Economic analysis of influenza vaccination and antiviral treatment for healthy working adults

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.

Association between Social Integration, Social Exclusion, and Vaccination Behavior among Internal Migrants in China: A Cross-Sectional Study

Cross-sectional studies about the association between social integration, social exclusion, and vaccination behavior among internal migrants in China are lacking. In this study, we aimed to explore the association between the influenza vaccination behavior and social integration as well as social exclusion in China based on a cross-sectional study. We included 12,467 participants aged 15 years old or above from the 2017 Migrant Population Dynamic Monitoring Survey (MDMS). We used univariate analysis and logistic regression models to access the association between social integration, exclusion status, and influenza vaccination rates. Results suggested that the association between social integration and the vaccination rate was significantly positive. Moving between different districts impact on people’s mental health and their health performance. Significant association between influenza vaccination behavior and education attainment, income status, health record, and awareness of basic public health services program was reported. Therefore, in order to reduce the incidence of influenza disease and increase the vaccination rate, policymakers and the public should promote social integration for internal migrants. Meanwhile, our finding also implies possible strategies to promote COVID-19 vaccination.

Comparison of Inconvenience Costs Between Influenza Antivirals for Japanese Pediatric Patients: A Conjoint Analysis of Parental Responses

Introduction

Certain drug characteristics, including dosage and form, are associated with either convenience or inconvenience for the patients taking them, and any inconvenience can be considered as a “cost” in disease treatment. Multiple antivirals are available for influenza in Japan, with various dosages and forms. This study evaluated the inconvenience costs associated with influenza antivirals for pediatric patients by using conjoint analysis on responses from their parents.

Methods

An online survey (May 2021) was conducted for parents whose child took antivirals for influenza at 6–11 years during the 3 years until March 2021. Attributes of the conjoint analysis were administration routes and formulation (tablet, capsule, dry syrup, or inhalant), duration of administration, frequency of administration per day, and out-of-pocket expenses. We assumed the efficacy and safety to be equivalent among the antivirals. A logistic regression model was applied to the analysis. We also asked parents about their recent experiences with antiviral treatment for their child.

Results

We collected responses from 3161 eligible individuals. The mean age (standard deviation) of the children when taking the antivirals and percentage of female children were 8.27 (1.63) years old and 53.2%, respectively. The tablet was the most preferred formulation; the inconvenience costs for each administration route and formulation, relative to the tablet as zero, were Japanese yen (JPY) 515 (US dollar 4.61, as of October 2021) for the inhalant, JPY 775 for the capsule, and JPY 804 for the dry syrup. The inconvenience costs for 5 days relative to 1 day and for twice a day relative to once a day were JPY 2150 and JPY 399, respectively.

Conclusion

Based on the conjoint analysis, a single-dose tablet antiviral was suggested to have the lowest inconvenience cost for pediatric patients.

Trial Registration

UMIN000044243.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02062-z.

Economic evaluations of interventions against influenza at workplaces: systematic review

BACKGROUND

The burden of influenza is mostly felt by employees and employers because of increased absenteeism rates, loss of productivity and associated direct costs. Even though interventions against influenza among working adults are effective, patronage and compliance to these measures especially vaccination are low compared to other risk groups.

AIMS

This study was aimed to assess evidence of economic evaluations of interventions against influenza virus infection among workers or in the workplace setting.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guideline for systematic reviews was followed. Three databases, PubMed, Web of Science and EconLit, were searched using keywords to identify relevant articles from inception till 25 October 2020. Original peer-reviewed papers that conducted economic evaluations of influenza interventions using cost-benefit, cost-effectiveness or cost-utility analysis methods focused on working-age adults or work settings were eligible for inclusion. Two independent teams of co-authors extracted and synthesized data from identified studies.

RESULTS

Twenty-four articles were included: 21 were cost-benefit analyses and 3 examined cost-effectiveness analyses. Two papers also presented additional cost-utility analysis. Most of the studies were pharmaceutical interventions (n = 23) primarily focused on vaccination programs while one study was a non-pharmaceutical intervention examining the benefit of paid sick leave. All but two studies reported that interventions against influenza virus infection at the workplace were cost-saving and cost-effective regardless of the analytic approach.

CONCLUSIONS

Further cost-effectiveness research in non-pharmaceutical interventions against influenza in workplace settings is warranted. There is a need to develop standardized methods for reporting economic evaluation methods to ensure comparability and applicability of future research findings.

Estimation of the value of convenience in taking influenza antivirals in Japanese adult patients between baloxavir marboxil and neuraminidase inhibitors using a conjoint analysis

AIMS

Estimating the monetary value of the convenience of using influenza antivirals approved in Japan from a patient perspective using a conjoint analysis.

METHODS

An online survey (August 2020) was performed on individuals aged 20-64 years living in Japan who had taken oral or inhalant antivirals for influenza treatment in the 2018/19 or 2019/20 seasons. Efficacy and safety were assumed to be equivalent among the antivirals. The attributes for the conjoint analysis included route (oral or inhalant), duration, frequency of administration, and out-of-pocket expenses. A conditional logit model was applied as a baseline model. The monetary value of each attribute was calculated by comparing the same utility of the linearly interpolated level of the out-of-pocket attribute. Another survey to determine the experiences of the latest antiviral intake was also conducted on the same respondents.

RESULTS

Of the respondents, 1,550 were men and 1,587 were women. The monetary value for oral antivirals was estimated to be higher, saving JPY 741 (USD 7.06, as of August 2020), compared with inhalant. Regarding the length and frequency of administration, five days corresponds to an increase of JPY 2,072, compared with one day, and twice a day corresponds to a JPY 574 increase compared to once a day.

CONCLUSIONS

The results suggest that - among the antivirals approved in Japan - the monetary value of the utility is the highest in the single dose oral antiviral, baloxavir marboxil (baloxavir). Although the drug cost was highest in baloxavir among the brand antivirals, the difference in the value of utility for influenza patient was estimated to be larger than the difference in the drug costs.

LIMITATIONS

Although individuals with diverse attributes from all over the country were included in the survey, they are not necessarily a representative population of the Japanese society.

Cost-effectiveness of a comprehensive immunization program serving high-risk, uninsured adults

Despite the numerous social and economic benefits of vaccination, adult immunization rates fall far short of recommended levels costing the United States $9 billion annually in health care expenditures and reduced productivity. While it is well recognized that childhood immunization is highly cost-effective, the economic impact of adult immunization programs varies by disease and is influenced by population demographics. This study aimed to assess the cost-effectiveness of a comprehensive adult immunization program serving high-need populations delivered by a local health department (LHD) in partnership with community organizations. We modeled incremental cost-effectiveness taking the payer perspective of each vaccine separately in simulated cohorts of 100,000 over a 20-year horizon using data provided by the LHD and data from the published literature. We adjusted the results to align with actual program delivery and used them to estimate an incremental cost-effectiveness ratio (ICER) for the entire program. We assessed the effects of varying our base model parameters in univariate sensitivity analyses. We discounted benefits and life years saved (LYS) at 3% and adjusted results to 2016 US$. Four of seven disease models were cost-effective (using a $100,000 CE threshold) with ICERS ranging from $14,260 to $79,022/LYS. Sensitivity analyses did not substantially impact the results. The ICER for program as a whole was $67,940/LYS. A community-delivered comprehensive immunization program serving uninsured, low income, high-risk adults is a cost-effective investment even when most do not receive the full regimen of some vaccines.

A Framework for Discovering Health Disparities among Cohorts in an Influenza Epidemic

Infectious diseases such as Influenza and Ebola pose a serious threat to everyone but certain demographics and cohorts face a higher risk of infection than others. This research provides a computational framework for studying health disparities among cohorts based on individual level features, such as age, gender, income, etc. We apply this framework to find health disparities among subpopulations in an influenza epidemic and evaluate vaccination prioritization strategies to achieve specific objectives. We explore the heterogeneities in individuals' demographic and socioeconomic attributes as the potential cause of health disparities. An agent-based model is used to simulate an influenza epidemic over a synthetic social contact network of the Montgomery County in Southwest Virginia to identify infected cases which are then labeled with a specific clinical outcome by using a predefined probability distribution based on age and risk level. We divide the population into age and income based cohorts and measure the direct and indirect economic impact of vaccination for each cohort. Simulation-based results find strong health disparities across age and income groups. Various vaccine distribution strategies are considered and outcomes are measured through metrics such as death count, total number of infections, net return per capita, net return per dollar spent and net return per vaccinated person. The results, framework, and methodology developed here can assist public health policy makers in efficiently allocating limited pharmaceutical resources.

Cost-effectiveness of adult vaccinations: A systematic review

BACKGROUND

Coverage levels for many recommended adult vaccinations are low. The cost-effectiveness research literature on adult vaccinations has not been synthesized in recent years, which may contribute to low awareness of the value of adult vaccinations and to their under-utilization. We assessed research literature since 1980 to summarize economic evidence for adult vaccinations included on the adult immunization schedule.

METHODS

We searched PubMed, EMBASE, EconLit, and Cochrane Library from 1980 to 2016 and identified economic evaluation or cost-effectiveness analysis for vaccinations targeting persons aged ≥18 years in the U.S. or Canada. After excluding records based on title and abstract reviews, the remaining publications had a full-text review from two independent reviewers, who extracted economic values that compared vaccination to "no vaccination" scenarios.

RESULTS

The systematic searches yielded 1688 publications. After removing duplicates, off-topic publications, and publications without a "no vaccination" comparison, 78 publications were included in the final analysis (influenza = 25, pneumococcal = 18, human papillomavirus = 9, herpes zoster = 7, tetanus-diphtheria-pertussis = 9, hepatitis B = 9, and multiple vaccines = 1). Among outcomes assessing age-based vaccinations, the percent indicating cost-savings was 56% for influenza, 31% for pneumococcal, and 23% for tetanus-diphtheria-pertussis vaccinations. Among age-based vaccination outcomes reporting $/QALY, the percent of outcomes indicating a cost per QALY of ≤$100,000 was 100% for influenza, 100% for pneumococcal, 69% for human papillomavirus, 71% for herpes zoster, and 50% for tetanus-diphtheria-pertussis vaccinations.

CONCLUSIONS

The majority of published studies report favorable cost-effectiveness profiles for adult vaccinations, which supports efforts to improve the implementation of adult vaccination recommendations.

Epidemiological and economic impact of pandemic influenza in Chicago: Priorities for vaccine interventions

The study objective is to estimate the epidemiological and economic impact of vaccine interventions during influenza pandemics in Chicago, and assist in vaccine intervention priorities. Scenarios of delay in vaccine introduction with limited vaccine efficacy and limited supplies are not unlikely in future influenza pandemics, as in the 2009 H1N1 influenza pandemic. We simulated influenza pandemics in Chicago using agent-based transmission dynamic modeling. Population was distributed among high-risk and non-high risk among 0–19, 20–64 and 65+ years subpopulations. Different attack rate scenarios for catastrophic (30.15%), strong (21.96%), and moderate (11.73%) influenza pandemics were compared against vaccine intervention scenarios, at 40% coverage, 40% efficacy, and unit cost of $28.62. Sensitivity analysis for vaccine compliance, vaccine efficacy and vaccine start date was also conducted. Vaccine prioritization criteria include risk of death, total deaths, net benefits, and return on investment. The risk of death is the highest among the high-risk 65+ years subpopulation in the catastrophic influenza pandemic, and highest among the high-risk 0–19 years subpopulation in the strong and moderate influenza pandemics. The proportion of total deaths and net benefits are the highest among the high-risk 20–64 years subpopulation in the catastrophic, strong and moderate influenza pandemics. The return on investment is the highest in the high-risk 0–19 years subpopulation in the catastrophic, strong and moderate influenza pandemics. Based on risk of death and return on investment, high-risk groups of the three age group subpopulations can be prioritized for vaccination, and the vaccine interventions are cost saving for all age and risk groups. The attack rates among the children are higher than among the adults and seniors in the catastrophic, strong, and moderate influenza pandemic scenarios, due to their larger social contact network and homophilous interactions in school. Based on return on investment and higher attack rates among children, we recommend prioritizing children (0–19 years) and seniors (65+ years) after high-risk groups for influenza vaccination during times of limited vaccine supplies. Based on risk of death, we recommend prioritizing seniors (65+ years) after high-risk groups for influenza vaccination during times of limited vaccine supplies.

The study objective is to estimate the epidemiological and economic impact of vaccine interventions during an influenza pandemic in Chicago, to assist in vaccine intervention priorities. Population dynamics play an important role in influenza pandemic planning and response. To optimally allocate limited vaccine resources, it is important to inform decision makers and public health officials about both the direct benefit among vaccinated population and the indirect benefit among non-vaccinated population. This study adds to the evidence of prior studies by using a detailed agent-based model for estimating the direct and indirect benefits of epidemiological and economic impact of vaccine-based interventions. This study can be extended to analyze for a range of vaccine compliance and efficacy values at different attack rates of influenza pandemics in different rural and urban areas of the United States and at the country level, to infer objective prioritization criteria for influenza vaccine interventions among different risk and age groups.

Systematic review of the cost-effectiveness of influenza immunization programs

BACKGROUND

Seasonal influenza immunization programs vary widely across jurisdictions. In Canada, some provinces offer universal programs while others target specific population groups. However, whether targeted or universal programs provide more benefit and value-for-money is unclear. The cost-effectiveness of influenza immunization programs was systematically reviewed to inform policy.

METHODS

Citation databases and the grey literature were searched for economic evaluations of influenza immunization programs. Eligible studies were appraised using the Scottish Intercollegiate Guidelines Network (SIGN) checklist with supplemental WHO vaccine-related questions. Data from high quality studies was extracted and the studies reviewed.

RESULTS

A total of 41influenza immunization studies were identified. Of these, 31 were high quality. For pregnant and postpartum women, vaccinating all versus only high risk women study results ranged from dominance (less costly and more effective) to $9773 per QALY gained (societal) and from dominance to $58,000 per QALY gained (healthcare system). Studies of vaccinating all versus only high risk children found vaccination to be dominant to $47,000 per QALY gained (societal), and dominant to $18,000 per QALY gained (healthcare system). Vaccinating high risk adults was highly cost-effective and vaccinating health care workers resulted in $35,000 per QALY gained. Results for healthy working adults were mixed and sensitive to vaccine uptake, efficacy, and productivity loss.

CONCLUSIONS

From the societal perspective, vaccination was cost-effective for children, pregnant and postpartum women, high risk groups, and in some cases, healthy working age adults. Immunization programs using group administration are more cost-effective than programs using individual administration. The perspective, programmatic design, setting, and inclusion of herd immunity affects cost-effectiveness. In regions with targeted programs, re-evaluating "high risk" criteria and consideration of a universal program is warranted.

The Business Case for Quality: Combining Medical Literature Research with Health Plan Data to Establish Value for Nonclinical Managers

Clinical managers face a growing need to communicate the value of what they do in terms that can be interpreted by nonclinical financial managers. We have sought to link the evidence basis of current guidelines to variables that will demonstrate in more financial terms the very real benefit of treating diseases aggressively. We have developed an approach using the medical literature that is designed to describe clinical initiatives in more concrete terms as desired by senior management. This becomes specifically critical during budget time and when justification for various clinical programs is needed. The approach uses medical research from the peer-reviewed literature to estimate the economic impact of various initiatives and then combines the analysis with an organization's actual data to impute potential benefit. A sample grid for developing the analysis is attached. A comprehensive bibliography that will assist others with similar endeavors has been included. Although not as rigorous as formal methods, actuarial analyses, or health services research activities, it presents a beginning framework around which an organization can create operational estimates of initiative effectiveness.

The impacts of simultaneous disease intervention decisions on epidemic outcomes

Mathematical models of the interplay between disease dynamics and human behavioural dynamics can improve our understanding of how diseases spread when individuals adapt their behaviour in response to an epidemic. Accounting for behavioural mechanisms that determine uptake of infectious disease interventions such as vaccination and non-pharmaceutical interventions (NPIs) can significantly alter predicted health outcomes in a population. However, most previous approaches that model interactions between human behaviour and disease dynamics have modelled behaviour of these two interventions separately. Here, we develop and analyze an agent based network model to gain insights into how behaviour toward both interventions interact adaptively with disease dynamics (and therefore, indirectly, with one another) during the course of a single epidemic where an SIRV infection spreads through a contact network. In the model, individuals decide to become vaccinated and/or practice NPIs based on perceived infection prevalence (locally or globally) and on what other individuals in the network are doing. We find that introducing adaptive NPI behaviour lowers vaccine uptake on account of behavioural feedbacks, and also decreases epidemic final size. When transmission rates are low, NPIs alone are as effective in reducing epidemic final size as NPIs and vaccination combined. Also, NPIs can compensate for delays in vaccine availability by hindering early disease spread, decreasing epidemic size significantly compared to the case where NPI behaviour does not adapt to mitigate early surges in infection prevalence. We also find that including adaptive NPI behaviour strongly mitigates the vaccine behavioural feedbacks that would otherwise result in higher vaccine uptake at lower vaccine efficacy as predicted by most previous models, and the same feedbacks cause epidemic final size to remain approximately constant across a broad range of values for vaccine efficacy. Finally, when individuals use local information about others’ behaviour and infection prevalence, instead of population-level information, infection is controlled more efficiently through ring vaccination, and this is reflected in the time evolution of pair correlations on the network. This model shows that accounting for both adaptive NPI behaviour and adaptive vaccinating behaviour regarding social effects and infection prevalence can result in qualitatively different predictions than if only one type of adaptive behaviour is modelled.

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We create an agent based network model that simulates an epidemic.

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We combine population decisions for vaccination and non-pharmaceutical interventions.

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Vaccination mitigates epidemic final size effectively for high transmission rates.

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Non-pharmaceutical interventions compensate for delays in vaccine availability.

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Non-pharmaceutical interventions can lower vaccine uptake and reduce epidemic size.

The Saudi Thoracic Society guidelines for influenza vaccinations

Influenza viruses are responsible for the influenza outbreaks that lead to significant burden and cause significant morbidity and mortality worldwide. Based on the core proteins, influenza viruses are classified into three types, A, B, and C, of which only A and B cause significant human disease and so the vaccine is directed against these two subtypes only. The effectiveness of the vaccine depends on boosting the immune system against the serotypes included within it. As influenza viruses undergo periodic changes in their antigen, the vaccine is modified annually to ensure susceptibility. In contrast to other countries, Saudi Arabia faces a unique and challenging situation due to Hajj and Umrah seasons, when millions of people gather at the holy places in Mecca and Madinah, during which influenza outbreaks are commonly found. Such challenges making the adoption of strict vaccination strategy in Saudi Arabia is of great importance. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and easy to use by health care workers. The guideline was designed to provide recommendations for problems frequently encountered in real life, with special consideration for special situations such as Hajj and Umrah seasons and pregnancy.

Economic analysis of rapid and sensitive polymerase chain reaction testing in the emergency department for influenza infections in children

BACKGROUND

Rapid multiplex polymerase chain reaction (PCR) assays simultaneously detect several respiratory viral pathogens with high sensitivity. Maximizing detection of influenza at the point of care has the potential to reduce unnecessary antibiotic use, laboratory tests and hospitalizations. However, the cost-effectiveness of rapid multiplex PCR assays for influenza has not been compared with other diagnostic methods in children.

METHODS

For children presenting to the emergency department with influenza-like illness, we compared costs and outcomes using 4 different testing strategies for detection of influenza: (1) a rapid multiplex PCR platform (FilmArray); (2) traditional PCR; (3) direct-fluorescent antibody and (4) rapid antigen tests. Costs were assessed from the hospital perspective, and effectiveness was defined as quality-adjusted life years (QALYs). Input parameters were obtained from previous studies, and the model was run separately for children aged 3-36 months and 3-18 years.

RESULTS

Rapid multiplex PCR testing was the most effective testing strategy for children in both age groups. The incremental cost-effectiveness when compared with rapid antigen tests was $115,556 per QALY for children aged 3-36 months and from $228,000 per QALY for children aged 3-18 years. The cost-effectiveness of rapid multiplex PCR was sensitive to estimates for influenza prevalence, the proportion of patients treated with antivirals and the cost per test.

CONCLUSIONS

Our model identifies scenarios in which identification of influenza in the emergency department using rapid multiplex PCR testing is a cost-effective strategy for infants and children 3 months through 18 years. Including detection of other respiratory viruses in the analysis would further improve cost-effectiveness.

Disease Interventions Can Interfere with One Another through Disease-Behaviour Interactions

Theoretical models of disease dynamics on networks can aid our understanding of how infectious diseases spread through a population. Models that incorporate decision-making mechanisms can furthermore capture how behaviour-driven aspects of transmission such as vaccination choices and the use of non-pharmaceutical interventions (NPIs) interact with disease dynamics. However, these two interventions are usually modelled separately. Here, we construct a simulation model of influenza transmission through a contact network, where individuals can choose whether to become vaccinated and/or practice NPIs. These decisions are based on previous experience with the disease, the current state of infection amongst one's contacts, and the personal and social impacts of the choices they make. We find that the interventions interfere with one another: because of negative feedback between intervention uptake and infection prevalence, it is difficult to simultaneously increase uptake of all interventions by changing utilities or perceived risks. However, on account of vaccine efficacy being higher than NPI efficacy, measures to expand NPI practice have only a small net impact on influenza incidence due to strongly mitigating feedback from vaccinating behaviour, whereas expanding vaccine uptake causes a significant net reduction in influenza incidence, despite the reduction of NPI practice in response. As a result, measures that support expansion of only vaccination (such as reducing vaccine cost), or measures that simultaneously support vaccination and NPIs (such as emphasizing harms of influenza infection, or satisfaction from preventing infection in others through both interventions) can significantly reduce influenza incidence, whereas measures that only support expansion of NPI practice (such as making hand sanitizers more available) have little net impact on influenza incidence. (However, measures that improve NPI efficacy may fare better.) We conclude that the impact of interference on programs relying on multiple interventions should be more carefully studied, for both influenza and other infectious diseases.

Mandatory Influenza Vaccination of Healthcare Workers: A 5-Year Study

Background.

The rate of influenza vaccination among healthcare workers (HCWs) is low, despite a good rationale and strong recommendations for vaccination from many health organizations.

Objective.

To increase influenza vaccination rates by instituting the first mandatory influenza vaccination program for HCWs.

Design and Setting.

A 5-year study (from 2005 to 2010) at Virginia Mason Medical Center, a tertiary care, multispecialty medical center in Seattle, Washington, with approximately 5,000 employees.

Methods.

All HCWs of the medical center were required to receive influenza vaccination. HCWs who were granted an accommodation for medical or religious reasons were required to wear a mask at work during influenza season. The main outcome measure was rate of influenza vaccination among HCWs.

Results.

In the first year of the program, there were a total of 4,703 HCWs, of whom 4,588 (97.6%) were vaccinated, and influenza vaccination rates of more than 98% were sustained over the subsequent 4 years of our study. Less than 0.7% of HCWs were granted an accommodation for medical or religious reasons and were required to wear a mask at work during influenza season, and less than 0.2% of HCWs refused vaccination and left Virginia Mason Medical Center.

Conclusion.

A mandatory influenza vaccination program for HCWs is feasible, results in extremely high vaccination rates, and can be sustained over the course of several years.

Influenza-related health care utilization and productivity losses during seasons with and without a match between the seasonal and vaccine virus B lineage

OBJECTIVE

To assess and compare direct medical costs (incurred by payers) and indirect productivity losses (incurred by employers) associated with influenza seasons with matched or mismatched circulating and vaccine containing influenza B lineages.

METHODS

A retrospective analysis, using two MarketScan databases, for the years 2000-2009. Each influenza season was categorized as matched or mismatched after comparing that season's circulating influenza B lineage and the vaccine influenza B lineage. Patients selected had at least one diagnosis claim for influenza (ICD-9-CM code 487.xx [influenza] or 488.1 [H1N1]) during an influenza season. We assessed the incidence of influenza (overall and influenza B), influenza-related medical utilization and associated costs, and productivity losses for each season.

RESULTS

The four matched seasons had lower average influenza incidence (overall incidence per 100,000 plan members: 509; 95% confidence interval [CI]: 505-512) than the five mismatched seasons (748; 95% CI: 745-751). The mismatched seasons had lower influenza B incidence (average incidence per 100,000 plan members: 126; 95% CI: 125-128) than the matched seasons (165; 95% CI: 163-167). The average, per-patient, total influenza-related medical costs in the mismatched seasons ($300.83; range: $245.38-$371.58) were approximately $61.00 higher than in the matched seasons ($239.43; range: $201.49-$264.01). The mismatched seasons had greater average per-patient, influenza-related productivity-loss costs than the matched seasons (mean: $237.31 vs. $175.10).

CONCLUSION

CDC data showed that influenza A was the predominant circulating strain during seasons in which the circulating influenza B lineage did not match the vaccine influenza B lineage. This resulted in lower influenza B incidence during the mismatched seasons. However, the average, per-patient, influenza-related direct medical costs and indirect productivity losses were higher during the mismatched seasons. Additional research is required to determine if these higher costs can be attributed to influenza B infections and if the influenza severity varies during mismatched seasons.

Policy resistance undermines superspreader vaccination strategies for influenza

Theoretical models of infection spread on networks predict that targeting vaccination at individuals with a very large number of contacts (superspreaders) can reduce infection incidence by a significant margin. These models generally assume that superspreaders will always agree to be vaccinated. Hence, they cannot capture unintended consequences such as policy resistance, where the behavioral response induced by a new vaccine policy tends to reduce the expected benefits of the policy. Here, we couple a model of influenza transmission on an empirically-based contact network with a psychologically structured model of influenza vaccinating behavior, where individual vaccinating decisions depend on social learning and past experiences of perceived infections, vaccine complications and vaccine failures. We find that policy resistance almost completely undermines the effectiveness of superspreader strategies: the most commonly explored approaches that target a randomly chosen neighbor of an individual, or that preferentially choose neighbors with many contacts, provide at best a 2% relative improvement over their non-targeted counterpart as compared to 12% when behavioral feedbacks are ignored. Increased vaccine coverage in super spreaders is offset by decreased coverage in non-superspreaders, and superspreaders also have a higher rate of perceived vaccine failures on account of being infected more often. Including incentives for vaccination provides modest improvements in outcomes. We conclude that the design of influenza vaccine strategies involving widespread incentive use and/or targeting of superspreaders should account for policy resistance, and mitigate it whenever possible.

Employer-incurred health care costs and productivity losses associated with influenza

The primary objective of this study was to assess trends in employer expenditures for both direct medical costs and indirect productivity losses associated with influenza. A retrospective analysis was performed using two of the MarketScan family of databases for 2005-2009. Patients with at least one diagnosis claim for influenza during an influenza season were selected. We estimated seasonal incidence of influenza in the employed population from the MarketScan Commercial Claims and Encounters database. Health care utilization and costs and productivity losses were assessed during the 21-d period following the influenza diagnosis date. Compared with the 2005-2006 season (493 per 100,000 plan members), influenza incidence increased during the 2006-2007 (598 per 100,000 plan members) and 2007-2008 (1,142 per 100,000 plan members) seasons and had a dramatic increase during the pandemic season of 2008-2009 (1,715 per 100,000 plan members) . The total influenza-related employer spending per 100,000 plan members also increased by over 400% during the 2008-2009 influenza season [$623,248; confidence interval (CI]):$601,518-$644,991], compared with 2005-2006 ($145,834; 95% CI: $135,067-$156,603). The primary drivers of the increased costs were emergency room, outpatient and inpatient visits. Total costs associated with influenza-related missed work time per 100,000 plan members increased over 4-fold from $26,479 in the 2005-2006 influenza season to $122,811 in 2008-2009. Overall, as expected, considerably higher direct and indirect costs were observed during the 2008-2009 influenza pandemic season than during other influenza seasons. In recent years, the influenza-related employer burden has increased considerably. In future, employers may need efficient resource allocation in order to address the productivity losses and increasing direct medical costs associated with increased influenza incidence. One of the strategies that employers may consider is increasing influenza vaccination rates among employees, which likely will help lower the influenza incidence and the associated downstream direct and indirect costs.

Choosing among employer-sponsored health plans: what drives employee choices?

OBJECTIVE

To probe employee basis for choosing health plans.

METHODS

In a Web study, 337 employees from large private and public employers were asked to choose among health plans varying on several common dimensions.

RESULTS

On per-dollar basis, respondents were more willing to spend $3 to $4 on out-of-pocket copayments than $1 on premiums. Nevertheless, sensitivity to monthly premium is greatest among those who are younger and cover only themselves, whereas sensitivity to the annual deductible is greatest among nonwhite families.

CONCLUSION

Employees are facing a complicated choice and might be well-served by more information about the value of options under different likelihood scenarios.

Recommendations for the prevention and treatment of influenza using antiviral drugs based on cost-effectiveness

Influenza is an acute respiratory disease that causes epidemics and pandemics in the human population of temperate regions. Influenza epidemics occur every year during the winter months, affecting approximately 10% of the population. The primary strategy for reducing the effect of influenza in the community is to vaccinate persons who are at risk or caring for high-risk individuals each year before seasonal increases in influenza virus circulation occur. Antiviral drugs can be used for the treatment of influenza and the prevention of seasonal and post-exposure influenza. Four antiviral drugs are available for the prevention and treatment of influenza infections: oseltamivir, zanamivir, rimantadine and amantadine. Antiviral drugs can be used for the treatment of influenza and for post-exposure and seasonal influenza prevention. The cost-effectiveness of antiviral therapies ranged from cost savings to more than US$130,000 per quality-adjusted life-year (QALY) for influenza treatment, from GB pound9000 to more than pound1 million per QALY for seasonal prevention and from cost savings to pound100,000 per QALY for post-exposure prevention. Based on the cost-effectiveness threshold of pound30,000 or $40,000 per QALY, antiviral therapies can be recommended for influenza treatment and post-exposure prevention in healthy and high-risk individuals and for seasonal prevention in high-risk individuals. Zanamivir, oseltamivir and amantadine have favorable cost-effectiveness ratios for these interventions, but amantadine should only be used in countries with a low prevalence of resistant virus. The stockpile of antiviral drugs should be maintained in developed countries because they are cost effective for the prevention and treatment of a possible influenza pandemic.

The impact of personal experiences with infection and vaccination on behaviour-incidence dynamics of seasonal influenza

Personal experiences with past infection events, or perceived vaccine failures and complications, are known to drive vaccine uptake. We coupled a model of individual vaccinating decisions, influenced by these drivers, with a contact network model of influenza transmission dynamics. The impact of non-influenzal influenza-like illness (niILI) on decision-making was also incorporated: it was possible for individuals to mistake niILI for true influenza. Our objectives were to (1) evaluate the impact of personal experiences on vaccine coverage; (2) understand the impact of niILI on behaviour-incidence dynamics; (3) determine which factors influence vaccine coverage stability; and (4) determine whether vaccination strategies can become correlated on the network in the absence of social influence. We found that certain aspects of personal experience can significantly impact behaviour-incidence dynamics. For instance, longer term memory for past events had a strong stabilising effect on vaccine coverage dynamics, although it could either increase or decrease average vaccine coverage depending on whether memory of past infections or past vaccine failures dominated. When vaccine immunity wanes slowly, vaccine coverage is low and stable, and infection incidence is also very low, unless the effects of niILI are ignored. Strategy correlations can occur in the absence of imitation, on account of the neighbour-neighbour transmission of infection and history-dependent decision making. Finally, niILI weakens the behaviour-incidence coupling and therefore tends to stabilise dynamics, as well as breaking up strategy correlations. Behavioural feedbacks, and the quality of self-diagnosis of niILI, may need to be considered in future programs adopting "universal" flu vaccines conferring long-term immunity. Public health interventions that focus on reminding individuals about their previous influenza infections, as well as communicating facts about vaccine efficacy and the difference between influenza and niILI, may be an effective way to increase vaccine coverage and prevent unexpected drops in coverage.

Issues in the economic evaluation of influenza vaccination by injection of healthy working adults in the US: a review and decision analysis of ten published studies

The objective was to review recent economic evaluations of influenza vaccination by injection in the US, assess their evidence, and conclude on their collective findings. The literature was searched for economic evaluations of influenza vaccination injection in healthy working adults in the US published since 1995. Ten evaluations described in nine papers were identified. These were synopsized and their results evaluated, the basic structure of all evaluations was ascertained, and sensitivity of outcomes to changes in parameter values were explored using a decision model. Areas to improve economic evaluations were noted. Eight of nine evaluations with credible economic outcomes were favourable to vaccination, representing a statistically significant result compared with a proportion of 50% that would be expected if vaccination and no vaccination were economically equivalent. Evaluations shared a basic structure, but differed considerably with respect to cost components, assumptions, methods, and parameter estimates. Sensitivity analysis indicated that changes in parameter values within the feasible range, individually or simultaneously, could reverse economic outcomes. Given stated misgivings, the methods of estimating influenza reduction ascribed to vaccination must be researched to confirm that they produce accurate and reliable estimates. Research is also needed to improve estimates of the costs per case of influenza illness and the costs of vaccination. Based on their assumptions, the reviewed papers collectively appear to support the economic benefits of influenza vaccination of healthy adults. Yet the underlying assumptions, methods and parameter estimates themselves warrant further research to confirm they are accurate, reliable and appropriate to economic evaluation purposes.

Seasonal influenza vaccination of healthy working-age adults: a review of economic evaluations

The recent impact of influenza on the working-age population of the US has led to changes in the recommendations for vaccination against seasonal influenza; however, the implications of vaccinating such a population have been debated. A review of cost-effectiveness analyses of vaccinating the working-age population of the US against seasonal influenza was conducted using articles published between January 1990 and January 2010. Studies considered for inclusion were identified using MEDLINE, EMBASE and Econlit. Reviewers worked in pairs, and each team member independently extracted relevant data using a standard abstraction form. The source and appropriateness of parameters (epidemiological data, probabilities and costs), the designs employed and the sufficiency of sensitivity analysis were considered during review. Key inputs extracted from the selected studies included influenza or influenza-like illness attack rates, outpatient visits averted, total vaccination days and lost workdays. Seven studies were identified as appropriate for this review. All studies were conducted in the US and from the societal perspective; three were randomized controlled trials and the remaining four were economic simulation models comparing vaccination and influenza antiviral drugs or no intervention; analyses focused on healthy working-age adults aged 18-49 years. Results ranged from net savings of $US68.96 to net costs of $US85.92 per person vaccinated (four studies) and net costs of $US104-1005 per episode of influenza averted (one study). Only two studies reported cost-effectiveness ratios; these ranged from $US26,565 to $US50,512 per quality-adjusted life-year gained. Nearly all of the studies conducted sensitivity analysis; results were most sensitive to variation in wage rates, levels of worker productivity, the costs and effectiveness of vaccination, and the rate of influenza illness. Review of the included studies suggests that seasonal influenza vaccination of healthy, working-age adults is generally not cost saving, requiring an investment to generate health benefits. The decision to vaccinate such a group will depend upon the societal and payer valuation of those benefits.

If we can force people to purchase health insurance, then let's force them to be treated too

Proponents of the 2010 Patient Protection and Affordable Care Act (PPACA) justify the Act's mandate that uninsured individuals either purchase a minimally defined health insurance policy (“Maintain Minimum Essential Coverage”) or pay a fine, as a necessary and proper exercise of Congress's express constitutional power to regulate interstate and foreign commerce. The United States Supreme Court will decide the correctness of that highly debatable position during its spring 2012 session.

Assuming, without by any means predicting, that the validity of all parts of the PPACA—including the individual insurance mandate—is upheld, the Court's (likely multiple) opinions will constitute a major development in the evolution of American constitutional jurisprudence, even if Congress subsequently repeals specific sections of the legislation. Several commentators have expressed concern about the ramifications of a judicially validated PPACA for attempts by the government, especially through the mechanism of Comparative Effectiveness Research (CER), to limit or ration particular forms of potentially beneficial medical care for some or all patients.

Resource Distribution Strategies for Mitigation of Cross-Regional Influenza Pandemics

As recently acknowledged by the Institute of Medicine, the existing pandemic mitigation models lack dynamic decision support capabilities. This paper develops a simulation optimization model for generating dynamic resource distribution strategies over a network of regions exposed to a pandemic. While the underlying simulation mimics the disease and population dynamics of the affected regions, the optimization model generates progressive allocations of mitigation resources, including vaccines, antivirals, healthcare capacities, and social distancing enforcement measures. The model strives to minimize the impact of ongoing outbreaks and the expected impact of the potential outbreaks, considering measures of morbidity, mortality, and social distancing, translated into the cost of lost productivity and medical expenses. The model was implemented on a simulated outbreak involving four million inhabitants. The strategy was compared to pro-rata and myopic strategies. The model is intended to assist public health policy makers in developing effective distribution policies during influenza pandemics.

Optimal control and sensitivity analysis of an influenza model with treatment and vaccination

We formulate and analyze the dynamics of an influenza pandemic model with vaccination and treatment using two preventive scenarios: increase and decrease in vaccine uptake. Due to the seasonality of the influenza pandemic, the dynamics is studied in a finite time interval. We focus primarily on controlling the disease with a possible minimal cost and side effects using control theory which is therefore applied via the Pontryagin's maximum principle, and it is observed that full treatment effort should be given while increasing vaccination at the onset of the outbreak. Next, sensitivity analysis and simulations (using the fourth order Runge-Kutta scheme) are carried out in order to determine the relative importance of different factors responsible for disease transmission and prevalence. The most sensitive parameter of the various reproductive numbers apart from the death rate is the inflow rate, while the proportion of new recruits and the vaccine efficacy are the most sensitive parameters for the endemic equilibrium point.

From the patient perspective: the economic value of seasonal and H1N1 influenza vaccination

Although studies have suggested that a patient's perceived cost-benefit of a medical intervention could affect his or her utilization of the intervention, the economic value of influenza vaccine from the patient's perspective remains unclear. Therefore, we developed a stochastic decision analytic computer model representing an adult's decision of whether to get vaccinated. Different scenarios explored the impact of the patient being insured versus uninsured, influenza attack rate, vaccine administration costs and vaccination time costs. Results indicated that the cost of avoiding influenza was fairly low (with one driver being required vaccination time). To encourage vaccination, decision makers may want to focus on ways to reduce this time, such as vaccinating at work, churches, or other normally frequented locations.

Economic Implications of Influenza and Influenza Vaccine

The objective of this chapter is to review and summarize the current economic estimates of influenza and the cost-effectiveness of its vaccines. We reviewed the published assessments of the economic costs of human seasonal and pandemic influenza internationally. Seasonal influenza costs Germany, France, and the USA between $4 and $87 billion annually. Depending upon the intensity of transmission and severity of disease, pandemic influenza may cause as many as 350 million deaths and result in economic losses topping $1 trillion – an impact great enough to create a worldwide recession. We then reviewed 100 papers primarily from more than a dozen countries which studied the cost-effectiveness of influenza vaccine in children, adults, and the elderly. These studies demonstrate that influenza vaccination is quite cost-effective among children 6 months to 18 years old, in health care workers and pregnant women, and in high-risk individuals. Remarkably, compared with the other recently introduced vaccines for children, such as rotavirus and pneumococcal polysaccharide, vaccinating children and school attendees results in societal cost savings because it obviates lost productivity and wages among infected individuals and their caretakers. Vaccination for children is recommended in the USA and in Canada, but public health policy makers in Europe have undervalued this vaccine and not recommended it so widely.

Modeling control strategies for concurrent epidemics of seasonal and pandemic H1N1 influenza

The lessons learned from the 2009-2010 H1N1 influenza pandemic, as it moves out of the limelight, should not be under-estimated, particularly since the probability of novel influenza epidemics in the near future is not negligible and the potential consequences might be huge. Hence, as the world, particularly the industrialized world, responded to the potentially devastating effects of this novel A-H1N1 strain with substantial resources, reminders of the recurrent loss of life from a well established foe, seasonal influenza, could not be ignored. The uncertainties associated with the reported and expected levels of morbidity and mortality with this novel A-H1N1 live in a backdrop of deaths, over 200,000 hospitalizations, and millions of infections (20% of the population) attributed to seasonal influenza in the USA alone, each year. So, as the Northern Hemisphere braced for the possibility of a potentially "lethal" second wave of the novel A-H1N1 without a vaccine ready to mitigate its impact, questions of who should be vaccinated first if a vaccine became available, came to the forefront of the discussion. Uncertainty grew as we learned that the vaccine, once available, would be unevenly distributed around the world. Nations capable of acquiring large vaccine supplies soon became aware that those who could pay would have to compete for a limited vaccine stockpile. The challenges faced by nations dealing jointly with seasonal and novel A-H1N1 co-circulating strains under limited resources, that is, those with no access to novel A-H1N1 vaccine supplies, limited access to the seasonal influenza vaccine, and limited access to antivirals (like Tamiflu) are explored in this study. One- and two-strain models are introduced to mimic the influenza dynamics of a single and co-circulating strains, in the context of a single epidemic outbreak. Optimal control theory is used to identify and evaluate the "best" control policies. The controls account for the cost associated with social distancing and antiviral treatment policies. The optimal policies identified might have, if implemented, a substantial impact on the novel H1N1 and seasonal influenza co-circulating dynamics. Specifically, the implementation of antiviral treatment might reduce the number of influenza cases by up to 60% under a reasonable seasonal vaccination strategy, but only by up to 37% when the seasonal vaccine is not available. Optimal social distancing policies alone can be as effective as the combination of multiple policies, reducing the total number of influenza cases by more than 99% within a single outbreak, an unrealistic but theoretically possible outcome for isolated populations with limited resources.

Predictive and Reactive Distribution of Vaccines and Antivirals during Cross-Regional Pandemic Outbreaks

As recently pointed out by the Institute of Medicine, the existing pandemic mitigation models lack the dynamic decision support capability. We develop a large-scale simulation-driven optimization model for generating dynamic predictive distribution of vaccines and antivirals over a network of regional pandemic outbreaks. The model incorporates measures of morbidity, mortality, and social distancing, translated into the cost of lost productivity and medical expenses. The performance of the strategy is compared to that of the reactive myopic policy, using a sample outbreak in Fla, USA, with an affected population of over four millions. The comparison is implemented at different levels of vaccine and antiviral availability and administration capacity. Sensitivity analysis is performed to assess the impact of variability of some critical factors on policy performance. The model is intended to support public health policy making for effective distribution of limited mitigation resources.

Cost analysis of public health influenza vaccine clinics in Ontario

OBJECTIVE

Public health in Ontario delivers, promotes and provides each fall the universal influenza immunization program. This paper addresses the question of whether Ontario public health agencies are able to provide the influenza immunization program within the Ministry of Health fiscal funding envelope of $5 per dose.

METHODS

Actual program delivery data from the 2006 influenza season of Wellington-Dufferin-Guelph Public Health (WDGPH) were used to create a model template for influenza clinics capturing all variable costs. Promotional and administrative costs were separated from clinic costs. Maximum staff workloads were estimated. Vaccine clinics were delivered by public health staff in accordance with standard vaccine administration practices.

RESULTS

The most significant economic variables for influenza clinics are labour costs and number of vaccines given per nurse per hour. The cost of facility rental was the only other significant cost driver. The ability of influenza clinics to break even depended on the ability to manage these cost drivers. At WDGPH, weekday flu clinics required the number of vaccines per nurse per hour to exceed 15, and for weekend flu clinics this number was greater than 21. We estimate that 20 vaccines per hour is at the limit of a safe workload over several hours. Managing cost then depends on minimizing hourly labour costs.

DISCUSSION

The results of this analysis suggest that by managing the labour costs along with planning the volume of patients and avoiding expensive facilities, flu clinics can just break even. However, any increased costs, including negotiated wage increases or the move to safety needles, with a fixed revenue of $5.00 per dose will negate this conclusion.

Cost-effective approaches to influenza prevention and treatment

Influenza, the seventh leading cause of death in the USA, accounts for 35,000 deaths and over 200,000 hospitalizations annually in that country alone. Recent advances in influenza vaccines, diagnosis and treatment have created numerous options for practicing clinicians, as well as economic opportunities for the makers of vaccines, rapid diagnostic tests and antiviral drugs. Since influenza-like illness affects up to half of the population each year, selective use of expensive tests and treatments is essential to the practice of cost-effective medicine. Over the past 5 years, dozens of economic evaluations of influenza vaccination, rapid testing and antiviral therapy have been published, many of which are free of commercial bias. The existing literature, drawing practical lessons for clinical practice is reviewed, and new developments on the horizon are explored including vaccines, surveillance methods, antiviral agents and pandemic preparedness.

Economic evaluations of neuraminidase inhibitors to control influenza

Up to 10% of individuals present influenza-like illness each year. Neuraminidase inhibitors significantly reduce the median duration of influenza symptoms by 1.38 days and median time to return to normal activities by 0.9 days in adults. This review presents the economic evaluations of neuraminidase inhibitors in adults. The choice of key parameter estimates in cost-effectiveness and cost-benefit analysis is sensitive to the perspective of analysis: healthcare payer or societal, including productivity gains. This review discusses, among other key parameters, the proportion of influenza-like illness due to the influenza virus (targeted by neuraminidase inhibitors and influenza vaccine), and the measure of health benefits by either quality-adjusted life years gained or willingness-to-pay for a day of symptoms averted. Overall, neuraminidase inhibitors are worth their costs and do not challenge annual influenza vaccination but should be seen as a complementary option to reduce the burden of influenza.

Workplace vaccination and other factors impacting influenza vaccination decision among employees in Israel

The study examined the factors affecting the decision to be vaccinated against influenza among employees in Israel. The research, conducted in 2007/2008, included 616 employees aged 18−65 at various workplaces in Israel, among them companies that offered their employees influenza vaccination. The research questionnaire included socio-demographic characteristics, and the Health Belief Model principles. The results show that the significant factors affecting vaccination compliance include a vaccination program at workplaces, vaccinations in the past, higher levels of vaccine’s perceived benefits, and lower levels of barriers to getting the vaccine. We conclude that vaccine compliance is larger at companies with workplace vaccination programs providing easier accessibility to vaccination.

Racial and ethnic disparities in pneumonia treatment and mortality

BACKGROUND

The extent to which racial/ethnic disparities in pneumonia care occur within or between hospitals is unclear.

OBJECTIVE

Examine within and between-hospital racial/ethnic disparities in quality indicators and mortality for patients hospitalized for pneumonia.

RESEARCH DESIGN

Retrospective cohort study.

SUBJECTS

A total of 1,183,753 non-Hispanic white, African American, and Hispanic adults hospitalized for pneumonia between January 2005 and June 2006.

MEASURES

Eight pneumonia care quality indicators and in-hospital mortality.

RESULTS

Performance rates for the 8 quality indicators ranged from 99.4% (oxygenation assessment within 24 hours) to 60.2% (influenza vaccination). Overall hospital mortality was 4.1%. African American and Hispanic patients were less likely to receive pneumococcal and influenza vaccinations, smoking cessation counseling, and first dose of antibiotic within 4 hours than white patients at the same hospital (ORs = 0.65-0.95). Patients at hospitals with the racial composition of those attended by average African Americans and Hispanics were less likely to receive all indicators except blood culture within 24 hours than patients at hospitals with the racial composition of those attended by average whites. Hospital mortality was higher for African Americans (OR = 1.05; 95% CI = 1.02, 1.09) and lower for Hispanics (OR = 0.85; 95% CI = 0.81, 0.89) than for whites within the same hospital. Mortality for patients at hospitals with the racial composition of those attended by average African Americans (OR = 1.21; 95% CI = 1.18, 1.25) or Hispanics (OR = 1.18; 95% CI = 1.14, 1.23) was higher than for patients at hospitals with the racial composition of those attended by average whites.

CONCLUSIONS

Racial/ethnic disparities in pneumonia treatment and mortality are larger and more consistent between hospitals than within hospitals.

Seasonal influenza in adults and children--diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America

Guidelines for the treatment of persons with influenza virus infection were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic issues, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal (interpandemic) influenza. They are intended for use by physicians in all medical specialties with direct patient care, because influenza virus infection is common in communities during influenza season and may be encountered by practitioners caring for a wide variety of patients.

Racial disparities in treatment preferences for rheumatoid arthritis

BACKGROUND

Data suggest that differences in patient preferences may account for racial disparities in the use of medical interventions. Racial disparities have also been noted in outcomes and the delivery of healthcare services in chronic disease. Whether treatment preferences in chronic disease differ by race is not known.

METHODS

We elicited treatment preferences for aggressive therapy in patients with rheumatoid arthritis who identified themselves as being black or white.

RESULTS

One hundred fifty consecutive eligible patients were invited to participate. Of these, 136 subjects completed the interview. In unadjusted analysis, 51% of white participants preferred aggressive therapy compared with 16% of blacks (P < 0.0001). Subjects who were married and reported having at least some college education had stronger preferences for aggressive therapy compared with their respective counterparts. After adjusting for covariates, race remained the strongest predictor of aggressive therapy examined in this study [adjusted odds ratio (95% confidence interval) = 11.2 (1.9-64.9)].

CONCLUSIONS

In this study, fewer black patients preferred aggressive treatment compared with white patients with similar disease severity. These results have important clinical implications because use of aggressive treatment improves both short- and long-term outcomes in rheumatoid arthritis. Efforts to improve patient education and physician communication should be made to ensure that all patients have an accurate understanding of the benefits, as well as risks, associated with the best available treatment options.

Cost effectiveness of influenza vaccination in older adults: a critical review of economic evaluations for the 50- to 64-year age group

Several recent studies have assessed the benefits of extending influenza vaccination programmes, which are currently targeted primarily at those aged over 65 years, to those aged 50-64 years. We identified and reviewed all cost-effectiveness studies of influenza vaccination in those aged 50-64 years published before July 2008. While the studies suggest that vaccination in this age-group is likely to be cost effective, these results were dependent on several key assumptions. The estimates of serious outcomes due to influenza and the estimates of vaccine effectiveness (VE) against these outcomes were found to have the most influence on cost effectiveness. However, due to factors including mismatches between the measure of VE and the outcome under consideration, as well as various other data limitations, there is significant uncertainty around these key assumptions that was not well explored. There was a failure in some studies to report fundamental inputs such as discount rates. Overall, there was a general lack of transparency in the studies and, consequently, the conclusions around the cost effectiveness of influenza vaccine in those aged 50-64 years must be interpreted with caution.

[Cost/effectiveness comparison of the vaccine campaign and reduction of sick leave, after vaccination against influenza among the Clermont-Ferrand University Hospital staff]

OBJECTIVE

The aim of this study was to compare the cost of vaccination for the Clermont-Ferrand University hospital (CHU) personnel and the cost of sick leave among vaccinated and non-vaccinated employees in 2003, 2004, and 2005.

DESIGN

The study included 7256 CHU staff (medical and non-medical personnel). The cost of sick leave was calculated on the basis of short-term disease (four to nine days) over the three months of the epidemic season in 2004, 2005, and 2006.

RESULTS

In 2005, the overall cost of vaccination was 4.02 euros per vaccinated employee. Over the three years, the total sick leave reached 804 days for employees vaccinated against 5670 for non-vaccinated employees. In 2003, 2004, and 2005, the vaccinal coverage was 13, 20.5, and 30.1%, the mean duration of sick leave was 0.16, 0.17, and 0.18 day among vaccinated staff, and 0.26, 0.39, and 0.34 day among non-vaccinated staff corresponding to a benefit per vaccinated employee of 5, 26, and 20 euros, respectively for each year. The total benefit for the institution was 86,458 euros (4630+38,168+43,660). If the vaccinated rate of 75% recommended by the Haute Autorité de santé (HAS) had been reached, the additional benefit would have been 250,193 euros (33,157+152,256+65,180).

CONCLUSIONS

The number of sick leave days and the related cost were approximately twice less important for vaccinated employees, economically justifying this vaccination including a period of weak epidemic, as checked over three consecutive years.

Low Flu Shot Rates Puzzle—Some Plausible Behavioral Explanations

The paper presents an economic model to analyze an individual's decision about whether or not to be vaccinated against influenza. It shows that based upon objective parameters, the vaccination rate should be high. Yet, empirical findings indicate low vaccination rates. Therefore, we use the behavioral approach and subjective variables to explain the empirical findings. The subjective variables in the model include perceived infection probability, time preference, subjective costs of vaccination, perceived severity of illness and perceived vaccination effectiveness. A low vaccination rate has a negative externality on society. The paper discusses potential policies that can be applied to changing the situation.

Oseltamivir and the risk of influenza-related complications and hospitalizations in patients with diabetes

OBJECTIVE

This subgroup analysis of a retrospective cohort study examined, from a managed care perspective, the risk of influenza-related complications and hospitalizations in patients with diabetes who were prescribed oseltamivir for the treatment of influenza and those who were not prescribed antiviral treatment.

METHODS

Health insurance claims data from the Thomson Healthcare MarketScan Research Database for 6 influenza seasons (October 1-March 31) between 2000 and 2006 were used to identify patients aged >/=18 years with influenza and diabetes. Patients who received a prescription for oseltamivir within 1 day of a diagnosis of influenza were compared with those who received no antiviral treatment. Outcomes included the frequency of pneumonia, respiratory diagnoses, and otitis media and its complications, and rates of hospitalization within 14 days of the diagnosis of influenza. Cox proportional hazards regression was used to determine the relative risk (RR) of influenza-related complications and hospitalizations.

RESULTS

A total of 9090 patients with diabetes and a diagnosis of influenza were identified who met all study criteria. Of these, 2919 (32%) received a prescription for oseltamivir and 6171 (68%) received no antiviral treatment. Patients receiving oseltamivir had a significant 17% reduction in the risk of respiratory illnesses (RR = 0.83; 95% CI, 0.73-0.93) and a 30% reduction in the risk of hospitalization for any reason (RR = 0.70; 95% CI, 0.52-0.94). There were no significant differences between the oseltamivir and control groups in terms of the risks for pneumonia (RR = 0.87; 95% CI, 0.64-1.18), otitis media and its complications (RR = 0.96; 95% CI, 0.48-1.91), or hospitalization for pneumonia (RR = 0.81; 95% CI, 0.41-1.58).

CONCLUSION

In this retrospective study, the risk of influenza-associated respiratory illnesses and the number of hospitalizations for any reason were reduced in patients with diabetes who were prescribed oseltamivir compared with an unmatched group that was not prescribed antiviral therapy.

Cost effectiveness of oseltamivir treatment of influenza: a critique of published methods and outcomes

OBJECTIVE

The objective of this review was to determine, from a systematic assessment of published data, the cost effectiveness of the neuraminidase inhibitor antiviral medication oseltamivir in comparison with usual care (i.e. over-the-counter medication such as analgesics and antipyretics for symptomatic relief) for the treatment of influenza. How the findings of each of the studies considered related to the methods used for each analysis and the assumptions made were specifically reviewed.

RESULTS

The online search found 80 individual articles, 66 of which did not meet the pre-defined screening criteria. The 14 studies remaining reported cost, cost-effectiveness and cost-utility analyses for oseltamivir treatment in various groups: healthy adults and adolescents, children, elderly, and individuals at increased risk.

CONCLUSION

Despite the range of values assumed for key probabilities such as the diagnostic certainty of influenza among people presenting with influenza-like illness, and how much work time is lost due to illness in healthy adults, base-case analyses consistently showed oseltamivir treatment to be cost effective or even cost saving for the four population groups studied, a conclusion that is in-line with previous reviews on this topic. However, clarity was frequently lacking in the published data in terms of various model assumptions and results, particularly with regards to the exact distributions of the constituting elements of savings and of quality-adjusted life years gained.