Discharge to post-acute care and other predictors of prolonged length of stay during the initial COVID-19 surge: a single site analysis.

BACKGROUND: During the initial surge of coronavirus disease 2019 (COVID-19), health-care utilization fluctuated dramatically, straining acute hospital capacity across the USA and potentially contributing to excess mortality. METHODS: This was an observational retrospective study of patients with COVID-19 admitted to a large US urban academic medical center during a 12-week COVID-19 surge in the Spring of 2020. We describe patterns in length of stay (LOS) over time. Our outcome of interest was prolonged LOS (PLOS), which we defined as 7 or more days. We performed univariate analyses of patient characteristics, clinical outcomes and discharge disposition to evaluate the association of each variable with PLOS and developed a final multivariate model via backward elimination, wherein all variables with a P-value above 0.05 were eliminated in a stepwise fashion. RESULTS: The cohort included 1366 patients, of whom 13% died and 29% were readmitted within 30 days. The LOS (mean: 12.6) fell over time (P < 0.0001). Predictors of PLOS included discharge to a post-acute care (PAC) facility (odds ratio [OR]: 11.9, 95% confidence interval [CI] 2.6-54.0), uninsured status (OR 3.2, CI 1.1-9.1) and requiring intensive care and intubation (OR 18.4, CI 11.5-29.6). Patients had a higher readmission rate if discharged to PAC facilities (40%) or home with home health agency (HHA) services (38%) as compared to patients discharged home without HHA services (26%) (P < 0.0001). CONCLUSION: Patients hospitalized with COVID-19 during a US COVID-19 surge had a PLOS and high readmission rate. Lack of insurance, an intensive care unit stay and a decision to discharge to a PAC facility were associated with a PLOS. Efforts to decrease LOS and optimize hospital capacity during COVID-19 surges may benefit from focusing on increasing PAC and HHA capacity and resources.

Psychotropic Medication Use among Insured Children with Autism Spectrum Disorder.

This study examined psychotropic medication use among 7901 children aged 1-17 with autism spectrum disorder (ASD) in five health systems, comparing to matched cohorts with no ASD. Nearly half (48.5 %) of children with ASD received psychotropics in the year observed; the most common classes were stimulants, alpha-agonists, or atomoxetine (30.2 %), antipsychotics (20.5 %), and antidepressants (17.8 %). Psychotropic treatment was far more prevalent among children with ASD, as compared to children with no ASD (7.7 % overall), even within strata defined by the presence or absence of other psychiatric diagnoses. The widespread use of psychotropics we observed, particularly given weak evidence supporting the effectiveness of these medications for most children with ASD, highlights challenges in ASD treatment and the need for greater investment in its evaluation.

Missing clinical and behavioral health data in a large electronic health record (EHR) system.

OBJECTIVE: Recent massive investment in electronic health records (EHRs) was predicated on the assumption of improved patient safety, research capacity, and cost savings. However, most US health systems and health records are fragmented and do not share patient information. Our study compared information available in a typical EHR with more complete data from insurance claims, focusing on diagnoses, visits, and hospital care for depression and bipolar disorder. METHODS: We included insurance plan members aged 12 and over, assigned throughout 2009 to a large multispecialty medical practice in Massachusetts, with diagnoses of depression (N = 5140) or bipolar disorder (N = 462). We extracted insurance claims and EHR data from the primary care site and compared diagnoses of interest, outpatient visits, and acute hospital events (overall and behavioral) between the 2 sources. RESULTS: Patients with depression and bipolar disorder, respectively, averaged 8.4 and 14.0 days of outpatient behavioral care per year; 60% and 54% of these, respectively, were missing from the EHR because they occurred offsite. Total outpatient care days were 20.5 for those with depression and 25.0 for those with bipolar disorder, with 45% and 46% missing, respectively, from the EHR. The EHR missed 89% of acute psychiatric services. Study diagnoses were missing from the EHR's structured event data for 27.3% and 27.7% of patients. CONCLUSION: EHRs inadequately capture mental health diagnoses, visits, specialty care, hospitalizations, and medications. Missing clinical information raises concerns about medical errors and research integrity. Given the fragmentation of health care and poor EHR interoperability, information exchange, and usability, priorities for further investment in health IT will need thoughtful reconsideration.

Creating a network of high-quality skilled nursing facilities: preliminary data on the postacute care quality improvement experiences of an accountable care organization.

Postacute care (PAC) is an important source of cost growth and variation in the Medicare program and is critical to accountable care organization (ACO) and bundled payment efforts to improve quality and value in the Medicare program, but ACOs must often look outside their walls to identify high-value external PAC partners, including skilled nursing facilities (SNFs). As a solution to this problem, the integrated health system, Partners HealthCare System (PHS) and its Pioneer ACO launched the PHS SNF Collaborative Network in October 2013 to identify and partner with high-quality SNFs. This study details the method by which PHS selected SNFs using minimum criteria based on public scores and secondary criteria based on self-reported measures, describes the characteristics of selected and nonselected SNFs, and reports SNF satisfaction with the collaborative. The selected SNFs (n = 47) had significantly higher CMS Five-Star scores than the nonselected SNFs (n = 93) (4.6 vs 3.2, P < .001) and were more likely than nonselected SNFs that met the minimum criteria (n = 35) to have more than 5 days of clinical coverage (17.0% vs 2.9%, P = .02) and to have a physician see admitted individuals within 24 (38.3% vs 17.1%, P = .02) and 48 hours (93.6% vs 80.0%, P = .03). A survey sent to collaborative SNFs found high satisfaction with the process (average satisfaction, 4.6/5, with 1 = very dissatisfied and 5 = very satisfied, n = 19). Although the challenges of improving care in SNFs remain daunting, this approach can serve as a first step toward greater clinical collaboration between acute and postacute settings that will lead to better outcomes for frail older adults.

Validation of Autism Spectrum Disorder Diagnoses in Large Healthcare Systems with Electronic Medical Records.

To identify factors associated with valid Autism Spectrum Disorder (ASD) diagnoses from electronic sources in large healthcare systems. We examined 1,272 charts from ASD diagnosed youth <18 years old. Expert reviewers classified diagnoses as confirmed, probable, possible, ruled out, or not enough information. A total of 845 were classified with 81% as a confirmed, probable, or possible ASD diagnosis. The predictors of valid ASD diagnoses were >2 diagnoses in the medical record (OR 2.94; 95% CI 2.03-4.25; p < 0.001) and being male (OR 1.51; 95% CI 1.05-2.17; p = 0.03). In large integrated healthcare settings, at least two diagnoses can be used to identify ASD patients for population-based research.

Use of leukotriene receptor antagonists are associated with a similar risk of asthma exacerbations as inhaled corticosteroids.

BACKGROUND: Based on results of clinical trials, inhaled corticosteroids (ICS) are the most-effective controller medications for preventing asthma-related exacerbations, yet few studies in real-life populations have evaluated the comparative effectiveness of ICS. OBJECTIVE: To determine the likelihood of asthma exacerbations among children with asthma after initiation of controller medications: ICS, leukotriene antagonists (LTRA), and ICS-long-acting ß-agonist (LABA) combination therapy. METHODS: This was a retrospective cohort study of subjects who were part of the Population-Based Effectiveness in Asthma and Lung Diseases Network. We conducted Cox regression analyses by adjusting for baseline covariates, adherence by using proportion of days covered, and high-dimensional propensity scores. The main outcome measurements were emergency department visits, hospitalizations, or oral corticosteroid use. RESULTS: Our population included 15,567 health plan subjects and 10,624 TennCare Medicaid subjects with uncontrolled asthma. Overall adherence to controller medications was low, with no more than 50% of the subjects refilling the medication after the initial fill. For subjects with allergic rhinitis, the subjects in TennCare Medicaid treated with LTRAs were less likely to experience ED visits (hazard ratio 0.44 [95% CI, 0.21-0.93]) compared with the subjects treated with ICS. For all other groups, the subjects treated with LTRA or ICS-LABA were just as likely to experience ED visits or hospitalizations, or need oral corticosteroids as the subjects treated with ICS. CONCLUSION: Risks of asthma-related exacerbations did not differ between children who initiated LTRA and ICS. These findings may be explainable by LTRA, which has similar effectiveness as ICS in real-life usage by residual confounding by indication or other unmeasured factors.

Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study.

OBJECTIVE: To investigate if the widely publicized warnings in 2003 from the US Food and Drug Administration about a possible increased risk of suicidality with antidepressant use in young people were associated with changes in antidepressant use, suicide attempts, and completed suicides among young people. DESIGN: Quasi-experimental study assessing changes in outcomes after the warnings, controlling for pre-existing trends. SETTING: Automated healthcare claims data (2000-10) derived from the virtual data warehouse of 11 health plans in the US Mental Health Research Network. PARTICIPANTS: Study cohorts included adolescents (around 1.1 million), young adults (around 1.4 million), and adults (around 5 million). MAIN OUTCOME MEASURES: Rates of antidepressant dispensings, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides. RESULTS: Trends in antidepressant use and poisonings changed abruptly after the warnings. In the second year after the warnings, relative changes in antidepressant use were -31.0% (95% confidence interval -33.0% to -29.0%) among adolescents, -24.3% (-25.4% to -23.2%) among young adults, and -14.5% (-16.0% to -12.9%) among adults. These reflected absolute reductions of 696, 1216, and 1621 dispensings per 100,000 people among adolescents, young adults, and adults, respectively. Simultaneously, there were significant, relative increases in psychotropic drug poisonings in adolescents (21.7%, 95% confidence interval 4.9% to 38.5%) and young adults (33.7%, 26.9% to 40.4%) but not among adults (5.2%, -6.5% to 16.9%). These reflected absolute increases of 2 and 4 poisonings per 100,000 people among adolescents and young adults, respectively (approximately 77 additional poisonings in our cohort of 2.5 million young people). Completed suicides did not change for any age group. CONCLUSIONS: Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting.

Factors associated with choice of web or print intervention materials in the healthy directions 2 study.

BACKGROUND: Many U.S. adults have multiple behavioral risk factors, and effective, scalable interventions are needed to promote population-level health. In the health care setting, interventions are often provided in print, although accessible to nearly everyone, are brief (e.g., pamphlets), are not interactive, and can require some logistics around distribution. Web-based interventions offer more interactivity but may not be accessible to all. Healthy Directions 2 was a primary care-based cluster randomized controlled trial designed to improve five behavioral cancer risk factors among a diverse sample of adults (n = 2,440) in metropolitan Boston. Intervention materials were available via print or the web. Purpose. To (a) describe the Healthy Directions 2 study design and (b) identify baseline factors associated with whether participants opted for print or web-based materials. METHODS: Hierarchical regression models corrected for clustering by physician were built to examine factors associated with choice of intervention modality. RESULTS: At baseline, just 4.0% of participants met all behavioral recommendations. Nearly equivalent numbers of intervention participants opted for print and web-based materials (44.6% vs. 55.4%). Participants choosing web-based materials were younger, and reported having a better financial status, better perceived health, greater computer comfort, and more frequent Internet use (p < .05) than those opting for print. In addition, Whites were more likely to pick web-based material than Black participants. CONCLUSIONS: Interventions addressing multiple behaviors are needed in the primary care setting, but they should be available in web and print formats as nearly equal number of participants chose each option, and there are significant differences in the population groups using each modality.

Statin exposure is associated with decreased asthma-related emergency department visits and oral corticosteroid use.

RATIONALE: Statins, or HMG-CoA reductase inhibitors, may aid in the treatment of asthma through their pleiotropic antiinflammatory effects. OBJECTIVES: To examine the effect of statin therapy on asthma-related exacerbations using a large population-based cohort. METHODS: Statin users aged 31 years or greater with asthma were identified from the Population-Based Effectiveness in Asthma and Lung population, which includes data from five health plans. Statin exposure and asthma exacerbations were assessed over a 24-month observation period. Statin users with a statin medication possession ratio greater than or equal to 80% were matched to non-statin users by age, baseline asthma therapy, site of enrollment, season at baseline, and propensity score, which was calculated based on patient demographics and Deyo-Charlson conditions. Asthma exacerbations were defined as two or more oral corticosteroid dispensings, asthma-related emergency department visits, or asthma-related hospitalizations. The association between statin exposure and each of the three outcome measures was assessed using conditional logistic regression. MEASUREMENTS AND MAIN RESULTS: Of the 14,566 statin users, 8,349 statin users were matched to a nonuser. After adjusting for Deyo-Charlson conditions that remained unbalanced after matching, among statin users, statin exposure was associated with decreased odds of having asthma-related emergency department visits (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.53-0.77; P < 0.0001) and two or more oral corticosteroid dispensings (OR, 0.90; 95% CI, 0.81-0.99; P = 0.04). There were no differences in asthma-related hospitalizations (OR, 0.91; 95% CI, 0.66-1.24; P = 0.52). CONCLUSIONS: Among statin users with asthma, statin exposure was associated with decreased odds of asthma-related emergency department visits and oral corticosteroid dispensings.

Using a discrete choice experiment to elicit time trade-off and willingness-to-pay amounts for influenza health-related quality of life at different ages.

BACKGROUND: Recent research suggests that values for health-related quality of life may vary with the age of the patient. Traditional health state valuation questions and discrete choice experiments are two approaches that could be used to value health. OBJECTIVE: To measure whether public values for health vary with the age of the affected individual. METHODS: A discrete choice experiment was administered via the Internet in December 2007 to measure preferences for different attributes of influenza-related health-related quality of life: age of hypothetical affected individual (range 1-85 years), length of episode (days of illness), severity of illness (workdays lost) and time trade-off or willingness-to-pay amounts. Each respondent answered identical choice questions for a hypothetical family member and for himself/herself. Data on sociodemographic characteristics and influenza illness experience were also collected. Respondents were US adults randomly sampled from an Internet survey panel (n = 1,012). The relative value of attributes was estimated using generalized estimating equations and controlling for sociodemographic characteristics and illness experience. Marginal time traded and marginal willingness to pay using discrete choice and traditional time trade-off or willingness-to-pay questions were compared. RESULTS: Respondents preferred shorter influenza episodes but did not significantly prefer fewer workdays lost if episode length was held constant. Respondents were more likely to choose to avert uncomplicated illness in children and less likely to choose to avert uncomplicated illness in working-age adults. Marginal time trade-off and willingness-to-pay amounts elicited using discrete choice questions were larger than those elicited using direct valuation questions. CONCLUSIONS: Approaches that assume values for health-related quality of life do not vary with the age of a patient may bias economic analyses that use these values. If patient age could affect valuations, then age should be included in the valuation exercise. Additional research should evaluate the effect of patient age on values for other conditions.

Why do children with ADHD discontinue their medication?

OBJECTIVE: To examine factors associated with parent-reported discontinuation of attention-deficit/hyperactivity disorder (ADHD) medication. METHODS: The authors conducted a telephone survey of parents of children 6 to 18 years old who had recently initiated ADHD medication according to insurance claims. RESULTS: A total of 127 parents of children with ADHD who had recently initiated ADHD medication completed the survey (43% response rate); 21% discontinued the ADHD medication. Parents of discontinuers were less likely to report having discussed the risks and benefits of ADHD medication with primary care providers (59% vs 82%, P = .03) and were more likely to report psychological side effects (58% vs 21%, P > .001). Multivariate analyses demonstrated that both psychological side effects and perceived inadequate medication effectiveness were associated with discontinuation. CONCLUSIONS: Many children discontinue ADHD medication within the first year, often because of psychological side effects or perceived inadequate medication effectiveness. Improved methods for psychological side effect management, setting realistic medication goals, and assessing therapeutic success are needed.

Parental and societal values for the risks and benefits of childhood combination vaccines.

BACKGROUND: New combination vaccines reduce the number of injections needed for immunization. However, possible drawbacks include higher prices, extra doses of vaccine antigens and increased minor adverse events. Our objective was to measure parental and societal values for attributes of childhood combination vaccines. METHODS: We conducted a discrete choice experiment using an online survey of adults administered by Knowledge Networks. Values were measured for attributes of combination vaccines for a hypothetical child aged 6 months: (1) number of injections, (2) extra dose of hepatitis B vaccine, (3) 20% higher chance of fever, (4) community-level immunization coverage of 2-year-olds of 90% or 80%, and (5) cost per visit. Logistic regression with generalized estimating equations was used to analyze the value of different attributes and generate a marginal willingness-to-pay for a change in attribute level. RESULTS: The response rate was 64% (N=558). Most respondents were parents (63%) and most respondents agreed that combination vaccines were safe (77%). Respondents were willing to pay $7.68 to avoid an injection (compared to $9.94 when looking at parents only). However, respondents were willing to pay $41.57 to avoid higher risk of fever after one set of immunizations (10% versus 30%) and $65.42 for higher immunization coverage rates. These results were very similar for parents only. There was no significant preference to avoid an extra dose of hepatitis B vaccine. CONCLUSIONS: Respondents were willing to pay larger amounts to avoid increased risk of minor adverse events and to increase community-level immunization coverage than to avoid injections. These values should be taken into account when determining the risks and benefits of combination vaccines.

Financing and systems barriers to seasonal influenza vaccine delivery in community settings.

BACKGROUND: Recommendations for annual seasonal influenza vaccination have expanded to now include >300 million children and adults each year. Community settings have become increasingly important venues for influenza vaccination. We sought to identify barriers to and solutions for expanding influenza vaccination in community settings. METHODS: Semi-structured telephone interviews were conducted from 01/09 to 06/10 with a range of stakeholders involved in influenza vaccination, including health plans, medical services firms, retail based clinics, pharmacies, schools, and state and local public health immunization programs. Participants (n=65) were asked about barriers and feasible solutions to influenza vaccine delivery to children and adults in community settings. Key themes were identified through iterative coding using a grounded theory approach. RESULTS: Stakeholders identified specific financial barriers to influenza vaccine delivery in 3 major areas: purchase and distribution, delivery, and reimbursement. Limited purchasing power, the uncertain nature of public demand, and unpredictable timing of influenza vaccine supply were important barriers to enhance delivery in community settings. Barriers to delivery included complexities in running off-site clinics, especially in school settings, the need to manage publicly vs. privately purchased vaccines separately, and state-to-state variability in requirements for credentialing, physician oversight, and reporting. Reimbursement barriers included a protracted credentialing process, the need to determine insurance eligibility at point-of-service, and lack of a billing infrastructure in off-site clinics. Opportunities to mitigate financial barriers to influenza vaccine delivery in community settings focused on coordination across providers and the role of public health as a "trusted broker" to overcome existing challenges. CONCLUSIONS: Financial and systems barriers hamper the optimal use of community settings to effectively deliver influenza vaccines. Public health partners at the federal, state, and local levels are well-positioned to facilitate the engagement of all stakeholders in this important and complex vaccine delivery system.

Valuing health across the lifespan: health state preferences for seasonal influenza illnesses in patients of different ages.

OBJECTIVE: This study sought to measure whether public values for health states vary with the age of the affected individual. METHODS: Health state preferences were measured via a 15-minute survey administered through the Internet in December 2007 using a probability sample of the adult population of the United States (N = 1012). Respondents were asked to value hypothetical descriptions of seasonal influenza illness (uncomplicated influenza illness, hospitalization) and possible vaccine-related adverse events (anaphylaxis, Guillain-Barré syndrome) using time trade-off or willingness-to-pay questions. Respondents were randomized to four different ages for an affected hypothetical individual: 1-year-old, 8-year-old, 35-year-old, 85-year-old. All other aspects of the health state description were held constant. Summary statistics for each health state and age were calculated. The Kruskal-Wallis test was used to measure differences in responses across ages of affected individuals in the hypothetical scenarios. Regression analyses were used to evaluate the effect of age on time trade-off or willingness-to-pay amounts controlling for respondent characteristics. RESULTS: Median values for time trade-off and willingness-to-pay were highest for young children. This pattern was generally consistent across responses and type of valuation. CONCLUSIONS: Approaches that assume health state values do not differ with the age of a patient may bias economic analyses that use these values. If patient age is likely to affect health state valuations, then age should be included as an attribute in the valuation exercise.

Financial barriers to the adoption of combination vaccines by pediatricians.

OBJECTIVES: To describe the prevalence of combination vaccine use and the associated financial barriers faced by pediatric practices, and to identify determinants of adoption of combination vaccines. DESIGN: Mailed national survey. SETTING: Pediatric practices during the period from August through October 2008. PARTICIPANTS: Pediatricians randomly selected from the American Medical Association Masterfile. MAIN OUTCOME MEASURE: Use of 1 of 2 infant combination vaccines (the diphtheria and tetanus toxoids and acellular pertussis, hepatitis B virus, and inactivated poliovirus [DTaP-HepB-IPV] vaccine or the DTaP, IPV, and Haemophilus influenzae type b [DTaP-IPV/Hib] vaccine). RESULTS: We received 629 responses (response rate, 67%). Four hundred ninety-two pediatricians (78%) reported using 1 or both of the infant combination vaccines of interest (ie, the DTaP-HepB-IPV or DTaP-IPV/Hib vaccine). More than half of the respondents said their practice did not receive adequate reimbursement for the purchase and administration of vaccines in general. More than one-fifth reported not using 1 or more of the combination vaccines because of inadequate reimbursement for the cost of vaccine doses (23% of respondents) and/or vaccine administration (20% of respondents). The infant combination vaccines studied were less likely to be used by smaller practices, by those with a lower proportion of publicly insured patients, and by those with less inclusive state vaccine financing policies. CONCLUSIONS: One in 5 pediatricians reported that inadequate reimbursement prevented their using 1 or more combination vaccines. Practice size as well as the proportion of children whose vaccinations are paid for by public funds appear to be important determinants of the adoption of combination vaccines.

Projected costs, risks, and benefits of expanded newborn screening for MCADD.

OBJECTIVE: To evaluate the cost-effectiveness of newborn screening for medium-chain acyl-coenzyme A dehydrogenase deficiency (MCADD) incorporating quality-of-life effects for false-positive newborn screens and recommended dietary treatment. METHODS: A computer simulation model was developed to predict costs and health outcomes for expanded newborn screening for MCADD compared with clinical identification. The modeled target population was a hypothetical cohort of 100 000 newborns in the United States. Probabilities, costs, and quality-of-life weights were derived from a long-term follow-up study of newborn screening compared with clinical identification, primary data collection, published data, and expert opinion. We used a lifetime time horizon and the societal perspective. The main outcome measure was the incremental cost-effectiveness ratio in dollars per quality-adjusted life-year (QALY) gained. Secondary outcomes included averted deaths and hospitalizations. RESULTS: Using base-case assumptions, the cost-effectiveness of newborn screening for MCADD was $21 273 per QALY gained. The cost-effectiveness ratio increased to $21 278/QALY when the loss in quality of life associated with false-positive test results was incorporated and to $27 423/QALY when the quality of life associated with lifelong dietary recommendations for treating MCADD was incorporated. Results were sensitive to the false-positive rate for the newborn screening test and the cost of the initial screen. CONCLUSIONS: Expanded newborn screening for MCADD is cost-effective compared with well-accepted pediatric health interventions. Losses in quality of life associated with dietary treatment for MCADD, however, may offset some of the gains in QALYs from newborn screening. Consideration of new disorders for expanded newborn screening panels should include the potential reduction in quality of life associated with treatments.

Willingness to pay for a QALY based on community member and patient preferences for temporary health states associated with herpes zoster.

BACKGROUND AND OBJECTIVES: A clear sense of what society is willing to pay for a QALY could enhance the usefulness of cost-effectiveness analysis as a field. Scant information exists on willingness to pay (WTP) for a QALY based on direct elicitation of preferences from community members or patients. We had the opportunity to evaluate WTP per QALY using data from a survey on temporary health outcomes related to herpes zoster. Our aims were to (i) describe how much community members are willing to pay to save a QALY based on scenarios describing temporary health states; (ii) evaluate how WTP per QALY varies based on experience with the disease being described and with demographic variables; and (iii) evaluate how the duration and intensity of pain in a scenario influences WTP per QALY. METHODS: Community members drawn from a nationally representative survey research panel (n = 478) completed an Internet-based survey using time trade-off (TTO) and WTP questions to value a series of scenarios that described herpes zoster cases of varying pain intensity (on a scale of 0-10) and duration (30 days to 1 year). Patients with shingles (n = 354) or postherpetic neuralgia (PHN; n = 120) [defined as having symptoms for 90 days or more] from two large healthcare systems completed telephone interviews with similar questions. Mean and median WTP per QALY values were calculated by dividing the WTP amount by the discounted time traded for each scenario. Responses with a WTP value of more than zero and a TTO value of zero (which would have resulted in an undefined value) were excluded. TTO values were discounted by 3% per year. WTP per QALY means were calculated after trimming the top and bottom 2.5% of responses. Multivariate analyses were conducted using generalized linear mixed models that assumed a negative binomial distribution. RESULTS: Among all respondents, the WTP per QALY ranged from a median of $US7000 to $US11,000 and a trimmed mean of $US26 000 to $US45,000 (year 2005 values), depending on the scenario described. WTP per QALY values varied significantly with respondent characteristics, as well as among respondents with similar characteristics. In multivariate analyses, the mean WTP per QALY was higher among respondents who were younger, male or had higher educational or income levels. After adjusting for these demographic variables, patients who had experienced shingles gave responses with the highest WTP per QALY values. Patients who had experienced PHN gave the lowest values, and community members gave values intermediate to the shingles and PHN groups. In multivariate models that evaluated the effects of pain and duration of the hypothetical zoster scenario, lower duration was associated with higher WTP per QALY. This effect appeared to be due to people increasing the amounts of time they would be willing to trade as duration increased, without proportional increases in the amounts of money they would be willing to pay. CONCLUSIONS: Community members and patients gave mean WTP per QALY values that varied significantly based on age, sex, socioeconomic status, experience with shingles and duration of the health state evaluated. The variability in WTP per QALY suggests that it may be difficult to define a unitary threshold of dollars per QALY for policy making based on cost-effectiveness analyses.

Financial barriers to implementing combination vaccines: perspectives from pediatricians and policy makers.

To describe the factors that affect the use of new combination vaccines, the authors conducted qualitative interviews with pediatricians (n = 7), state immunization program managers (n = 7), and health insurance plan representatives (n = 6 plans). Respondents from each group identified reduction in pain and potentially increased immunization coverage as key benefits of new combination vaccines. For several pediatricians, low reimbursement for cost of vaccine doses and potential loss of fees for vaccine administration were barriers to using combination vaccines. For most state immunization programs, the higher cost of combination vaccines relative to separate vaccines was an important consideration but not a barrier to adoption. Most insurers were not aware of the financial issues for providers, but some had changed or were willing to change reimbursement to support the use of new combination vaccines. Financial issues for pediatric practices that purchase and provide vaccines for children may be an important barrier to offering combination vaccines.