outpatient health service costs including care at out-of-plan facilities. Costs were assessed for 5 years after stroke, expressed in 2003 US dollars, and stratified by age at stroke onset (neonatal, defined as <29 days of life, vs childhood). Stroke costs were adjusted for costs in stroke-free age-matched controls.

RESULTS

Average adjusted 5-year costs for pediatric stroke are substantial: $51,719 for neonatal stroke and $135,161 for childhood stroke. The average cost of a childhood stroke admission was $81,869. The average birth admission cost for a neonatal stroke was $39,613; adjustment for control birth admission costs reduced this by only $4,792, suggesting the stroke accounted for 88% of costs. Even among neonates whose strokes were not recognized until later in childhood ("presumed perinatal strokes"), admission costs exceeded those of controls. Chronic costs were highest in the first year poststroke, but continued to exceed control costs even in the fifth year by an average of $2,016.

CONCLUSIONS

The economic burden of neonatal and childhood stroke is both large and sustained.

New vaccines against otitis media: projected benefits and cost-effectiveness

OBJECTIVE

New vaccines that offer protection against otitis media caused by nontypeable Haemophilus influenzae and by Moraxella catarrhalis are under development. However, the potential health benefits and economic effects of such candidate vaccines have not been systematically assessed.

METHODS

We created a computerized model to compare the projected benefits and costs of (1) the currently available 7-valent pneumococcal conjugate vaccine, (2) a candidate pneumococcal-nontypeable H influenzae vaccine that has been tested in Europe, (3) a hypothetical pneumococcal-nontypeable H influenzae-Moraxella vaccine, and (4) no vaccination. The clinical probabilities of acute otitis media and of otitis media with effusion were generated from multivariate analyses of data from 2 large health maintenance organizations and from the Pittsburgh Child Development/Otitis Media Study cohort. Other probabilities, costs, and quality-of-life values were derived from published and unpublished sources. The base-case analysis assumed vaccine dose costs of $65 for the 7-valent pneumococcal conjugate vaccine, $100 for the pneumococcal-nontypeable H influenzae vaccine, and $125 for the pneumococcal-nontypeable H influenzae-Moraxella vaccine.

RESULTS

With no vaccination, we projected that 13.7 million episodes of acute otitis media would occur annually in US children aged 0 to 4 years, at an annual cost of $3.8 billion. The 7-valent pneumococcal conjugate vaccine was projected to prevent 878,000 acute otitis media episodes, or 6.4% of those that would occur with no vaccination; the corresponding value for the pneumococcal-nontypeable H influenzae vaccine was 3.7 million (27%) and for the pneumococcal-nontypeable H influenzae-Moraxella vaccine was 4.2 million (31%). Using the base-case vaccine costs, pneumococcal-nontypeable H influenzae vaccine use would result in net savings compared with nontypeable 7-valent pneumococcal conjugate use. Conversely, pneumococcal-nontypeable H influenzae-Moraxella vaccine use would not result in savings compared with pneumococcal-nontypeable H influenzae vaccine use, but would cost $48 000 more per quality-adjusted life-year saved. The results were sensitive to variations in assumptions on vaccine effectiveness and vaccine dose costs but not to variations in other assumptions.

CONCLUSIONS

New candidate vaccines against otitis media have the potential to prevent millions of disease episodes in the United States annually. If priced comparably with other recently introduced vaccines, these new otitis vaccines could achieve cost-effectiveness comparable with or more favorable than that of the 7-valent pneumococcal conjugate vaccine.

Trends in invasive pneumococcal disease-associated hospitalizations

BACKGROUND

The heptavalent pneumococcal conjugate vaccine was licensed in the United States in 2000 for use in infants and children. Postlicensure surveillance revealed substantial regional and national decreases in invasive pneumococcal disease. It is not known whether widespread vaccine use has led to a concomitant decrease in invasive pneumococcal disease-associated hospitalization rates.

OBJECTIVE

We examined national trends in rates of hospitalization among both children and adults with invasive pneumococcal disease.

METHODS

Data from the 1998-2003 National Hospital Discharge Survey and population estimates from the National Center for Health Statistics were used to calculate rates of hospital discharge for patients admitted with invasive pneumococcal disease, defined as meningitis or bacteremia caused by Streptococcus pneumoniae.

RESULTS

Rates of hospital discharge for patients admitted with invasive pneumococcal disease decreased during the study period from a peak of 12.03 discharges per 100,000 population in 1999 to 5.60 discharges per 100,000 population in 2003 (P < .001). Rates of hospital discharge for persons admitted with pneumococcal meningitis decreased from 1.60 discharges per 100,000 person-years in the prelicensure period to 0.53 discharges per 100,000 person-years in the postlicensure period. For persons > or = 65 years of age but not for those < 4 years of age, the rates of hospital discharge for those admitted with pneumococcal bacteremia were significantly lower during the postlicensure period, compared with the prelicensure period.

CONCLUSIONS

Hospital discharge rates for persons admitted with invasive pneumococcal disease, including meningitis, have decreased since introduction of the heptavalent pneumococcal conjugate vaccine. The decrease was driven in part by the reduction of invasive pneumococcal disease-associated hospitalizations in the subgroup aged > or = 65 years.

Cost-effectiveness of universal pneumococcal vaccination for infants in Italy

This study aimed at estimating the health and economic outcomes of universal infant vaccination with seven-valent pneumococcal conjugate vaccine (PCV-7) in Italy. A Markov model simulated lifetime evolution of a birth cohort (538,138 children): universal vaccination would avert 769 invasive infections, 18 deaths and 1323 life years. At base-case analysis, universal three-dose vaccination would cost euro 26,449 (95% CI: 1975-62,075) and euro 38,286 (95% CI: 22,164-70,801) per life year-saved in the societal and the NHS perspective, respectively. In the hypothesis of a 5-year long protection period, vaccination would cost euro 32,694 and euro 43,115 per life-year saved. Considering yearly incidence of invasive pneumococcal disease reported for Veneto and Sardinia regions, PCV-7 vaccination would result highly cost-effective determining a cost of euro 10,479 and euro 16,890 per life year-save in the NHS and the societal perspective, respectively.

Community-acquired pneumonia in children: quantifying the burden on patients and their families including decrease in quality of life

OBJECTIVES

Childhood respiratory infections have an important impact on society and are a frequent cause of physician visits, consumption of antibiotics and over-the-counter drugs, work loss, and reduction of quality of life. The aim of this study was to assess the burden of community-acquired pneumonia (CAP) on children and their families, including quantification of expenses and decrease in quality of life.

METHODS

Patients <3 years old with pneumonia were enrolled in 3 sites in southern Israel: pediatric wards, the pediatric emergency department, and a primary health clinic. In the primary health clinic, the diagnosis was based on clinical judgment, and in the hospital the diagnosis was based on the World Health Organization Standardization of Interpretation of Chest Radiographs for the diagnosis of CAP in children. Data regarding the children's medical history and various aspects of direct and indirect burden were gathered every 2 to 3 days during the 29 days of follow-up. The patients' parents were asked to give the names of 2 healthy children who could serve as controls from among the child's friends, neighbors, or day care center attendees.

RESULTS

Two-hundred thirteen children with pneumonia were enrolled: 34 (16.0%) in the pediatric wards, 73 (34.2%) in the pediatric emergency department, and 106 (49.8%) in the primary pediatric clinic. The control group consisted of 99 children. During the 29 follow-up days, hospitalized children had the most severe and prolonged symptoms, followed in decreasing order by children seen at the emergency department, primary health clinic, and controls: The mean +/- standard deviation (SD) of febrile days was 4.9 +/- 2.8, 4.8 +/- 3.1, 3.3 +/- 2.5, and 1.4 +/- 3.3, respectively (statistically significant between any patient group and the control group). The mean duration of respiratory distress +/- SD was 3.8 +/- 5.6, 2.8 +/- 4.4, 2.2 +/- 4.4, and 0.4 +/- 1.8 days, respectively (statistically significant between any patient group and the control group). The median duration of nonroutine days as judged by the parents was 13, 8, 7, and 0, respectively. The mean number of workdays lost by working mothers +/- SD was 4.2 +/- 4.8, 2.0 +/- 2.6, 1.7 +/- 1.9, and 0.2 +/- 0.9, respectively (between any patient group and the control group). The quality-of-life-questionnaire analysis reveals statistically significant differences with regard to all 11 questions asked between any of the patient groups and the control group. There was a clear trend toward decreasing quality of life from the control group to the primary health clinic, pediatric emergency department, and pediatric wards groups.

CONCLUSIONS

CAP in children causes a significant burden on both patients and their families, including substantial expenses, loss of routine, and decrease in quality of life.

Australian public health policy in 2003 - 2004

In Australia, compared with other developed countries the many and varied programs which comprise public health have continued to be funded poorly and unsystematically, particularly given the amount of publicly voiced political support.In 2003, the major public health policy developments in communicable disease control were in the fields of SARS, and vaccine funding, whilst the TGA was focused on the Pan Pharmaceutical crisis. Programs directed to health maintenance and healthy ageing were approved. The tertiary education sector was involved in the development of programs for training the public health workforce and new professional qualifications and competencies. The Abelson Report received support from overseas experts, providing a potential platform for calls to improve national funding for future Australian preventive programs; however, inconsistencies continued across all jurisdictions in their approaches to tackling national health priorities. Despite 2004 being an election year, public health policy was not visible, with the bulk of the public health funding available in the 2004/05 federal budget allocated to managing such emerging risks as avian flu. We conclude by suggesting several implications for the future.

Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and pneumonia with consolidation on x-ray in children under two years of age

BACKGROUND

Pneumonia, most commonly caused by Streptococcus pneumoniae (Pnc), is a major cause of morbidity and mortality among young children especially in developing countries. Recently, the prevalence of antibiotic-resistant Pnc has increased worldwide such that the effectiveness of preventive strategies, like the new pneumococcal conjugate vaccines (PCV) on rates of invasive pneumococcal disease (IPD) and pneumonia, needs to be evaluated.

OBJECTIVES

To determine the efficacy of PCV in reducing the incidence of IPD due to vaccine serotypes (VT) and x-ray confirmed pneumonia with consolidation of unspecified etiology in children who received PCV before 12 months of age.

SEARCH STRATEGY

We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2004), MEDLINE (1990 to March 2004) and EMBASE (1990 to December 2003). Reference list of articles, and books of abstracts of relevant symposia, were hand searched. Researchers in the field were also contacted.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing PCV with placebo, or another vaccine, among children below two years with IPD and clinical/radiographic pneumonia as outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently identified eligible studies, assessed trial quality, and extracted data. Differences were resolved by discussion. The inverse variance method was used to pool effect sizes.

MAIN RESULTS

We identified four trials assessing the efficacy of PCV in reducing the incidence of IPD, two on x-ray confirmed pneumonia as outcome, and one on clinical pneumonia, with or without x-ray confirmation. Results from pooling HIV-1 negative children from the South African study with the other studies were as follows: the pooled vaccine efficacy (VE) for vaccine-type IPD was 88% (95% confidence interval (CI) 73% to 94%; fixed effect and random effects models), the effect measure was statistically significant (p <0.00001) and there was no heterogeneity (p = 0.77I2 0%); the pooled VE for all-serotype IPD was 66% (95% CI 46% to 79%; fixed effect model), the effect measure was statistically significant (p <0.00001) and there was no statistical heterogeneity (p = 0.09, I2 51%); the pooled VE for x-ray confirmed pneumonia was 22% (95% CI 11% to 31%; both fixed effect and random effects models) and there was no statistical heterogeneity (p = 0.80, I2 0%). Analyses that included all the children in the South African study (HIV-1 negative and HIV-1 positive children) and pooled with data from the other studies gave very similar results.

REVIEWERS' CONCLUSIONS

PCV is effective in reducing the incidence of IPD from all serotypes but exerts a greater effect in reducing VT IPD. Although PCV is also effective in reducing the incidence of x-ray confirmed pneumonia, there are still uncertainties about the definition of this outcome. Additional randomised controlled trials are currently in progress.

What can children gain from pneumococcal conjugate vaccines?

In excess of 1 million young children die every year as a consequence of disease caused by Streptococcus pneumoniae, the vast majority in developing countries. Although the first vaccine against the Pneumococcus was produced before the First World War, licensure of the first vaccine with documented efficacy against severe infections in infants and young children did not occur until February 2000 in the United States. This conjugate vaccine consists of purified polysaccharide, from each of seven pneumococcal serotypes, chemically linked to a carrier protein. A high degree of efficacy of the new vaccine against potentially life-threatening infections has been shown in both poor and affluent countries. The vaccine's potential to protect from acute otitis media, however, is very limited, although encouraging indirect effects, such as reduced antibiotic prescriptions, have been reported. An inherent problem with the new pneumococcal conjugate vaccines is that, while more than 20 pneumococcal serotypes may cause invasive disease, only a more limited number of polysaccharides, 11 or so, can in practice be conjugated to carrier protein as part of a single vaccine formulation. Because of variation in the ranking of serotypes most commonly responsible for pneumococcal disease, by region, age and disease manifestation, compromise was required in selecting serotype-specific saccharides for inclusion.

CONCLUSION

Complex conjugate technology comes at a price, and the present costs keep most of the world's children far out of reach of an effective vaccine. However, the pneumococcal conjugate vaccine is a highly functional weapon against deadly pneumococcal infections, and strenuous efforts are needed to maximise its accessibility to children most at risk.

Economic aspects of pneumococcal pneumonia: a review of the literature

In this review, the economic aspects of pneumococcal pneumonia are analysed, including the costs, cost effectiveness and cost benefit of treatment and prevention. We identified eight cost-of-illness studies, 15 analyses comparing the costs of different treatment options and 15 economic evaluations of prevention that met our search criteria. The studies were conducted largely in Europe and the US. Most pertained to community-acquired pneumonia (CAP) in general, without specific analysis of pneumococcus-related illness. Many of the studies were considered to be of poor quality for the following reasons: comparison without randomisation or control variables, disregard of health outcomes, small sample size, restriction of costs to drug costs and vague or disputable sources of cost information. In the US, hospitalisation costs resulting from CAP can be estimated to be between US 7,000 dollars and US 8,000 dollars per admission or US 4 million dollars per 100,000 population. Hospitalisation costs are significant (representing about 90% of total costs), but are much lower in Europe than in the US (one-third to one-ninth of the US estimates in the UK and Spain, respectively). In general, economic studies of treatment for pneumococcal pneumonia are in line with clinical evidence. A drug with proven clinical effectiveness would also appear to be supported from an economic stand point. Furthermore, economic data support an early switch from an intravenous to an oral antibacterial, the use of quinolones for inpatients with CAP, and also the use of guidelines built on clinical evidence. Of all the possible preventive strategies for pneumococcal pneumonia, only vaccination has been subjected to economic evaluation. Pneumococcal polysaccharide vaccine seems relatively cost effective (and potentially cost saving) for those between 65 and 75 years of age, for military recruits and for HIV positive patients with a sufficiently high CD4 cell count. Evaluations of the pneumococcal conjugate vaccine (PCV) indicate the price of the vaccine to be the main determinant of cost effectiveness. As the current price is high (in the order of US 50 dollars per dose), the economic attractiveness of the universal PCV vaccination strategies hinges on the potential for price reductions and the willingness of decision makers to adopt a societal perspective.

The cost-burden of paediatric pneumococcal disease in the UK and the potential cost-effectiveness of prevention using 7-valent pneumococcal conjugate vaccine

We modelled the epidemiology and cost of pneumococcal disease in children in the UK and the cost-effectiveness of immunisation with 7-valent pneumococcal conjugate vaccine (PCV). We estimated the incidence of pneumococcal meningitis, pneumococcal septicaemia, all-cause pneumonia and all-cause otitis media (OM). We further estimated the impact of vaccination with associated costs and outcomes. Vaccine cost was pound 39.25 per dose with a pound 10 administration cost; vaccination schedule and efficacy were taken from a recent trial. We estimated that in each UK annual birth cohort there are 881,146 episodes of these infections and 149 deaths associated with pneumococcal meningitis, pneumococcal septicaemia or all-cause pneumonia and that PCV would prevent 54,384 episodes and 29 deaths. NHS cost per life year gained was estimated at pound 31,512, close to the limit at which PCV would be considered cost-effective.

Paediatric community-acquired pneumonia: current concept in pharmacological control

Community-acquired pneumonia (CAP) is one of the most frequent infections in childhood but it is not easy to establish a rational therapeutic approach for a number of reasons, including difficulties in identifying the aetiology, the fact that the most frequent bacterial pathogens become resistant to commonly used antibiotics and the lack of certain information concerning the possible preventive role of conjugate vaccines. This leads paediatricians to treat almost all cases of CAP with antibiotics, often using a combination of different antimicrobial classes. In order to avoid unnecessary antibiotic use and limit the spread of antibiotic resistance, consensus guidelines for the management of CAP in childhood should be developed and used by practitioners in their offices and hospitals.