Estimating Transition Probabilities for Modeling Major Depression in Adolescents by Sex and Race or Ethnicity Combinations in the USA

OBJECTIVE

About one-fifth of US adolescents experienced major depressive symptoms, but few studies have examined longitudinal trends of adolescents developing depression or recovering by demographic factors. We estimated new transition probability inputs, and then used them in a simulation model to project the epidemiologic burden and trajectory of depression of diverse adolescents by sex and race or ethnicity combinations.

METHODS

Transition probabilities were first derived using parametric survival analysis of data from the National Longitudinal Study of Adolescent to Adult Health and then calibrated to cross-sectional data from the National Survey on Drug Use and Health. We developed a cohort state-transition model to simulate age-specific depression outcomes of US adolescents. A hypothetical adolescent cohort was modeled from 12-22 years with annual transitions. Model outcomes included proportions of youth experiencing depression, recovery, or depression-free cases and were reported for a US adolescent population by sex, race or ethnicity, and sex and race or ethnicity combinations.

RESULTS

At 22 years of age, approximately 16% of adolescents had depression, 12% were in recovery, and 72% had never developed depression. Depression prevalence peaked around 16-17 years-old. Adolescents of multiracial or other race or ethnicity, White, American Indian or Alaska Native, and Hispanic, Latino, or Spanish descent were more likely to experience depression than other racial or ethnic groups. Depression trajectories generated by the model matched well with historical observational studies by sex and race or ethnicity, except for individuals from American Indian or Alaska Native and multiracial or other race or ethnicity backgrounds.

CONCLUSIONS

This study validated new transition probabilities for future use in decision models evaluating adolescent depression policies or interventions. Different sets of transition parameters by demographic factors (sex and race or ethnicity combinations) were generated to support future health equity research, including distributional cost-effectiveness analysis. Further data disaggregated with respect to race, ethnicity, religion, income, geography, gender identity, sexual orientation, and disability would be helpful to project accurate estimates for historically minoritized communities.

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations: A Report of the SHEER Task Force

BACKGROUND

Omission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed.

AIM

To promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice.

METHODS

A modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds.

RESULTS

This report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed.

CONCLUSIONS

Consideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation.

Preferences and experiences of pediatricians on implementing national guidelines on universal routine screening of adolescents for major depressive disorder: A qualitative study

BACKGROUND

To explore the preferences of pediatricians for key factors around the implementation of universal routine screening guidelines for major depressive disorder in adolescent patients in a primary care setting.

METHOD

Semi-structured qualitative interviews were conducted with U.S. pediatricians. Participants were recruited by convenience sampling and snowball sampling. Qualitive data were summarized using thematic analysis to identify themes relevant to preferences around implementing screening strategies for adolescent patients. Recruitment ended upon reaching thematic saturation when no new themes were revealed.

RESULTS

Of the 14 participants, 11 identified as female, 3 male, 10 white, and 4 Asian. Top themes among pediatrician participants were around the screening modality (14/14 participants), screening validity (14/14), time barriers (14/14), and confidentiality barriers (12/14). Less frequently mentioned themes by pediatricians were workplace coordination and logistics (7/14), alternative starting ages for screening (7/14), more frequent screenings than annual screenings (3/14), and additional clinical training regarding depression diagnosis and treatment (2/14).

LIMITATIONS

Pool of interviewed participants was limited by diversity in terms of geography, race/ethnicity, or practice settings.

CONCLUSIONS

To promote the uptake of universal routine screening of adolescent major depression, pediatricians expressed it was important to address key implementation factors regarding the screening modality, screening validity, time constraints, and confidential care concerns in a primary care delivery context. Findings could be used to inform the development of implementation strategies to facilitate depression screening in primary care. Future research is needed to quantitively assess decisions and tradeoffs that pediatricians make when implementing universal screening to support adolescent mental health.

Economic Evaluation Design within the HEAL Prevention Cooperative

The rapid rise in opioid misuse, disorder, and opioid-involved deaths among older adolescents and young adults is an urgent public health problem. Prevention is a vital part of the nation's response to the opioid crisis, yet preventive interventions for those at risk for opioid misuse and opioid use disorder are scarce. In 2019, the National Institutes of Health (NIH) launched the Preventing Opioid Use Disorder in Older Adolescents and Young Adults cooperative as part of its broader Helping to End Addiction Long-term (HEAL) Initiative ( https://heal.nih.gov/ ). The HEAL Prevention Cooperative (HPC) includes ten research projects funded with the goal of developing effective prevention interventions across various settings (e.g., community, health care, juvenile justice, school) for older adolescent and young adults at risk for opioid misuse and opioid use disorder (OUD). An important component of the HPC is the inclusion of an economic evaluation by nine of these research projects that will provide information on the costs, cost-effectiveness, and sustainability of these interventions. The HPC economic evaluation is integrated into each research project's overall design with start-up costs and ongoing delivery costs collected prospectively using an activity-based costing approach. The primary objectives of the economic evaluation are to estimate the intervention implementation costs to providers, estimate the cost-effectiveness of each intervention for reducing opioid misuse initiation and escalation among youth, and use simulation modeling to estimate the budget impact of broader implementation of the interventions within the various settings over multiple years. The HPC offers an extraordinary opportunity to generate economic evidence for substance use prevention programming, providing policy makers and providers with critical information on the investments needed to start-up prevention interventions, as well as the cost-effectiveness of these interventions relative to alternatives. These data will help demonstrate the valuable role that prevention can play in combating the opioid crisis.

Evidence and Recommendation for Guanidinoacetate Methyltransferase Deficiency Newborn Screening

Guanidinoacetate methyltransferase (GAMT) deficiency is an autosomal recessive disorder of creatine biosynthesis due to pathogenic variants in the GAMT gene that lead to cerebral creatine deficiency and neurotoxic levels of guanidinoacetate. Untreated, GAMT deficiency is associated with hypotonia, significant intellectual disability, limited speech development, recurrent seizures, behavior problems, and involuntary movements. The birth prevalence of GAMT deficiency is likely between 0.5 and 2 per million live births. On the basis of small case series and sibling data, presymptomatic treatment with oral supplements of creatine, ornithine, and sodium benzoate, and a protein-restricted diet to reduce arginine intake, appear to substantially improve health and developmental outcomes. Without newborn screening, diagnosis typically happens after the development of significant impairment, when treatment has limited utility. GAMT deficiency newborn screening can be incorporated into the tandem-mass spectrometry screening that is already routinely used for newborn screening, with about 1 per 100 000 newborns screening positive. After a positive screen, diagnosis is established by finding an elevated guanidinoacetate concentration and low creatine concentration in the blood. Although GAMT deficiency is significantly more rare than other conditions included in newborn screening, the feasibility of screening, the low number of positive results, the relative ease of diagnosis, and the expected benefit of presymptomatic dietary therapy led to a recommendation from the Advisory Committee on Heritable Disorders in Newborns and Children to the Secretary of Health and Human Services that GAMT deficiency be added to the Recommended Uniform Screening Panel. This recommendation was accepted in January 2023.

Preexisting Financial Hardship Among Caregivers of Hospitalized Children

This cross-sectional study examines preexisting financial hardship among caregivers of hospitalized children.

Cost-effectiveness of routine annual influenza vaccination by age and risk status

BACKGROUND

The epidemiology of circulating seasonal influenza strains changed following the 2009 pandemic influenza A(H1N1). A universal influenza vaccination recommendation has been implemented and new vaccine types have become available post-2009. The objective of this study was to evaluate the cost-effectiveness of routine annual influenza vaccination in the context of this new evidence.

METHODS

A state transition simulation model was constructed to estimate the health and economic outcomes of influenza vaccination compared to no vaccination for hypothetical US cohorts stratified by age and risk status. Model input parameters were derived from multiple sources, including post-2009 vaccine effectiveness data from the US Flu Vaccine Effectiveness Network. The analysis used societal and healthcare sector perspectives and a one-year time horizon, except permanent outcomes were also included. The primary outcome was the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life years (QALYs) gained.

RESULTS

Compared to no vaccination, vaccination yielded ICERs lower than $95,000/QALY for all age and risk groups, except for non-high-risk adults 18-49 years ($194,000/QALY). Vaccination was cost-saving for adults ≥50 years at higher risk for influenza-related complications. Results were most sensitive to changes in the probability of influenza illness. Performing the analysis from the healthcare sector perspective, excluding vaccination time costs, delivering vaccinations in lower-cost settings, and including productivity losses improved the cost-effectiveness of vaccination. Sensitivity analysis revealed that vaccination remains below $100,000/QALY for older persons ≥65 years at vaccine effectiveness estimates as low as 4 %.

CONCLUSIONS

Cost-effectiveness of influenza vaccination varied by age and risk status and was less than $95,000/QALY for all subgroups, except for non-high-risk working-age adults. Results were sensitive to the probability of influenza illness and vaccination was more favorable under certain scenarios. Vaccination for higher risk subgroups resulted in ICERs below $100,000/QALY even at low levels of vaccine effectiveness or circulating virus.

Eliciting Trade-Offs Between Equity and Efficiency: A Methodological Scoping Review

OBJECTIVES

To identify differences in the approaches and results of studies that elicit equity-efficiency trade-offs that can inform equity-informative cost-effectiveness analysis for healthcare resource allocation.

METHODS

We searched Ovid (Medline), EconLit, and Scopus prior to June 25, 2021. Inclusion criteria were: (1) peer-reviewed or (2) gray literature; (3) published in English; (4) survey-based; (5) parameterized a social welfare function to quantify inequality aversion or (6) elicited a trade-off in equity and efficiency characteristics of health interventions. Exclusion criteria were: (1) studies that did not conduct a trade-off or (2) theoretical studies. We abstracted details on study methods, results, and limitations. Studies were grouped by following approach: (1) social welfare function or (2) preference ranking and distributional weighting. We described findings separately for each approach category.

RESULTS

Seventy-seven papers were included, 28 parameterized social welfare functions and 49 were classified as preference ranking and distributional weighting. Study methods were heterogeneous. Studies were conducted across 29 countries. Sample sizes and composition, survey methods and question framing varied. Preferences for equity were mixed. Across both approach categories: 39 studies were classified as clear evidence of inequality aversion; 33 found mixed evidence; and 4 had no evidence of aversion. Evidence of between and within-study heterogeneity was found. Preferences for equity may differ by gender, profession, political ideology, income, and education.

CONCLUSIONS

Substantial variability in study methods limit the direct comparability of findings and their use in equity-informed cost-effectiveness analysis. Future researches using representative samples that explore within and between country heterogeneity is needed.

Developing Criteria for Health Economic Quality Evaluation Tool

OBJECTIVES

Because existing publication guidelines and checklists have limitations when used to assess the quality of cost-effectiveness analysis, we developed a novel quality assessment tool for cost-effectiveness analyses, differentiating methods and reporting quality and incorporating the relative importance of different quality attributes.

METHODS

We defined 15 quality domains from a scoping review and identified 72 methods and reporting quality attributes (36 each). After designing a best-worst scaling survey, we fielded an online survey to researchers and practitioners to estimate the relative importance of the attributes in February 2021. We analyzed the survey data using a sequential conditional logit model. The final tool included 48 quality attributes deemed most important for assessing methods and reporting quality (24 each), accompanied by a free and web-based scoring system.

RESULTS

A total of 524 participants completed the methodology section, and 372 completed both methodology and reporting sections. Quality attributes pertaining to the "modeling" and "data inputs and evidence synthesis" domains were deemed most important for methods quality, including "structure of the model reflects the underlying condition and intervention's impact" and "model validation is conducted." Quality attributes pertaining to "modeling" and "Intervention/comparator(s)" domains were considered most important for reporting quality, including "model descriptions are detailed enough for replication." Despite its growing prominence, "equity considerations" were not deemed as important as other quality attributes.

CONCLUSIONS

The Criteria for Health Economic Quality Evaluation tool allows users to differentiate methods and reporting as well as quantifies the relative importance of quality attributes. Alongside other considerations, it could help assess and improve the quality of cost-effectiveness evidence to inform value-based decisions.

Cost-Effectiveness Analysis of Vaccination With Recombinant Zoster Vaccine Among Hematopoietic Cell Transplant Recipients and Persons With Other Immunocompromising Conditions Aged 19 to 49 Years

OBJECTIVES

This study aimed to estimate the cost-effectiveness of the use of recombinant zoster vaccine (RZV) (Shingrix), which protects against herpes zoster (HZ), among immunocompromised adults aged 19 to 49 years, as a contribution to deliberations of the Advisory Committee on Immunization Practices.

METHODS

Hematopoietic cell transplant (HCT) recipients experience a high incidence of HZ, and the efficacy of RZV in preventing HZ has been studied in clinical trials. The cost-effectiveness model calculated incremental cost-effectiveness ratios that compared vaccination with RZV with a no vaccination strategy among adults aged 19 to 49 years. Costs and outcomes were calculated until age 50 years using the healthcare sector perspective and summarized as cost per quality-adjusted life-year (QALY) gained. The base case represents HCT recipients, with scenario analyses representing persons with other immunocompromising conditions, including hematologic malignancies, human immunodeficiency virus, and autoimmune and inflammatory conditions. Uncertainty was investigated using univariate, multivariate, and probabilistic sensitivity analyses.

RESULTS

Base-case results indicated vaccination with RZV would avert approximately 35% of HZ episodes and complications, while saving approximately 11% of net costs. Compared with no vaccination, vaccination of HCT recipients with RZV generated cost-savings (ie, lower costs and improved health) in the base case and in 81% of simulations in the probabilistic analysis. In scenario analyses, vaccination cost US dollar ($) 9500/QALY among patients with hematologic malignancies, $79 000/QALY among persons living with human immunodeficiency virus, and $208 000/QALY among persons with selected autoimmune and inflammatory conditions.

CONCLUSIONS

Generally favorable economic estimates supported recommendations for vaccination of immunocompromised adults with RZV to prevent episodes of HZ and related complications.

Evidence and recommendation for mucopolysaccharidosis type II newborn screening in the United States

Mucopolysaccharidosis type II (MPS II), also known as Hunter syndrome, is an X-linked condition caused by pathogenic variants in the iduronate-2-sulfatase gene. The resulting reduced activity of the enzyme iduronate-2-sulfatase leads to accumulation of glycosaminoglycans that can progressively affect multiple organ systems and impair neurologic development. In 2006, the US Food and Drug Administration approved idursulfase for intravenous enzyme replacement therapy for MPS II. After the data suggesting that early treatment is beneficial became available, 2 states, Illinois and Missouri, implemented MPS II newborn screening. Following a recommendation of the Advisory Committee on Heritable Disorders in Newborns and Children in February 2022, in August 2022, the US Secretary of Health and Human Services added MPS II to the Recommended Uniform Screening Panel, a list of conditions recommended for newborn screening. MPS II was added to the Recommended Uniform Screening Panel after a systematic evidence review reported the accuracy of screening, the benefit of presymptomatic treatment compared with usual case detection, and the feasibility of implementing MPS II newborn screening. This manuscript summarizes the findings of the evidence review that informed the Advisory Committee's decision.

Preferences for Sexually Transmitted Infection and Cancer Vaccines in the United States and in China

OBJECTIVES

This study assessed preferences for hypothetical vaccines for children in 2 large vaccine markets according to how the vaccine-preventable disease is transmitted via a discrete choice experiment.

METHODS

Surveys in China (N = 1350) and the United States (N = 1413) were conducted from April to May 2021. The discrete choice experiment included attributes of cost, age at vaccination, transmission mode of the vaccine-preventable disease, and whether the vaccine prevents cancer. Preference utilities were modeled in a Bayesian, multinomial logistic regression model, and respondents were grouped by vaccine preference classification through a latent class analysis.

RESULTS

Individuals favored vaccines against diseases with transmission modes other than sexual transmission (vaccine for sexually transmitted infection [STI] vs airborne disease, in the United States, odds ratio 0.71; 95% credible interval 0.64-0.78; in China, odds ratio 0.76; 95% credible interval 0.69-0.84). The latent class analysis revealed 6 classes: vaccine rejecters (19% in the United States and 8% in China), careful deciders (18% and 17%), preferring cancer vaccination (20% and 19%), preferring vaccinating children at older ages (10% and 11%), preferring vaccinating older ages, but indifferent about cancer vaccines (23% and 25%), and preferring vaccinating children at younger ages (10% and 19%). Vaccine rejection was higher with age in the United States versus more vaccine rejection among those at the age of 18 to 24 and ≥ 64 years in China.

CONCLUSION

The public had strong preferences against giving their child an STI vaccine, and the class preferring a cancer vaccine was less accepting of an STI vaccine. Overall, this study points to the need for more education about how some STI vaccines could also prevent cancers.

A Discrete Choice Analysis Comparing COVID-19 Vaccination Decisions for Children and Adults

IMPORTANCE

COVID-19 vaccination rates in the US remain below optimal levels. Patient preferences for different attributes of vaccine products and the vaccination experience can be important in determining vaccine uptake decisions.

OBJECTIVE

To assess preferences for attributes of adult and pediatric COVID-19 vaccination among US adults.

DESIGN, SETTING, AND PARTICIPANTS

An online survey of a national panel of 1040 US adults was conducted in May and June 2021. A discrete choice analysis was used to measure the relative value of each attribute in the decision to choose a COVID-19 vaccination option for adults or children. Six attributes were used to described hypothetical vaccination options: vaccine effectiveness, mild side effects, rare adverse events, number of doses, time required for vaccination, and regulatory approval. Respondents chose between hypothetical vaccination profiles or no vaccination. Additional survey questions asked about vaccination beliefs, COVID-19 illness experience, COVID-19 risk factors, vaccination status, and opinions about the risk of COVID-19.

EXPOSURES

Respondents chose which vaccine profile they would prefer to receive for themselves (or no vaccination). Respondents then considered an identical set of profiles for a hypothetical child aged 0 to 17 years.

MAIN OUTCOMES AND MEASURES

Relative value of vaccination-related attributes were estimated using Bayesian logit regression. Preference profiles for subgroups were estimated using latent class analyses.

RESULTS

A total of 1040 adults (610 [59%] female; 379 participants [36%] with an age of 55 years and older years) responded to the survey. When asked about vaccination choices for themselves, participants indicated that vaccine effectiveness (95% vs 60%) was a significant attribute (β, 9.59 [95% CrI, 9.20-10.00] vs β, 0.41 [95% CrI, 0-0.80]). Respondents also preferred fewer rare adverse events (β, 6.35 [95% CrI, 5.74-6.86), fewer mild side effects (β, 5.49; 95% CrI, 5.12-5.87), 1 dose (β, 5.41; 95% CrI, 5.04-5.78), FDA approval (β, 6.01; 95% CrI, 5.64-6.41), and shorter waiting times (β, 5.67; 95% CrI, 4.87-6.48). Results were very similar when framing the question as adult or child vaccination, with slightly stronger preference for fewer rare adverse events for children. Latent class analysis revealed 4 groups of respondents: (1) individuals sensitive to safety and regulatory status, (2) individuals sensitive to convenience, (3) individuals who carefully considered all attributes in making their choices, and (4) individuals who rejected the vaccine.

CONCLUSIONS AND RELEVANCE

In this survey study of US adults, the identification of 4 distinct preference groups provides new information to guide communications to support vaccine decision making. In particular, the group that prioritize convenience (less time required for vaccination and fewer doses) may present an opportunity to create actionable strategies to increase vaccination uptake for both adult and pediatric populations.

Projected risks and health benefits of vaccination against herpes zoster and related complications in US adults

The Advisory Committee on Immunization Practices (ACIP) recommends recombinant zoster vaccine (RZV) to prevent against herpes zoster (HZ) and related complications in immunocompetent adults ≥50 y and immunocompromised adults ≥19 y. In 2019, a statistical safety signal for Guillain-Barré syndrome (GBS) following RZV was identified using data from the Vaccine Safety Datalink (VSD). Subsequently, the U.S. Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), and collaborators undertook additional analyses using Centers for Medicare & Medicaid Services (CMS) Medicare data to further investigate the potential risk of GBS following RZV. Concurrently, epidemiologic data suggested a potentially elevated risk of GBS following HZ in U.S. adults. Using data from these sources and a published simulation model, this study evaluated the health benefits and risks associated with vaccinating immunocompetent adults ≥50 y with RZV compared to no vaccination. In the base case analysis, RZV vaccination averted 43,000-63,000 cases of HZ, including GBS complications, per million vaccinated per 10-y age cohort compared to 3-6 additional cases of GBS projected following RZV per million vaccinated in the same population. This analysis highlights the projected health benefits of RZV vaccination compared to the relatively low potential risk of GBS following RZV.

New and Progressive Medical Conditions After Pediatric Sepsis Hospitalization Requiring Critical Care

Importance

Children commonly experience physical, cognitive, or emotional sequelae after sepsis. However, little is known about the development or progression of medical conditions after pediatric sepsis.

Objective

To quantify the development and progression of 4 common conditions in the 6 months after sepsis and to assess whether they differed after hospitalization for sepsis vs nonsepsis among critically ill children.

Design, Setting, and Participants

This cohort study of 101 511 children (<19 years) with sepsis or nonsepsis hospitalization used a national administrative claims database (January 1, 2010, to June 30, 2018). Data management and analysis were conducted from April 1, 2020, to July 7, 2022.

Exposures

Intensive care unit hospitalization for sepsis vs all-cause intensive care unit hospitalizations, excluding sepsis.

Main Outcomes and Measures

Primary outcomes were the development of 4 target conditions (chronic respiratory failure, seizure disorder, supplemental nutritional dependence, and chronic kidney disease) within 6 months of hospital discharge. Secondary outcomes were the progression of the 4 target conditions among children with the condition before hospitalization. Outcomes were identified via diagnostic and procedural codes, durable medical equipment codes, and prescription medications. Differences in the development and the progression of conditions between pediatric patients with sepsis and pediatric patients with nonsepsis who survived intensive care unit hospitalization were assessed using logistic regression with matching weights.

Results

A total of 5150 survivors of pediatric sepsis and 96 361 survivors of nonsepsis intensive care unit hospitalizations were identified; 2593 (50.3%) were female. The median age was 9.5 years (IQR, 3-15 years) in the sepsis cohort and 7 years (IQR, 2-13 years) in the nonsepsis cohort. Of the 5150 sepsis survivors, 670 (13.0%) developed a new target condition, and 385 of 1834 (21.0%) with a preexisting target condition had disease progression. A total of 998 of the 5150 survivors (19.4%) had development and/or progression of at least 1 condition. New conditions were more common among sepsis vs nonsepsis hospitalizations (new chronic respiratory failure: 4.6% vs 1.9%; odds ratio [OR], 2.54 [95% CI, 2.19-2.94]; new supplemental nutritional dependence: 7.9% vs 2.7%; OR, 3.17 [95% CI, 2.80-3.59]; and new chronic kidney disease: 1.1% vs 0.6%; OR, 1.65 [95% CI, 1.25-2.19]). New seizure disorder was less common (4.6% vs 6.0%; OR, 0.77 [95% CI, 0.66-0.89]). Progressive supplemental nutritional dependence was more common (1.5% vs 0.5%; OR, 2.95 [95% CI, 1.60-5.42]), progressive epilepsy was less common (33.7% vs 40.6%; OR, 0.74 [95% CI, 0.65-0.86]), and progressive respiratory failure (4.4% vs 3.3%; OR, 1.35 [95% CI, 0.89-2.04]) and progressive chronic kidney disease (7.9% vs 9.2%; OR, 0.84 [95% CI, 0.18-3.91]) were similar among survivors of sepsis vs nonsepsis admitted to an intensive care unit.

Conclusions and Relevance

In this national cohort of critically ill children who survived sepsis, 1 in 5 developed or had progression of a condition of interest after sepsis hospitalization, suggesting survivors of pediatric sepsis may benefit from structured follow-up to identify and treat new or worsening medical comorbid conditions.

Usability of NewSTEPs Data for Assessing the Characteristics of Infants with Newborn Screening Disorders

Most state newborn screening programs in the U.S. currently contribute case data to the Newborn Screening Technical Assistance and Evaluation Program (NewSTEPs). To assess the usability of these data for research, we examined the completeness of key variables, particularly race and ethnicity. Data included 24,129 cases of 34 newborn screening disorders from 45 states available in NewSTEPs as of 31 August 2020. Birth years of cases ranged between 2006 and 2020. Rates of missing data for sex, gestational age, birth weight, and race/ethnicity were 3.8%, 31.7%, 7.0%, and 39.7%, respectively. After excluding 21 states for which ≥50% of cases had missing data on race and/or ethnicity, 16,010 cases from 24 states remained. The disorders with the highest proportions in which cases were recorded as Hispanic ethnicity/any race were methylmalonic acidemia (48.7%) and maple syrup urine disease (45.7%). Analyses indicated that sex and birth weight data in NewSTEPs are reasonably complete, but missing data are common for gestational age and race/ethnicity. Despite this, our analyses revealed several novel associations between race/ethnicity and newborn screening disorders, such as the high burden of maple syrup urine disease among Hispanic patients. This demonstrates the potential usefulness of NewSTEPs for research if investments in higher-quality data are made.

Families' healthcare experiences for children with inherited metabolic diseases: protocol for a mixed methods cohort study

INTRODUCTION

Children with inherited metabolic diseases (IMDs) often have complex and intensive healthcare needs and their families face challenges in receiving high-quality, family centred health services. Improvement in care requires complex interventions involving multiple components and stakeholders, customised to specific care contexts. This study aims to comprehensively understand the healthcare experiences of children with IMDs and their families across Canada.

METHODS AND ANALYSIS

A two-stage explanatory sequential mixed methods design will be used. Stage 1: quantitative data on healthcare networks and encounter experiences will be collected from 100 parent/guardians through a care map, 2 baseline questionnaires and 17 weekly diaries over 5-7 months. Care networks will be analysed using social network analysis. Relationships between demographic or clinical variables and ratings of healthcare experiences across a range of family centred care dimensions will be analysed using generalised linear regression. Other quantitative data related to family experiences and healthcare experiences will be summarised descriptively. Ongoing analysis of quantitative data and purposive, maximum variation sampling will inform sample selection for stage 2: a subset of stage 1 participants will participate in one-on-one videoconference interviews to elaborate on the quantitative data regarding care networks and healthcare experiences. Interview data will be analysed thematically. Qualitative and quantitative data will be merged during analysis to arrive at an enhanced understanding of care experiences. Quantitative and qualitative data will be combined and presented narratively using a weaving approach (jointly on a theme-by-theme basis) and visually in a side-by-side joint display.

ETHICS AND DISSEMINATION

The study protocol and procedures were approved by the Children's Hospital of Eastern Ontario's Research Ethics Board, the University of Ottawa Research Ethics Board and the research ethics boards of each participating study centre. Findings will be published in peer-reviewed journals and presented at scientific conferences.

Optimizing scalable, technology-supported behavioral interventions to prevent opioid misuse among adolescents and young adults in the emergency department: A randomized controlled trial protocol

Preventing opioid misuse and opioid use disorder is critical among at-risk adolescents and young adults (AYAs). An Emergency Department (ED) visit provides an opportunity for delivering interventions during a rapidly changing opioid landscape. This paper describes pilot data and the protocol for a 2 × 2 factorial randomized controlled trial testing efficacy of early interventions to reduce escalation of opioid (prescription or illicit) misuse among at-risk AYAs. Interventions are delivered using technology by health coaches. AYAs ages 16-30 in the ED screening positive for prescription opioid use (+ ≥ 1 risk factor) or opioid misuse will be stratified by risk severity, sex, and age group. Participants will be randomly assigned to a condition at intake, either a live video health coach-delivered single session or a control condition of an enhanced usual care (EUC) community resource brochure. They are also randomly assigned to one of two post-intake conditions: health coach-delivered portal-like messaging via web portal over 30 days or EUC delivered at 30 days post-intake. Thus, the trial has four groups: health coach-delivered session+portal, health coach-delivered session+EUC, EUC + portal, and EUC + EUC. Outcomes will be measured at 3-, 6-, and 12-months. The primary outcome is opioid misuse based on a modified Alcohol Smoking and Substance Involvement Screening Test. Secondary outcomes include other opioid outcomes (e.g., days of opioid misuse, overdose risk behaviors), other substance misuse and consequences, and impaired driving. This study is innovative by testing the efficacy of feasible and scalable technology-enabled interventions to reduce and prevent opioid misuse and opioid use disorder. Trial Registration:ClinicalTrials.gov University of Michigan HUM00177625 NCT Registration: NCT04550715.

Vaccine Hesitancy and Rejection of a Vaccine for the Novel Coronavirus in the United States

The arrival of the COVID-19 vaccine has been accompanied by increased discussion of vaccine hesitancy. However, it is unclear if there are shared patterns between general vaccine hesitancy and COVID-19 vaccine rejection, or if these are two different concepts. This study characterized rejection of a hypothetical COVID-19 vaccine, and compared patterns of association between general vaccine hesitancy and COVID-19 vaccine rejection. The survey was conducted online March 20-22, 2020. Participants answered questions on vaccine hesitancy and responded if they would accept the vaccine given different safety and effectiveness profiles. We assessed differences in COVID-19 rejection and general vaccine hesitancy through logistic regressions. Among 713 participants, 33.0% were vaccine hesitant, and 18.4% would reject a COVID-19 vaccine. Acceptance varied by effectiveness profile: 10.2% would reject a 95% effective COVID-19 vaccine, but 32.4% would reject a 50% effective vaccine. Those vaccine hesitant were significantly more likely to reject COVID-19 vaccination [odds ratio (OR): 5.56, 95% confidence interval (CI): 3.39, 9.11]. In multivariable logistic regression models, there were similar patterns for vaccine hesitancy and COVID-19 vaccine rejection by gender, race/ethnicity, family income, and political affiliation. But the direction of association flipped by urbanicity (P=0.0146, with rural dwellers less likely to be COVID-19 vaccine rejecters but more likely to be vaccine hesitant in general), and age (P=0.0037, with fewer pronounced differences across age for COVID-19 vaccine rejection, but a gradient of stronger vaccine hesitancy in general among younger ages). During the COVID-19 epidemic’s early phase, patterns of vaccine hesitancy and COVID-19 vaccine rejection were relatively similar. A significant minority would reject a COVID-19 vaccine, especially one with less-than-ideal effectiveness. Preparations for introducing the COVID-19 vaccine should anticipate substantial hesitation and target concerns, especially among younger adults.

Incorporating Cascade Effects of Genetic Testing in Economic Evaluation: A Scoping Review of Methodological Challenges

Cascade genetic testing is indicated for family members of individuals testing positive on a genetic test, and is particularly relevant for child health because of their vulnerability and the long-term health and economic implications. Cascade testing has patient- and health system-level implications; however cascade costs and health effects are not routinely considered in economic evaluation. The methodological challenges associated with incorporating cascade effects in economic evaluation require examination. The purpose of this scoping review was to identify published economic evaluations that considered cascade genetic testing. Citation databases were searched for English-language economic evaluations reporting on cascade genetic testing. Nineteen publications were included. In four, genetic testing was used to identify new index patients—cascade effects were also considered; thirteen assessed cascade genetic testing strategies for the identification of at-risk relatives; and two calculated the costs of cascade genetic testing as a secondary objective. Methodological challenges associated with incorporating cascade effects in economic evaluation are related to study design, costing, measurement and valuation of health outcomes, and modeling. As health economic studies may currently be underestimating both the cost and health benefits attributable to genetic technologies through omission of cascade effects, development of methods to address these difficulties is required.

Health and economic outcomes of newborn screening for infantile-onset Pompe disease

PURPOSE

To estimate health and economic outcomes associated with newborn screening (NBS) for infantile-onset Pompe disease in the United States.

METHODS

A decision analytic microsimulation model simulated health and economic outcomes of a birth cohort of 4 million children in the United States. Universal NBS and treatment was compared with clinical identification and treatment of infantile-onset Pompe disease. Main outcomes were projected cases identified, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) over the life course.

RESULTS

Universal NBS for Pompe disease and confirmatory testing was estimated to cost an additional $26 million annually. Additional medication costs associated with earlier treatment initiation were $181 million; however, $8 million in medical care costs for other services were averted due to delayed disease progression. Infants with screened and treated infantile-onset Pompe disease experienced an average lifetime increase of 11.66 QALYs compared with clinical detection. The ICER was $379,000/QALY from a societal perspective and $408,000/QALY from the health-care perspective. Results were sensitive to the cost of enzyme replacement therapy.

CONCLUSION

Newborn screening for Pompe disease results in substantial health gains for individuals with infantile-onset Pompe disease, but with additional costs.

Assessing the Appropriateness of the EQ-5D for Duchenne Muscular Dystrophy: A Patient-Centered Study

Background

Duchenne muscular dystrophy is a rare degenerative neuromuscular disorder with pediatric onset. Recent approvals in Duchenne have placed attention on the economic evaluation in pricing and reimbursement decisions across a range of rare conditions. We sought to assess the appropriateness of the EQ-5D, a common measure of generic health state utility, for use among patients and caregivers affected by Duchenne.

Methods

An international, cross-sectional sample of adults with Duchenne and caregivers reported patient health status using self- or proxy-reported EQ-5D-3L. Appropriateness was assessed across 6 domains of concern raised by stakeholders in Duchenne. These concerns were that the EQ-5D/EQ-VAS would not capture meaningful differences in health status, correlate with disease-specific measures, reflect real health status, exhibit face validity, be accurately interpreted, and be low burden. We evaluated these concerns by comparing EQ-5D index score and EQ-VAS scores to other condition-specific functional measures and open- and closed-ended questions.

Results

In total, 263 participants (74% response) completed the survey, 24% of whom were adult patients. Most participants lived in the United States or United Kingdom (58%). Patient age ranged from 1 to 48 y. EQ-5D index was higher in ambulatory than nonambulatory patients (0.60 v. 0.30, P < 0.001) and was negatively correlated with upper limb impairment ( r = 0.61, P < 0.001). Three-quarters of respondents agreed that EQ-5D measured real health status (74%). Most respondents interpreted EQ-VAS anchors of best and worst imaginable health as full health (61%) and death/near death (58%). Respondents indicated the EQ-5D was easy to understand (86%) and answer (71%).

Conclusions

Contrary to anecdotal concerns, we found support for the appropriateness of EQ-5D to assess health status in Duchenne. While other measures may be more sensitive to specific outcomes in Duchenne, there may be some value in results using the EQ-5D measure.

What's the Cost? Measuring the Economic Impact of Pediatric Sepsis

Sepsis, life-threatening organ dysfunction secondary to infection, hospitalizes nearly 75,000 children each year in the United States. Most children survive sepsis. However, there is increasing recognition of the longer-term consequences of pediatric sepsis hospitalization on both the child and their family, including medical, psychosocial, and financial impacts. Here, we describe family spillover effects (the impact of illness on caregivers) of pediatric sepsis, why measurement of family spillover effects is important, and the ways in which family spillover effects can be measured.

Examining Equity Effects of Health Interventions in Cost-Effectiveness Analysis: A Systematic Review

OBJECTIVE

This systematic review aims to catalogue and describe published applications of equity-informative cost-effectiveness analysis (CEAs).

METHODS

Following PRISMA guidelines, we searched Medline for English-language, peer-reviewed CEAs published on or before August 2019. We included CEAs that evaluated 2 or more alternatives; explicitly mentioned equity as a consideration or decision-making principle; and applied an equity-informative CEA method to analyze or examine at least 1 equity criterion in an applied CEA. We extracted data on selected characteristics and analyzed reporting quality using the CHEERS checklist.

RESULTS

Fifty-four articles identified through a search and bibliography reviews met the inclusion criteria. All articles were published on or after 2010, with 80% published after 2015. Most studies evaluated primary prevention interventions in disease areas such as cancer, infectious diseases, and cardiovascular disease. Equity impact analysis alone was the most common equity-informative CEA (56%), followed by equity impact analysis with financial protection effects (30%). At least 11 different equity criteria have been used in equity-informative CEAs; socioeconomic status and race/ethnicity were used most frequently. Seventy-eight percent of studies reported finding "greater value" in an intervention after examining its distributional effects.

CONCLUSION

The number of equity-informative CEAs is increasing, and the wide range of equity criteria, diseases, interventions, settings, and populations represented suggests that broad application of these methods is feasible but will require further refinement. Inclusion of equity into CEAs may shift the value of evaluated interventions and can provide crucial additional information for decision makers.

Vaccine Hesitancy and Concerns About Vaccine Safety and Effectiveness in Shanghai, China

INTRODUCTION

Rapidly urbanizing communities in middle-income countries could be sources of vaccine hesitancy, and may create hot spots of low vaccination coverage. This study characterizes vaccine hesitancy in Shanghai and identifies disparities in vaccine safety and efficacy concerns by residency status-a marker for recent migration into the city.

METHODS

Parents of children aged ≤18 years from immunization clinics in Shanghai were enrolled in summer 2019, with the data analyzed during winter 2019-2020. The paper questionnaire used the Parental Attitudes towards Childhood Vaccines scale, which included questions about vaccine safety and efficacy concerns. The primary independent variable was residency-whether an individual was a Shanghai local or a recent migrant (i.e., non-local). Linear regression models assessed the relationship between residency and vaccine safety and efficacy concerns.

RESULTS

Among 1,021 participants, 65.4% had local residency, and the remainder were urban non-locals (13.1%) or rural non-locals (21.5%). A majority of parents expressed concerns about vaccine side effects (73.8%), vaccine safety (63.9%), and vaccine effectiveness (52.4%). Compared with locals, rural non-locals were more concerned about vaccine side effects (β=0.26, 95% CI=0.07, 0.46), vaccine safety (β=0.42, 95% CI=0.19, 0.65), and vaccine effectiveness (β=0.37, 95% CI=0.16, 0.58).

CONCLUSIONS

Differences in vaccine hesitancy by residency could lead to geographical and sociodemographic disparities in vaccination coverage and outbreaks of vaccine-preventable disease.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Factors Associated With School Attendance Plans and Support for COVID-19 Risk Mitigation Measures Among Parents and Guardians

OBJECTIVE

To determine which factors are associated with plans for in-person school attendance during the 2020-2021 school year and with support for 15 school-based COVID-19 risk mitigation measures among parents and guardians.

METHODS

In June 2020, we conducted an online survey of parents and guardians of public school children in Illinois, Michigan, and Ohio. In a child-level analysis, we used linear regression to assess which demographic factors, health-related concerns, and parent/guardian views were associated with plans for in-person school attendance. In a respondent-level analysis, we used linear regression to assess factors associated with the number of risk mitigation measures supported.

RESULTS

Among 2202 children in the child-level analysis, in-person school attendance was planned for 71.0%. Such plans were less likely among children of Black respondents (-14.1 percentage points, 95% confidence interval [CI]: -25.7, -2.6) and Asian respondents (-16.8, 95% CI: -31.3, -2.2), and among children with perceived high-risk health conditions (-9.7, 95% CI: -15.8, -3.6). Among 1,126 respondents in the respondent-level analysis, the mean number of measures supported was 8.0 (SD 4.4). Several factors were associated with support, but the magnitude of associations was generally modest.

CONCLUSIONS

During the COVID-19 pandemic, families of children with health conditions or who are of Black or Asian race/ethnicity may be less likely to opt for in-person learning. For these families, addressing barriers to remote education is critical. As schools plan for the 2020-2021 school year and beyond, they should respond to the desire among parents and guardians to implement substantial numbers of risk mitigation measures.

Cost-effectiveness of the Adaptive Implementation of Effective Programs Trial (ADEPT): approaches to adopting implementation strategies

BACKGROUND

Theory-based methods to support the uptake of evidence-based practices (EBPs) are critical to improving mental health outcomes. Implementation strategy costs can be substantial, and few have been rigorously evaluated. The purpose of this study is to conduct a cost-effectiveness analysis to identify the most cost-effective approach to deploying implementation strategies to enhance the uptake of Life Goals, a mental health EBP.

METHODS

We used data from a previously conducted randomized trial to compare the cost-effectiveness of Replicating Effective Programs (REP) combined with external and/or internal facilitation among sites non-responsive to REP. REP is a low-level strategy that includes EBP packaging, training, and technical assistance. External facilitation (EF) involves external expert support, and internal facilitation (IF) augments EF with protected time for internal staff to support EBP implementation. We developed a decision tree to assess 1-year costs and outcomes for four implementation strategies: (1) REP only, (2) REP+EF, (3) REP+EF add IF if needed, (4) REP+EF/IF. The analysis used a 1-year time horizon and assumed a health payer perspective. Our outcome was quality-adjusted life years (QALYs). The economic outcome was the incremental cost-effectiveness ratio (ICER). We conducted deterministic and probabilistic sensitivity analysis (PSA).

RESULTS

Our results indicate that REP+EF add IF is the most cost-effective option with an ICER of $593/QALY. The REP+EF/IF and REP+EF only conditions are dominated (i.e., more expensive and less effective than comparators). One-way sensitivity analyses indicate that results are sensitive to utilities for REP+EF and REP+EF add IF. The PSA results indicate that REP+EF, add IF is the optimal strategy in 30% of iterations at the threshold of $100,000/QALY.

CONCLUSIONS

Our results suggest that the most cost-effective implementation support begins with a less intensive, less costly strategy initially and increases as needed to enhance EBP uptake. Using this approach, implementation support resources can be judiciously allocated to those clinics that would most benefit. Our results were not robust to changes in the utility measure. Research is needed that incorporates robust and relevant utilities in implementation studies to determine the most cost-effective strategies. This study advances economic evaluation of implementation by assessing costs and utilities across multiple implementation strategy combinations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02151331 , 05/30/2014.

Priorities for Investing in Community Health Improvement: A Comparison of Decision Makers in Public Health, Nonprofit Hospitals, and Community Nonprofits

CONTEXT

As a result of additional requirements for tax exemption, many nonprofit hospitals have become more actively involved in community health improvement. There is an open question, however, as to how decision makers in hospitals decide which kind of improvement projects should receive priority and how hospital managers' priorities compare with those of decision makers in public health agencies and community-based nonprofits.

OBJECTIVE

To understand the priorities that guide decision makers in public health, nonprofit hospitals, and community nonprofits when allocating resources to community health projects.

DESIGN

We conducted an online survey with a discrete choice experiment, asking respondents to choose between different types of community health projects, which varied along several project characteristics. Respondents included managers of community health and community benefit at nonprofit hospitals (n = 225), managers at local public health departments (n = 200), and leaders of community nonprofits (n = 136). Respondents were located in 47 of 50 US states. A conditional logit model was used to estimate how various project characteristics led to greater or lesser support of a given health project. Open-ended questions aided in interpretation of results.

RESULTS

Respondents from all 3 groups showed strong agreement on community health priorities. Projects were more likely to be selected when they addressed a health issue identified on community health needs assessment, involved cross-sector collaboration, or were supported by evidence. Project characteristics that mattered less included the time needed to measure the project's impact and the project's target population.

CONCLUSION

Elements often considered central to community health, such as long-term investment and prioritizing vulnerable populations, may not be considered by decision makers as important as other aspects of resource allocation. If we want greater priority for ideas such as health equity and social determinants of health, it will take a concerted effort from practitioners and policy makers to reshape expectations.

Preferences for vaccination program attributes among parents of young infants in Shanghai, China

Compared to many other countries, China offers fewer pediatric vaccines. Future attempts to add mandatory vaccines may run counter to parents' preferences for shot-limiting. The aim of this study was to assess Chinese parents' preferences and willingness-to-pay (WTP) for programmatic attributes of vaccination services. Parents of young infants ≤3 months of age presenting at immunization clinics in Shanghai, China, in 2017 completed a discrete choice experiment (DCE) on vaccination program attributes: waiting time at the clinic, number of shots before 7 months, number of injections per visit, cost per visit, and location of the shot. We estimated preference utilities and WTP using logistic regression. In total, 590 completed the DCE. Caregivers expressed greater utility for less waiting time, fewer office visits, lower cost of vaccines, and fewer injections co-administered. Over the course of their child's first 6 months, parents were willing to pay 113 RMB ($17) to avoid an additional 10 minutes of waiting at each appointment (95% confidence interval [CI]: 213, 929), 474 RMB ($70) to avoid an additional office visit (95% CI: 241, 707), and 703 RMB ($104) to avoid an additional injection at each appointment (95% CI: 337, 1068). As China expands its list of publicly funded vaccines, public health officials will have to counter Chinese parents' strong preferences for limiting the total number of office visits and the number of injections administered at each visit, potentially through the use of combination vaccines.

Using discrete choice experiments to develop and deliver patient-centered psychological interventions: a systematic review

Developing and/or tailoring psychological interventions to align with patient preferences is a critical component of patient-centered care and has the potential to improve patient engagement and treatment outcomes. Discrete choice experiments (DCEs) are a quantitative method of assessing patient preferences that offer numerous strengths (i.e., ability to account for trade-offs), but are not routinely incorporated into health psychology coursework, likely leaving many unaware of the potential benefits of this methodology. To highlight the potential applications of DCEs within health psychology, this systematic review synthesises previous efforts to utilise DCEs to inform the design of patient-centered psychological care, defined as interventions targeting psychological (e.g., depression, anxiety) or behavioural health (e.g., pain management, adherence) concerns. Literature searches were conducted in March 2017 and November 2019 for articles reporting on DCEs using the terms 'discrete choice', 'conjoint', or 'stated preference'. Thirty-nine articles met all inclusion criteria and used DCEs to understand patient preferences regarding psychosocial clinical services (n = 12), lifestyle behaviour change interventions (n = 11), HIV prevention and/or intervention services (n = 10), disease self-management programmes (n = 4), or other interventions (n = 2). Clinical implications as well as limitations and directions for future research are discussed.

Importance of reasons for stocking adult vaccines

OBJECTIVES

To identify the most important reasons underlying decisions to stock or not stock adult vaccines.

STUDY DESIGN

US physicians, nurses, pharmacists, and administrators of internal medicine, family medicine, obstetrics/gynecology, and multispecialty practices who were involved in vaccine stocking decisions (N = 125) completed a best-worst scaling survey online between February and April 2018.

METHODS

Sixteen potential factors influencing stocking decisions were developed based on key informant interviews and focus groups. Respondents selected factors that were most and least important in vaccine stocking decisions. Relative importance scores for the best-worst scaling factors were calculated. Survey respondents described which vaccines their practice stocks and reasons for not stocking specific vaccines. Subgroup analyses were performed based on the respondent's involvement in vaccine decision making, role in the organization, specialty, and affiliation status, as well as practice characteristics such as practice size, insurance mix, and patient age mix.

RESULTS

Relative importance scores for stocking vaccines were highest for "cost of purchasing vaccine stock," "expense of maintaining vaccine inventory," and "lack of adequate reimbursement for vaccine acquisition and administration." Most respondents (97%) stocked influenza vaccines, but stocking rates of other vaccines varied from 39% (meningococcal B) to 83% (tetanus-diphtheria-pertussis). Best-worst scaling results were consistent across respondent subgroups, although the range of vaccine types stocked differed by practice type.

CONCLUSIONS

Economic factors associated with the purchase and maintenance of vaccine inventory and inadequate reimbursement for vaccination services were the most important to decision makers when considering whether to stock or not stock vaccines for adults.

Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act

BACKGROUND

Provider concern regarding insurance non-payment for vaccines is a common barrier to provision of adult immunizations. We examined current adult vaccination billing and payment associated with two managed care populations to identify reasons for non-payment of immunization insurance claims.

METHODS

We assessed administrative data from 2014 to 2015 from Blue Care Network of Michigan, a nonprofit health maintenance organization, and Blue Cross Complete of Michigan, a Medicaid managed care plan, to determine rates of and reasons for non-payment of adult vaccination claims across patient-care settings, insurance plans, and vaccine types. We compared commercial and Medicaid payment rates to Medicare payment rates and examined patient cost sharing.

RESULTS

Pharmacy-submitted claims for adult vaccine doses were almost always paid (commercial 98.5%; Medicaid 100%). As the physician office accounted for the clear majority (79% commercial; 69% Medicaid) of medical (non-pharmacy) vaccination services, we limited further analyses of both commercial and Medicaid medical claims to the physician office setting. In the physician office setting, rates of payment were high with commercial rates of payment (97.9%) greater than Medicaid rates (91.6%). Reasons for non-payment varied, but generally related to the complexity of adult vaccine recommendations (patient diagnosis does not match recommendations) or insurance coverage (complex contracts, multiple insurance payers). Vaccine administration services were also generally paid. Commercial health plan payments were greater for both vaccine dose and vaccine administration than Medicare payments; Medicaid paid a higher amount for the vaccine dose, but less for vaccine administration than Medicare. Patients generally had very low (commercial) or no (Medicaid) cost-sharing for vaccination.

CONCLUSIONS

Adult vaccine dose claims were usually paid. Medicaid generally had higher rates of non-payment than commercial insurance.

Application of a Discrete Choice Experiment to Assess Adherence-Related Motivation Among Adolescents and Young Adults With Cancer

Objective

To develop and pilot test a discrete choice experiment (DCE) to assess the specific factors likely to motivate a given adolescent or young adult with cancer to adhere to medications included in treatment protocols.

Methods

A multimethod and iterative approach was used. Twenty adolescents and young adults with cancer participated in DCE pilot testing and refinement. Hierarchical Bayes was used to estimate attribute and attribute-level preference scores for each participant.

Results

The final DCE included nine choice sets composed of four attributes. The resulting DCE was modified with feedback from 20 adolescents and young adults (M[SD] age = 18.66 [2.95]) with cancer. The DCE was understandable and relevant. The factors likely to motivate adolescents and young adults with cancer to be adherent differed across individuals.

Conclusions

DCEs including the measure developed in this manuscript offer a novel approach to understanding individual-level differences critical for informing adherence-promotion efforts.

Use of a choice survey to identify adult, adolescent and parent preferences for vaccination in the United States

Background

Adult and adolescent vaccination rates are far below coverage targets in the United States. Our objective was to identify the most influential factors related to vaccine uptake among adults, adolescents, and parents of adolescents (parents) in the United States.

Methods

We used a fractional factorial design to create a binary choice survey to evaluate preferences for vaccination. The national survey was fielded to a sample of adults, adolescents ages 13–17 years, and parents, using a national probability-based online research panel in November 2015. Respondents were presented with 5 profiles of a hypothetical vaccine and asked in a series of questions whether they would accept each vaccine. We analyzed the binary choice data using logistic regression in STATA v13 (College Station, TX) to calculate the odds that a participant would choose to accept the vaccine.

Results

We received completed responses from 334 (51%) of 652 adults, 316 (21%) of 1516 adolescents, and 339 (33%) of 1030 parents. Respondents were generally representative of the U.S. population. Vaccine effectiveness was the most influential factor in the choice to vaccinate for all groups. Other most influential factors were primary care provider (PCP) recommendation and the out-of-pocket cost of the vaccine. Other factors such as risk of illness, risk of vaccine side effects, vaccination location, and time for vaccination were not important in the decision to get vaccinated.

Conclusions

Adults, adolescents, and parents are most sensitive to vaccine effectiveness, PCP recommendation, and out-of-pocket cost for vaccination in their decision to get vaccinated. Strong PCP recommendations that focus on vaccine effectiveness and health care policies that minimize out-of-pocket costs for vaccinations may increase vaccine uptake by adults and adolescents.

Electronic supplementary material

The online version of this article (10.1186/s41687-019-0135-0) contains supplementary material, which is available to authorized users.

Assessment of Prescriber and Pharmacy Shopping Among the Family Members of Patients Prescribed Opioids

IMPORTANCE

Most prescription opioid misuse involves opioids prescribed to others-a form of opioid diversion. However, few indicators of diversion risk exist. Because family members can often access patients' opioids, one such indicator may be the frequency with which opioid prescriptions are filled by patients when their family members are engaged in opioid prescriber and pharmacy shopping ("doctor and pharmacy shopping"). To date, this frequency has not been estimated.

OBJECTIVE

To estimate the proportion of opioid prescription fills for which family members meet prescriber and pharmacy shopping criteria.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of 2015-2016 claims from a national commercial insurer was conducted from August to October, 2018. The sample included patients without cancer who were covered by family insurance plans and had 1 or more opioid prescription fill in 2016, as measured by prescription drug claims. Fills were the unit of analysis.

MAIN OUTCOMES AND MEASURES

For each fill in 2016 by the patient and each family member enrolled in the same plan (eg, spouse or child), the number of prescribers and number of pharmacies in the prior 12 months were counted. Prescriber and pharmacy shopping was defined as 4 or more prescribers and 4 or more pharmacies, following a National Quality Forum-endorsed measure. The proportion of fills for which 1 or more family member met criteria and the proportion for which the patient met criteria were calculated.

RESULTS

Among 554 417 patients in the sample, 301 297 (54.3%) were female and 48 047 (8.7%) were children. Mean (SD) age was 41.4 (16.4) years. Patients were enrolled in 469 913 plans and, after exclusions, filled 1 471 971 opioid prescriptions in 2016. For 8485 fills (0.6%), 1 or more family member met prescriber and pharmacy shopping criteria. For 44 547 fills (3.0%), the patient met criteria. For 6947 of the 8485 fills (81.9%) for which 1 or more family member met criteria, patients did not meet criteria. When criteria were 3 or more prescribers at 3 or more pharmacies, the proportion of fills for which 1 or more family member met criteria increased to 1.9%.

CONCLUSIONS AND RELEVANCE

In this national study of US patients with private family insurance plans, 0.6% of opioid prescription fills occurred when at least 1 of the patient's family members met prescriber and pharmacy shopping criteria. For most of these fills, patients did not meet criteria. Findings suggest the potential for opioid diversion within families.

Spillover Effects on Caregivers' and Family Members' Utility: A Systematic Review of the Literature

BACKGROUND

A growing body of research has identified health-related quality-of-life effects for caregivers and family members of ill patients (i.e. 'spillover effects'), yet these are rarely considered in cost-effectiveness analyses (CEAs).

OBJECTIVE

The objective of this study was to catalog spillover-related health utilities to facilitate their consideration in CEAs.

METHODS

We systematically reviewed the medical and economic literatures (MEDLINE, EMBASE, and EconLit, from inception through 3 April 2018) to identify articles that reported preference-based measures of spillover effects. We used keywords for utility measures combined with caregivers, family members, and burden.

RESULTS

Of 3695 articles identified, 80 remained after screening: 8 (10%) reported spillover utility per se, as utility or disutility (i.e. utility loss); 25 (30%) reported a comparison group, either population values (n = 9) or matched, non-caregiver/family member or unaffected individuals' utilities (n = 16; 3 reported both spillover and a comparison group); and 50 (63%) reported caregiver/family member utilities only. Alzheimer's disease/dementia was the most commonly studied disease/condition, and the EQ-5D was the most commonly used measurement instrument.

CONCLUSIONS

This comprehensive catalog of utilities showcases the spectrum of diseases and conditions for which caregiver and family members' spillover effects have been measured, and the variation in measurement methods used. In general, utilities indicated a loss in quality of life associated with being a caregiver or family member of an ill relative. Most studies reported caregiver/family member utility without any comparator, limiting the ability to infer spillover effects. Nevertheless, these values provide a starting point for considering spillover effects in the context of CEA, opening the door for more comprehensive analyses.

Parent Preferences for Health Outcomes Associated with Autism Spectrum Disorders

BACKGROUND

Few studies have used preference-based quality-of-life outcomes to assess how autism spectrum disorders (ASDs) affect children and parents, and none have examined variation by ASD severity.

OBJECTIVE

Our objective was to derive parent valuations of child and parent health associated with varying ASD severity levels.

METHODS

Parents of children aged 3-17 years with and without ASD were selected from a nationally representative research panel to complete a survey. We asked parents time trade-off (TTO) questions to value their own and their child's current health. Parents of children with ASD were asked to report the severity of their child's core ASD symptoms. We calculated utility values from each TTO amount, and used a two-part regression model to estimate the change in parent-reported child health utility, as well as parent health utility, associated with ASD diagnosis and increasing symptom severity, controlling for respondent and child characteristics.

RESULTS

Sixty-nine percent of parents responded (final sample size was 135 in the ASD group and 120 in the comparison group). In adjusted analyses, there was a 0.12 (95% confidence interval [CI] 0.03-0.21) decrease in the parent-reported health utility of children with ASD, a 15% decrease from the mean health utility of children without ASD. On average, having a child with ASD was not significantly associated with a decrease in parent health utility, but there was a 0.14 (95% CI 0.01-0.26) reduction in health utility among parents of children with severe ASD, a 15% decrease from the comparison group mean.

CONCLUSIONS

Overall, ASD had a significant impact on parent-reported child health utility, and the health utility of parents of children with severe ASD.

Family Spillover Effects in Pediatric Cost-Utility Analyses

BACKGROUND

Childhood illness can impose significant costs and health strains on family members, but these are not routinely captured by pediatric economic evaluations. This review investigated how family "spillover effects" related to costs and health outcomes are considered in pediatric cost-utility analyses (CUAs).

METHODS

We reviewed pediatric CUAs published between 2000 and 2015 using the Tufts Medical Center Cost-effectiveness Analysis (CEA) Registry and the Pediatric Economic Database Evaluation (PEDE) Registry. We selected studies conducted from the societal perspective and included in both registries. We investigated how frequently family spillover was incorporated into analyses, and how the inclusion of spillover health effects and costs changed CUA results.

RESULTS

We found 142 pediatric CUAs meeting inclusion criteria. Of those, 105 (72%) considered either family spillover costs (n = 98 time costs, n = 33 out-of-pocket costs, n = 2 caregiver healthcare costs) or health outcomes (n = 15). Twenty-four studies included 43 pairs of incremental cost-effectiveness ratios (ICERs) with and without spillover. In 19 pairs of ICERs, adding spillover changed the ICER enough to cross a common cost-effectiveness threshold (i.e., $50,000/QALY, $100,000/QALY, $150,000/QALY; values are in 2016 US$). Incorporating spillover generally made interventions more cost-effective (n = 18; 42%), or did not change CUA results enough to cross a threshold (n = 24; 56%). Including family spillover reduced ICERs by 31% ($40,000/QALY) on average.

CONCLUSION

Most pediatric CUAs conducted from a societal perspective include family costs but fewer include family health effects. Inclusion of family spillover effects tends to make CUA results more favorable. Future pediatric CUAs should aim to more fully incorporate the family burden of illness.

A Cost-Effectiveness Analysis of Vaccination for Prevention of Herpes Zoster and Related Complications: Input for National Recommendations

BACKGROUND

The U.S. Advisory Committee on Immunization Practices recently developed recommendations for use of a new recombinant zoster vaccine (RZV).

OBJECTIVE

To evaluate the cost-effectiveness of vaccination with RZV compared with zoster vaccine live (ZVL) and no vaccination, the cost-effectiveness of vaccination with RZV for persons who have previously received ZVL, and the cost-effectiveness of preferential vaccination with RZV over ZVL.

DESIGN

Simulation (state-transition) model using U.S. epidemiologic, clinical, and cost data.

DATA SOURCES

Published data.

TARGET POPULATION

Hypothetical cohort of immunocompetent U.S. adults aged 50 years or older.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal and health care sector.

INTERVENTION

Vaccination with RZV (recommended 2-dose regimen), vaccination with ZVL, and no vaccination.

OUTCOME MEASURES

The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

RESULTS OF BASE-CASE ANALYSIS

For vaccination with RZV compared with no vaccination, ICERs ranged by age from $10 000 to $47 000 per quality-adjusted life-year (QALY), using a societal perspective and assuming 100% completion of the 2-dose RZV regimen. For persons aged 60 years or older, ICERs were less than $60 000 per QALY. Vaccination with ZVL was dominated by vaccination with RZV for all age groups 60 years or older.

RESULTS OF SENSITIVITY ANALYSIS

Results were most sensitive to changes in vaccine effectiveness, duration of protection, herpes zoster incidence, and probability of postherpetic neuralgia. Vaccination with RZV after previous administration of ZVL yielded an ICER of less than $60 000 per QALY for persons aged 60 years or older. In probabilistic sensitivity analyses, RZV remained the preferred strategy in at least 95% of simulations, including those with 50% completion of the second dose.

LIMITATION

Few data were available on risk for serious adverse events, adherence to the recommended 2-dose regimen, and probability of recurrent zoster.

CONCLUSION

Vaccination with RZV yields cost-effectiveness ratios lower than those for many recommended adult vaccines, including ZVL. Results are robust over a wide range of plausible values.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Health utilities and parental quality of life effects for three rare conditions tested in newborns

BACKGROUND

Measurement of health utilities is required for economic evaluations. Few studies have evaluated health utilities for rare conditions; even fewer have incorporated disutility that may be experienced by caregivers. This study aimed to (1) estimate health utilities for three rare conditions currently recommended for newborn screening at the state or federal level, and (2) estimate the disutility, or spillover, experienced by parents of patients diagnosed with a rare, heritable disorder.

METHODS

A stated-preference survey using a time trade-off approach elicited health utilities for Krabbe disease, phenylketonuria, and Pompe disease at varying stages (mild, moderate, severe) and onset of disease symptoms (infancy, childhood, and adulthood). We recruited respondents from a nationally representative community sample (n = 862). Respondents valued disease specific health states in three consecutive question frames: (1) adult health state (> = 18 years of age), (2) child health state (< 18 years of age), and (3) as a parent of a child with a condition (parent spillover state). Corresponding mean utilities were calculated for plausible disease states in adulthood and childhood. Mean disutility was estimated for parental spillover. Predictors of utilities were evaluated using a negative binomial regression model.

RESULTS

More severe conditions and infant health states received lower estimated utility and greater estimated disutility among parents. Conditions with the lowest estimated health utilities were severe infantile Pompe disease (0.40, CI: 0.34-0.46) and infantile Krabbe disease (0.37, CI: 0.32-0.43). Disutility was evident for all conditions evaluated (range: 0.07-0.19).

CONCLUSIONS

Rare childhood conditions are associated with substantial estimated losses in quality of life. Evidence of disutility among parents further warrants the inclusion of spillover effects in cost-effectiveness analyses. Continued research is needed to assess and measure the effects of childhood disease from a family perspective.

Patient Preferences for Bariatric Surgery: Findings From a Survey Using Discrete Choice Experiment Methodology

Importance

Surgical options for weight loss vary considerably in risks and benefits, but the relative importance of procedure-associated characteristics in patient decision making is largely unknown.

Objective

To identify patient preferences for risks, benefits, and other attributes of treatment options available to individuals who are candidates for bariatric surgery.

Design, Setting, and Participants

This discrete choice experiment of weight loss procedures was performed as an internet-based survey administered to patients recruited from bariatric surgery information sessions in the State of Michigan. Each procedure was described by the following set of attributes: (1) treatment method, (2) recovery and reversibility, (3) time that treatment has been available, (4) expected weight loss, (5) effect on other medical conditions, (6) risk of complication, (7) adverse effects, (8) changes to diet, and (9) out-of-pocket costs. Participants chose between surgical profiles by comparing attributes. Survey data were collected from May 1, 2015, through January 30, 2016, and analyzed from February 1 to June 30, 2016.

Main Outcomes and Measures

Estimated relative value of risks and benefits for leading weight-loss surgical options and marginal willingness to pay for procedure attributes. A latent class analysis identified respondent subgroups.

Results

Among the 815 respondents (79.9% women; mean [SD] age, 44.5 [12.0] years), profiles of hypothetical procedures that included resolution of medical conditions (coefficient for full resolution, 0.229 [95% CI, 0.177 to 0.280; P < .001]; coefficient for no resolution, -0.207 [95% CI, -0.254 to -0.159; P < .001]), higher total weight loss (coefficient for each additional 20% loss, 0.185 [95% CI, 0.166 to 0.205; P < .001]), and lower out-of-pocket costs (coefficient for each additional $1000, -0.034 [95% CI, -0.042 to -0.025; P < .001]) were most likely to be selected. Younger respondents were more likely than older respondents to choose treatments with higher weight loss (coefficient for loss of 80% excess weight 0.543 [95% CI, 0.435-0.651] vs 0.397 [95% CI, 0.315-0.482]) and were more sensitive to out-of-pocket costs (coefficient for $100 out-of-pocket costs, 0.346 [95% CI, 0.221-0.470] vs 0.262 [95% CI, 0.174 to 0.350]; coefficient for $15 000 in out-of-pocket costs, -0.768 [95% CI, -0.938 to -0.598] vs -0.384 [95% CI, -0.500 to -0.268]). Marginal willingness to pay indicated respondents would pay $5470 for losing each additional 20% of excess body weight and $12 843 for resolution of existing medical conditions, the most desired procedure attributes. Latent class analysis identified the following 3 unobserved subgroups: cost-sensitive (most concerned with costs); benefit-focused (most concerned with excess weight loss and resolution of medical conditions); and procedure-focused (most concerned with how the treatment itself worked, including recovery and reversibility).

Conclusions and Relevance

Candidates for bariatric surgery identified costs, expected weight loss, and resolution of medical conditions as the most important characteristics of weight loss surgery decisions. Other information, such as risk of complications and adverse effects, were important to patients but less so.

An Assessment of Public Preferences for Newborn Screening Using Best-Worst Scaling

OBJECTIVE

To identify and quantify public preferences for attributes of newborn screening conditions.

STUDY DESIGN

We conducted an online national survey of the public (n = 502) to evaluate preferences for attributes of candidate newborn screening conditions. Respondents were presented with hypothetical condition profiles that were defined using 10 attributes with 2-6 levels per attribute. Participants indicated whether they would recommend screening for a condition and which condition attributes were most and least important when making this decision (best-worst scaling). Difference scores were calculated and stratified by condition recommendation (recommend or not recommend for screening). Regression analyses were used to evaluate the effect of attributes on choice to screen or not screen.

RESULTS

The number of babies diagnosed was important to those who would recommend newborn screening for a profile, and age at which the treatment would start was important to those who would not recommend newborn screening. Cost was considered to be a key attribute, and treatment effectiveness and impact of making the diagnosis through newborn screening were of low importance for both groups.

CONCLUSION

Public preferences identified through survey methods that provide an adequate baseline understanding of newborn screening can be used to inform newborn screening decisions.

What are the clinical, quality-of-life, and cost consequences of 30 years of excellent vs. poor glycemic control in type 1 diabetes?

OBJECTIVE

The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy for type 1 diabetes delayed the development of microvascular and neuropathic complications compared to conventional therapy. At the end of DCCT, all participants were trained in intensive therapy, care was transferred to community providers, and the difference in HbA1c between treatment groups narrowed and disappeared. Our objective was to describe the outcomes and the quality-of-life and costs associated with those outcomes in participants who maintained excellent vs. poor glycemic control over 30 years.

RESEARCH DESIGN AND METHODS

We assessed the incidence of retinopathy, nephropathy, neuropathy, cardiovascular disease, acute metabolic complications, death, quality-of-life, and costs in the tertile of DCCT intensive therapy participants who achieved a mean updated HbA1c of <7.2% (55 mmol/mol) and the tertile of DCCT conventional therapy participants (n = 240) who achieved a mean updated HbA1c of >8.8% (73 mmol/mol) over 30 years.

RESULTS

Thirty years of excellent vs. poor glycemic control substantially reduced the incidence of retinopathy requiring laser therapy (5% vs. 45%), end-stage renal disease (0% vs. 5%), clinical neuropathy (15% vs. 50%), myocardial infarction (3% vs. 5%), stroke (0.4% vs. 2%), and death (6% vs. 20%). It also resulted in a gain of ~1.62 quality-adjusted life-years and averted ~$90,900 in costs of complications per participant.

CONCLUSIONS

Thirty years of excellent vs. poor glycemic control for T1DM can substantially reduce the incidence of complications, comorbidities, and death, improve quality-of-life, and reduce costs. These estimates represent the benefits that may be achieved with excellent glycemic control.