Vaccine-Preventable Hospitalisations from Seasonal Respiratory Diseases: What Is Their True Value?

Hospitals in England experience extremely high levels of bed occupancy in the winter. In these circumstances, vaccine-preventable hospitalisations due to seasonal respiratory infections have a high cost because of the missed opportunity to treat other patients on the waiting list. This paper estimates the number of hospitalisations that current vaccines against influenza, pneumococcal disease (PD), COVID-19, and a hypothetical Respiratory Syncytial Virus (RSV) vaccine, could prevent in the winter among older adults in England. Their costs were quantified using a conventional reference costing method and a novel opportunity costing approach considering the net monetary benefit (NMB) obtained from alternative uses of the hospital beds freed-up by vaccines. The influenza, PD and RSV vaccines could collectively prevent 72,813 bed days and save over £45 million in hospitalisation costs. The COVID-19 vaccine could prevent over 2 million bed days and save £1.3 billion. However, the value of hospital beds freed up by vaccination is likely to be 1.1-2 times larger (£48-93 million for flu, PD and RSV; £1.4-2.8 billion for COVID-19) when quantified in opportunity cost terms. Considering opportunity costs is key to ensuring maximum value is obtained from preventative budgets, as reference costing may significantly underestimate the true value of vaccines.

Opportunity cost determines free-operant action initiation latency and predicts apathy.

BACKGROUND: Apathy, a disabling and poorly understood neuropsychiatric symptom, is characterised by impaired self-initiated behaviour. It has been hypothesised that the opportunity cost of time (OCT) may be a key computational variable linking self-initiated behaviour with motivational status. OCT represents the amount of reward which is foregone per second if no action is taken. Using a novel behavioural task and computational modelling, we investigated the relationship between OCT, self-initiation and apathy. We predicted that higher OCT would engender shorter action latencies, and that individuals with greater sensitivity to OCT would have higher behavioural apathy. METHODS: We modulated the OCT in a novel task called the 'Fisherman Game', Participants freely chose when to self-initiate actions to either collect rewards, or on occasion, to complete non-rewarding actions. We measured the relationship between action latencies, OCT and apathy for each participant across two independent non-clinical studies, one under laboratory conditions (n = 21) and one online (n = 90). 'Average-reward' reinforcement learning was used to model our data. We replicated our findings across both studies. RESULTS: We show that the latency of self-initiation is driven by changes in the OCT. Furthermore, we demonstrate, for the first time, that participants with higher apathy showed greater sensitivity to changes in OCT in younger adults. Our model shows that apathetic individuals experienced greatest change in subjective OCT during our task as a consequence of being more sensitive to rewards. CONCLUSIONS: Our results suggest that OCT is an important variable for determining free-operant action initiation and understanding apathy.

Incorporating Value of Health System Impact in Economic Evaluations of Therapies of Chronic Diseases

Objectives: Economic assessments of healthcare interventions for health technology assessments (HTAs) limit societal impact to productivity losses. Other societal impact has been highlighted by the Covid-19 pandemic that was associated with a severe impairment of the ability of the healthcare system to provide adequate and timely care to patients in many indications due to unprecedented increases in hospitalizations. The impact of healthcare interventions on health care system capacity and security has been identified as a priority value item for consideration by HTA recently. In imperfect markets with permanent excess demand, the accounting costs of resources underestimate their opportunity costs. Hence, reliance on accounting costs in economic evaluations of interventions that can avoid future demand for care leads to undervaluation of these interventions. Attempts have been made to evaluate the value of vaccines by accounting for their impact on health system capacity, through valuing bed-days used by patients with vaccine-preventable disease by their opportunity cost. Method(s): We apply theoretical methods for calculating opportunity costs of services proposed by Sandmann et al. to interventions in a chronic disease. An example is shown for chronic kidney disease that has high and increasing prevalence, and an associated surge in the demand for renal care services, coupled with supply shortages of dialysis equipment and adequate workforce, creating a situation of permanent overdemand on the market of renal care services. The quantitative magnitude of the undervaluation of delaying dialysis and renal transplant is demonstrated by accounting for opportunity costs of resource use as opposed to valuing used resources on accounting price. Its potential impact on results of economic evaluations of CKD therapies and HTA decisions is shown in a simple model on eGFR slope, and methods are assessed and compared. We generalize our findings to other chronic therapies. Copyright © 2022

Globally optimal trial design and risk sharing arrangements are key to avoiding opportunity costs of delay and enabling equitable, feasible and effective global vaccine research and implementation in current or future pandemics.

Global vaccination in the face of pandemics such as COVID-19 and new variants is a race against time. Avoiding the opportunity costs of delay and the associated health, social, and downstream economic impacts is a challenge and an imperative. Failures to address the global challenges posed by COVID-19 have become increasingly evident as waves of vaccine-evading mutations have emerged, facilitated by unequal vaccination coverage and diminishing immunity against new variants worldwide. To address these challenges, societal decision-makers (governments) and industry manufacturer interests must be better aligned for rapid, globally optimal trial design, ideally with research coverage, implementation, and accessibility of effective vaccines across joint research, implementation, and distribution cycles to address pandemic evolution in real time. Value of information (VoI) methods for optimal global trial design and risk-sharing arrangements align the research, distribution, and implementation interests and efforts globally to meet head-on the imperative of avoiding opportunity costs of delay and enabling consistent global solutions with maximizing local and global net benefits. They uniquely enable feasible early adoption of the most promising strategies in real time while the best globally translatable evidence is collected and interests are aligned for global distribution and implementation. Furthermore, these methods are generally shown to be imperative for feasible, fast, and optimal solutions across joint research, reimbursement, and regulatory processes for current and future pandemics and other global existential threats. Establishing pathways for globally optimal trial designs, risk-sharing agreements, and efficient translation to practice is urgent on many fronts.

Patient-reported drivers of financial toxicity in gynecologic cancers: A focus group study (337)

Objectives: We aimed to better understand how treatment-related financial burden affects gynecologic cancer patients and identify targets for future interventions to reduce financial toxicity. Methods: Patients with invasive gynecologic cancer diagnoses were invited to participate in a qualitative focus group study. Each participant first completed an online, secure survey that included questions regarding diagnosis, mode of treatment, employment status, and income. The Comprehensive Score for Financial Toxicity (COST) tool was used to measure economic burden (COST score 0-44), with lower scores demonstrating worse financial toxicity. Each participant then took part in one of four virtual semi-structured focus groups through a secure video platform with a social worker and a study staff member. Three investigators independently analyzed the transcripts for common themes and reconciled disagreement through consensus. Results: Of the 13 participants, over 60% had private insurance, and 54% had moderate to high financial toxicity (COST scores <23). The five most commonly discussed themes included the extent of insurance coverage, out-of-pocket health expenses, changes in employment status, inefficient care coordination, and opportunity costs. Other themes that were discussed included stress associated with diagnosis, delays in care, confusion with medical bills, and impacts of COVID-19. Three participants suggested consolidation of bills to decrease obscurity with billing, and two attributed a slower recovery process to financial stress. Participants with worse financial toxicity (COST score <23) reported strain associated with opportunity costs, confusion with billing, and employment status changes more often than those with mild financial toxicity (COST score ≥23). Concerns about insurance coverage were universally reported, irrespective of participant financial toxicity score. Conclusions: Financial toxicity is an increasingly recognized obstacle for patients with gynecologic cancer, though efforts to alleviate patient burdens are lacking. The findings of this study suggest that patient-centered interventions to optimize insurance coverage and enhance care coordination could reduce financial toxicity. This is important given that both targets are potentially immediately actionable and could have downstream effects on health outcomes. Meanwhile, advocacy efforts to improve work leave policies and reduce out-of-pocket health expenditures through insurance reform are broader system-level interventions that also should be considered to curtail financial toxicity.

Defining and Measuring Health System Pressure: A Conceptual Framework and Application to RSV and C. Difficile Infections

Objectives: Since the COVID-19 pandemic, the potential for vaccines to reduce pressure on health care systems has received much attention. However, evaluation of how vaccination may impact health system pressure is hindered by lack of a formal definition and measurement framework. We developed an approach for defining health system pressure and measuring its impact in healthcare settings and applied this approach to respiratory syncytial virus (RSV) and Clostridioides difficile (C. difficile) infections. Methods: We conducted a targeted literature review and assessed hospital guidelines for prevention and control of RSV and C. difficile infections in hospital settings in Germany, Italy, and the UK. The definition and framework were tested via semi-structured interviews among healthcare professionals. Results: Health system pressure can be generally defined as resource utilisation given a pre-set usable capacity. Its impact can be measured as the opportunity cost of actions taken to prevent or mitigate pressure. Actions to prevent or mitigate pressure due to RSV or C difficile can be classified by their impact on staff (labour resources), stuff (non-labour resources and materials), and structure capacity. Increased staffing needs drive RSV pressure during the RSV respiratory season and are considered to be extremely likely and extremely costly by 75% of the interviewees. C. difficile pressure is driven by the activation of outbreak-induced infection control protocols, which are likely to affect every capacity dimensions according to over 60% of the interviewees, and lead to large costs of infrastructure needed to isolate patients. In general, actions to mitigate pressure are associated with higher costs than actions used to prevent pressure before it occurs. Conclusions: This research describes a novel definition and framework for health system pressure. Further development and application of this framework may enable HTA bodies to describe and measure the potential impact of vaccination on health care systems.

ACCEPTABILITY OF REMOTE CONSULTING DURING COVID-19 AMONG PATIENTS WITH TWO COMMON LONGTERM MUSCULOSKELETAL CONDITIONS: FINDINGS FROM THREE QUALITATIVE STUDIES AND RECOMMENDATIONS FOR PRACTICE

Background/Aims The COVID-19 pandemic led to the widespread adoption of remote consultations. Whilst remote consultations offer many potential advantages to patients and healthcare services, they are unlikely to be suitable for all. Guidance encourages clinicians to consider patient preferences when choosing face-to-face vs remote consultations. However, little is known about acceptability of, and preferences for remote consultations, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, remote consultations among patients with osteoporosis and rheumatoid arthritis. Methods Data for this study derived from three UK qualitative studies: iFraP (improving fracture prevention study), Blast Off (BO;Bisphosphonate aLternAtive regimenS for the prevenTion of Osteoporotic Fragility Fractures), and ERA (Exploring people with Rheumatoid Arthritis' experience of the pandemic). Each study explored patient experiences of accessing and receiving healthcare during the pandemic year. Transcripts from each data set relating to remote consulting were extracted. A minimum of two study team members worked independently, following a consistent approach, to conduct a rapid deductive analysis using the Theoretical Framework of Acceptability (TFA). The TFA consists of 7 constructs to understand acceptability of, in this context, remote consultations, including: affective attitudes;intervention coherence;perceived effectiveness;burden;self-efficacy;opportunity- costs;and ethicality. Following coding, the findings of all three studies were pooled. Analysis was facilitated by group meetings to discuss interpretations. Results Findings from 1 focus group and 64 interviews with 35 people, who had mostly experienced telephone consultations, were included the analysis. Participants' emotional attitudes to remote consultations, views on fairness (ethicality) and sense making (intervention coherence) varied according to their specific needs for the consultation and values, relative to the pandemic context;participants perceived remote consultations as making more sense and being 'fairer' earlier in the pandemic. Some participants valued the reduced burden associated with remote consultations, while others highly valued, and did not want to give up, non-verbal communication or physical examination associated with face-to-face consults (opportunity costs);although perceived need for physical examination in participants with RA was associated with strong preference for face-to-face consultations, asymptomatic participants with RA and osteoporosis also expressed similar strong preferences. Some participants described low confidence (self-efficacy) in being able to communicate in remote consultations and others perceived remote consultations as ineffective, in part due to suboptimal communication. Conclusion Acceptability of, and preferences for remote consultation appear to be influenced by a range of societal, healthcare provider and personal factors and in this study, were not fixed, or condition-dependent. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation. The findings have supported the development of patient-centred recommendations for practice that should be considered alongside clinician-focused recommendations when deciding whether remote consultations are appropriate.

The Fibromyalgia Active Management and Exercise (FAME) programme: A service evaluation

Keywords: Fibromyalgia;Theoretical Framework of acceptability;Rehabilitation Purpose: Fibromyalgia affects over 5% of the UK population. Guidelines recommend multi-modal, non-pharmacological interventions. The Fibromyalgia Active Management and Exercise (FAME) programme was developed by a multidisciplinary team, at King's College Hospital. The Programme, informed by evidence and clinical guidelines, aimed to improve function and quality of life by facilitating self-management and increasing physical activity. It consisted of 12, two hour weekly face-to-face group sessions delivered by a multidisciplinary team (physiotherapists, pain nurses, psychologist) and incorporated education, exercise, Cognitive Behavioural Therapy and mindfulness approaches. This qualitative service evaluation aimed to assess the acceptability of FAME from the perspective of both the patients’ and healthcare practitioners’ (HCP) and identity refinements to the programme. Methods: All patients and HCP involved in the first FAME programme were invited to attend either a focus group (1 patient, 1 HCP group) or 1:1 semi-structured interviews. Topic guides were developed a priori and informed by previous literature and the Theoretical Framework of Acceptability (TFA, seven constructs (Affective Attitude;Burden;Ethicality;Intervention Coherence;Opportunity Costs;Perceived Effectiveness;Self-efficacy)). Interviews and focus groups were conducted by one of three researchers, audio recorded, transcribed verbatim and analysed thematically. Results: Sixteen participants (six HCP (three physiotherapists, two nurses, one psychologist) and seven patients (mean age 46 (7.5) years, all female, mean duration of symptoms 12 (4.9) years) were enrolled. Focus groups were 60 min and interviews were 30 min duration. FAME was broadly acceptable to HCP participants but not to all patient participants. Some patient participants reported that FAME did not meet their expectations or address areas of importance to them. Five themes that could be explained by four of the TFA constructs were identified: role of social support (self-efficacy), FAME as a learning opportunity (perceived effectiveness), fit for FAME (affective attitude), understanding FAME (intervention coherence) and a journey towards self-management (perceived effectiveness). Both patient and HCP participants expressed that social support was important and influenced their experience of FAME. Patient participants perceived that support from peers facilitated their attendance at FAME and adherence to the recommended exercise programme. Learning from the experience of their peers and mindfulness training were their favoured elements of the programme. Conclusion(s): FAME is a new bespoke management programme for people with fibromyalgia. It was acceptable for HCPs but further adaptation was required to optimise acceptability for patients. Refinements made to FAME included: establishing an introductory session and active ‘opt-in’ requirement, a booklet rather than handouts, inclusion of an expert patient, and adaptation for online delivery due to COVID-19. Strengths of the project included the recruitment of both patients and HCPS and use of the TFA to inform the study. However, only regular attenders engaged although all patients were invited. Future work should therefore incorporate their views. Impact: Working with patient and HCP during the development of interventions is essential to optimise acceptability, and this may influence fidelity and feasibility of the new programme. For patients and HCP social support is the most important element in programmes for fibromyalgia. Thus, social support must be prioritised when transforming services. Funding acknowledgements: The work was not funded.

Coronavirus: Where Has All the Health Economics Gone?

As the coronavirus disease 2019 (COVID-19) pandemic continues to unfold there is an untold number of trade-offs being made in every country around the globe. The experience in the United Kingdom and Canada to date has not seen much uptake of health economics methods. We provide some thoughts on how this could take place, specifically in three areas. Firstly, this can involve understanding the impact of lockdown policies on national productivity. Secondly, there is great importance in studying trade-offs with respect to enhancing health system capacity and the impact of the mix of private-public financing. Finally, there are key trade-offs that will continue to be made both in terms of access to testing and ventilators which would benefit greatly from economic appraisal. In short, health economics could - and we would argue most certainly should - play a much more prominent role in policy-making as it relates to the current as well as future pandemics.