[Study of flu costs]

Excess hospitalizations and mortality associated with seasonal influenza in Spain, 2008-2018

BACKGROUND

Influenza may trigger complications, particularly in at-risk groups, potentially leading to hospitalization or death. However, due to lack of routine testing, influenza cases are infrequently coded with influenza-specific diagnosis. Statistical models using influenza activity as an explanatory variable can be used to estimate annual hospitalizations and deaths associated with influenza. Our study aimed to estimate the clinical and economic burden of severe influenza in Spain, considering such models.

METHODS

The study comprised ten epidemic seasons (2008/2009-2017/2018) and used two approaches: (i) a direct method of estimating the seasonal influenza hospitalization, based on the number of National Health Service hospitalizations with influenza-specific International Classification of Diseases (ICD) codes (ICD-9: 487-488; ICD-10: J09-J11), as primary or secondary diagnosis; (ii) an indirect method of estimating excess hospitalizations and deaths using broader groups of ICD codes in time-series models, computed for six age groups and four groups of diagnoses: pneumonia or influenza (ICD-9: 480-488, 517.1; ICD-10: J09-J18), respiratory (ICD-9: 460-519; ICD-10: J00-J99), respiratory or cardiovascular (C&R, ICD-9: 390-459, 460-519; ICD-10: I00-I99, J00-J99), and all-cause. Means, excluding the H1N1pdm09 pandemic (2009/2010), are reported in this study.

RESULTS

The mean number of hospitalizations with a diagnosis of influenza per season was 13,063, corresponding to 28.1 cases per 100,000 people. The mean direct annual cost of these hospitalizations was €45.7 million, of which 65.7% was generated by patients with comorbidities. Mean annual influenza-associated C&R hospitalizations were estimated at 34,894 (min: 16,546; max: 52,861), corresponding to 75.0 cases per 100,000 (95% confidence interval [CI]: 63.3-86.3) for all ages and 335.3 (95% CI: 293.2-377.5) in patients aged ≥ 65 years. We estimate 3.8 influenza-associated excess C&R hospitalizations for each hospitalization coded with an influenza-specific diagnosis in patients aged ≥ 65 years. The mean direct annual cost of the estimated excess C&R hospitalizations was €142.9 million for all ages and €115.9 million for patients aged ≥ 65 years. Mean annual influenza-associated all-cause mortality per 100,000 people was estimated at 27.7 for all ages.

CONCLUSIONS

Results suggest a relevant under-detected burden of influenza mostly in the elderly population, but not neglectable in younger people.

Cost-effectiveness of cladribine tablets and dimethyl fumarate in the treatment of relapsing remitting multiple sclerosis in Spain

Aim: To analyze the cost-effectiveness of treatment of relapsing remitting multiple sclerosis (RRMS) with cladribine tablets (CladT) and dimethyl fumarate (DMF) from the perspective of the Spanish National Health System (NHS). Methods: A probabilistic Markov model (second-order Monte Carlo simulation) with a 10-year time horizon and annual Markov cycles was performed. Results: CladT was the dominant treatment, with lower costs (-74,741 € [95% CI: -67,247; -85,661 €]) and greater effectiveness (0.1920 [95% CI: -0.1659; 0.2173] QALY) per patient, compared with DMF. CladT had a 95.1% probability of being cost-effective and a 94.1% chance of being dominant compared with DMF. Conclusion: CladT is the dominant treatment (lower costs, with more QALYs) compared with DMF in the treatment of RRMS in Spain.

Clinical and economic burden of physician-diagnosed influenza in adults during the 2017/2018 epidemic season in Spain

BACKGROUND

Influenza is an acutely debilitating respiratory infection, contributing significantly to outpatient visits and hospitalizations. Spain lacks comprehensive and updated data on the burden of influenza, particularly in the outpatient setting. Our study aimed to fill this gap by estimating the clinical and economic burden of physician-diagnosed influenza cases in adults from four Spanish regions, stratified by age groups and presence of comorbidities.

METHODS

A retrospective cost-of-illness study was conducted using data from an electronic medical records database from the National Healthcare Service (NHS) of four Spanish regions for individuals aged ≥ 18 years diagnosed for influenza during the 2017/2018 epidemic season. Health resource utilization and related cost data were collected, including primary care visits, referrals to other specialists, visits to the emergency department, hospitalizations, and prescribed medicines.

RESULTS

The study reported a total of 28,381 patients aged ≥ 18 years diagnosed with influenza, corresponding to 1,804 cases per 100,000 population. Most patients were aged < 65 years: 60.5% (n = 17,166) aged 18-49 and 26.3% (n = 7,451) 50-64 years. A total of 39.2% (n = 11,132) of patients presented a comorbidity. Cardiovascular diseases were the most common comorbidity reported along with influenza. The mean healthcare cost per case was estimated at €235.1 in population aged 18-49 years, increasing by 1.7 and 4.9 times in those aged 50-64 (€402.0) and ≥ 65 (€1,149.0), respectively. The mean healthcare cost per case was 3.2 times higher in patients with comorbidities. The total healthcare cost of medically attended influenza cases was mainly driven by primary care (45.1%) and hospitalization (42.0%). Patients aged 18-64 years old accounted for 61.9% of the costs of medically attended influenza. Irrespective of age, patients with comorbidities accounted for 67.1% of costs.

CONCLUSIONS

Season 2017/2018 was associated with a considerable burden of influenza in Spain, which increased with age and presence of comorbidities. Individuals with comorbidities accounted for most of the costs of influenza. Results suggest that population aged 18-64 years old is generating the highest share of costs to the NHS when all healthcare costs are considered. Preventive strategies targeting subjects with comorbidities, regardless of age, should be warranted.

Direct Medical Costs of Four Vaccine-Preventable Infectious Diseases in Older Adults in Spain

OBJECTIVE

Protection against vaccine-preventable diseases is especially relevant in older adults due to age-related decline in immunity (immunosenescence). However, adult vaccination remains a challenge with overall low coverage rates, which has an impact on both the patients who have these diseases and the health care system in terms of resource use and costs derived. This study aimed to estimate the direct economic impact of herpes zoster, pneumococcal disease, influenza and pertussis in Spanish adults 45 years and older.

METHODS

Data from 2015 were extracted from two Spanish public databases: the Minimum Basic Data Set for Hospitalisations and the Clinical Database of Primary Care. Codes from the International Classification of Diseases and the International Classification of Primary Care were used to identify and classify the diseases analysed. The variables extracted and calculated were hospitalisation (cases, percentage, length of stay, costs, mortality), primary care (cases, percentage, costs) and referrals (cases, percentage, costs). Results were presented for the age groups 45-64 years, 65-74 years, > 74 years and all ages.

RESULTS

In adults 45 years and older, total costs amounted to €134.1 million in 2015 (i.e. 63.9% of the total direct costs for all age groups): 44.4% due to pneumococcal disease, 39.5% due to influenza, 16.0% due to herpes zoster and 0.1% due to pertussis. Hospitalisations represented 58.1% (€77.9 million) of the total costs, with 15,910 admissions, 144,752 days of hospitalisation and 1170 deaths. Primary care registered 566,556 visits with a cost of €35.0 million, and 269,186 referrals with a cost of €21.1 million.

CONCLUSION

The direct economic burden of herpes zoster, pneumococcal disease, influenza and pertussis in adults 45 years and older was high in Spain, and may be underestimated as it only considered medical assistance and not other applicable direct or indirect costs. Increasing vaccination rates in adults may potentially reduce the economic burden derived from these diseases, although future cost-effectiveness analysis including other disease-related costs, vaccination costs and vaccination effectiveness would be needed.

Cost of illness of invasive meningococcal disease caused by serogroup B Neisseria meningitidis in Spain

INTRODUCTION

Invasive meningococcal disease (IMD) is a severe infectious disease, mainly affecting children under 5 years, associated with long-term physical, neurological and psychological sequelae. In Spain, most IMD cases are caused by meningococcal serogroup B (MenB). This study estimates its economic burden from a societal perspective in Spain.

METHODS

A previously published bottom-up, model-based incidence costing approach by Scholz et al. (2019) to estimate the economic burden of MenB in Germany was adapted to the Spanish setting. Diagnosis and age-related costs for a hypothetical Spanish cohort were calculated over a lifetime horizon. Official Spanish databases, literature and expert opinion were used as data sources. The costs were updated to 2019 prices, and a 3% discount rate was applied. Direct costs related to the acute IMD phase, long-term sequelae, rehabilitation and public health response were considered. Indirect costs included productivity losses and premature mortality and were calculated using the human-capital approach (HCA) and friction-cost approach (FCA). Deterministic and probabilistic sensitivity analyses were also performed.

RESULT

At base-case, the total cost for a cohort of 142 patients (2017-2018 period) was €4.74 million (€33,484/case) using the FCA and €13.14 million (€92,768/case) using the HCA. Direct costs amounted to €4.65 million (€32,765/case). Sequelae costs represented 62.46% of the total cost using the FCA and 77.63% using the HCA. Deterministic sensitivity analysis showed that variation of ± 20% in the input parameter values (population, epidemiology, productivity, costs) had the greatest influence on the base-case results, and the probabilistic sensitivity analysis showed the probability of fitting base-case estimates was > 99%, both for FCA and HCA.

DISCUSSION

MenB IMD is an uncommon but severe disease, with a high economic burden for Spanish society. The elevated costs per IMD case reflect its severity in each patient suffering this disease, especially due to the development of sequelae.

Real-time surveillance systems: Applicability for the control of influenza in acute care

Background

The high morbidity and mortality caused by influenza viruses translate into a great impact on specialized health care. Apart from the annual vaccination, the relevance of other measures to prevent and control this infection is unknown. The objective of our research was to determine the importance of a real‐time surveillance system to establish early extended transmission precautions.

Methods

Quasi‐experimental before‐and‐after study comparing the influenza cases detected in hospitalized adults during the 2016/2017 season (264 patients) with those detected after the implementation of a real‐time surveillance system in the 2017/2018 season (519 patients). The improvements included early microbiological diagnosis, immediate communication of results, constant updating of patient information, coordination among professionals, periodic surveillance of the adequacy of preventive measures, and greater control of roommates. The effectiveness of the intervention was determined from the nosocomial infection rate in each season.

Results

After the real‐time surveillance system for influenza was implemented, patients with early microbiological diagnosis and immediate isolation increased significantly (13.7% vs 68.2%; P < .001). In addition, nosocomial infections decreased from 17% to 9.2% (P = .001) and overall hospital stay was significantly reduced. Assuming that the entire effect was due to the intervention, the absolute risk reduction was 7.8% and number needed to treat was 12.8.

Conclusion

The results in our study reveal the impact of nosocomial transmission of influenza virus in a tertiary hospital and highlight the need to supplement traditional strategies with novel methodologies such as modern surveillance systems based on early diagnosis, close case monitoring, and coordination among professionals.

[Economic and Health impact of influenza vaccination with adjuvant MF59 in population over 64 years in Spain]

OBJECTIVE

Influenza is an important health problem due to the mortality it can cause directly or indirectly as well as the complications and the economic and social costs it produces. Influenza epidemics are being addressed through vaccination campaigns aimed at preventing cases and complications, and the vaccine is officially recommended, as in the case of Spain, for certain risk groups, such as older people, chronic diseases and institutionalized population. The adjuvanted influenza vaccine with MF59, indicated for population over 65 years, has been shown to be more immunogenic than conventional influenza vaccines. The objective of this study is to assess the impact on the national and regional budget of the seasonal vaccination campaigns carried out in Spain using the MF59 adjuvanted vaccine compared to a conventional vaccine in a population older than 65 years.

METHODS

We analyzed the budgetary impact of the use of the MF59-adjuvanted vaccine in the national territory and by Autonomous Communities through a modeling of two alternatives, conventional vaccination versus adjuvant vaccination with MF59 in a population older than 65 years. The cases of avoided influenza, avoided complications and avoided costs, as well as the economic impact of the vaccination program have been calculated.

RESULTS

With the available information, the budgetary impact of using the influenza vaccine with MF59 in all the over 65 years, amounts to 6,967,288.10 €, avoiding for the national set a cost of 89.5 million Euros, which represents a potential savings of 82 million Euros and a cost-benefit ratio of 12.83.

CONCLUSIONS

The use of the influenza vaccine with the MF59 adjuvant to all those over 65 years would mean an increase in the efficiency of the vaccination programs currently proposed in all the Autonomous Communities and in the Spanish state.

Influenza cost and cost-effectiveness studies globally--a review

Every year, approximately 10-20% of the world's population is infected with influenza viruses, resulting in a significant number of outpatient and hospital visits and substantial economic burden both on health care systems and society. With recently updated WHO recommendations on influenza vaccination and broadening vaccine production, policy makers in middle- and low-income countries will need data on the cost of influenza disease and the cost effectiveness of vaccination. We reviewed the published literature to summarize estimates of cost and cost-effectiveness of influenza vaccination. We searched PUBMED (MEDLINE), EMBASE, WEB of KNOWLEDGE, and IGOOGLE using the key words 'influenza', 'economic cost', 'cost effectiveness', and 'economic burden'. We identified 140 studies which estimated either cost associated with seasonal influenza or cost effectiveness/cost-benefit of influenza vaccination. 118 of these studies were conducted in World Bank-defined high income, 22 in upper-middle income, and no studies in low and lower-middle income countries. The per capita cost of a case of influenza illness ranged from $30 to $64. 22 studies reported that influenza vaccination was cost-saving; reported cost-effectiveness ratios were $10,000/outcome in 13 studies, $10,000 to $50,000 in 13 studies, and ≥$50,000 in 3 studies. There were no studies from low income countries and few studies among pregnant women. Substantial differences in methodology limited the generalization of results. Decision makers in lower income countries lack economic data to support influenza vaccine policy decisions, especially of pregnant women. Standardized cost-effectiveness studies of influenza vaccination of WHO-recommended risk groups' methods are urgently needed.

Health services utilization, work absenteeism and costs of pandemic influenza A (H1N1) 2009 in Spain: a multicenter-longitudinal study

BACKGROUND

The aim of this study was to estimate healthcare resource utilization, work absenteeism and cost per patient with pandemic influenza (H1N1)2009, from its beginning to March 2010, in Spain. We also estimated the economic impact on healthcare services.

METHODS AND FINDINGS

Longitudinal, descriptive, multicenter study of in- and outpatients with confirmed diagnosis of influenza A (H1N1) in Spain. Temporal distribution of cases was comparable to that in Spain. Information of healthcare and social resources used from one week before admission (inpatient) or index-medical visit (outpatient) until recovery was gathered. Unit cost was imputed to utilization frequency for the monetary valuation of use. Mean cost per patient was calculated. A sensitivity analysis was conducted, and variables correlated with cost per patient were identified. Economic impact on the healthcare system was estimated using healthcare costs per patient and both, the reported number of confirmed and clinical cases in Spain. 172 inpatients and 224 outpatients were included. Less than 10% were over 65 years old and more than 50% had previous comorbidities. 12.8% of inpatients were admitted to the Intensive Care Unit. Mean length of hospital stay of patients not requiring critical care was 5 days (SD = 4.4). All working-inpatients and 91.7% working-outpatients went on sick leave. On average, work absenteeism was 30.5 days (SD = 20.7) for the first ones and 9 days (SD = 6.3) for the latest. Caregivers of 21.7% of inpatients and 8.5% of outpatients also had work absenteeism during 10.7 and 4.1 days on average respectively. Mean cost was €6,236/inpatient (CI95% = 1,384-14,623) and €940/outpatient (CI95% = 66-3,064). The healthcare economic burden of patients with confirmed influenza was €144,773,577 (IC95% 13,753,043-383,467,535). More than 86% of expenditures were a result of outpatients' utilization.

CONCLUSION

Cost per H1N1-patient did not defer much from seasonal influenza estimates. Hospitalizations and work absenteeism represented the highest cost per patient.

[Flu vaccination in the elderly]

Seasonal flu is a very serious public health problem in the elderly due to its morbidity and mortality and financial and social costs arising from this. The aim of this review is to describe the magnitude and importance of seasonal flu in this population group, and its prevention by means of vaccination. For this reason, an updated account of the composition of the vaccine, its dosage and administration route, vaccine safety and the evaluation of the immunogenicity and effectiveness of vaccination. There is variation between different countries and official organisations on the age at which flu vaccination must be established in the elderly. New flu vaccination strategies need to be introduced, to further improve flu vaccination cover in Spain.