Take Your Best Shot: Which SARS-CoV-2 Vaccine Should I Get?

Background. Three vaccines against SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) have now received emergency use authorization by the US Food and Drug Administration. Patients may have the opportunity to make a choice about which vaccine they prefer to receive. Vaccine hesitancy is a hurdle to the development of widespread immunity, with many patients struggling to decide whether to get vaccinated at all. Objective. Develop a decision model exploring the question, "Should I get vaccinated with mRNA or adenovirus vector vaccine (AVV) if either is available now?"Design. Markov state transition model with lifetime time horizon. Data Sources. MEDLINE searches, bibliographies from relevant English-language articles. Setting. United States, ambulatory clinical setting. Participants. Previously uninfected, nonimmunized adults in the United States. Interventions. 1) Do Not Vaccinate, 2) Vaccination with mRNA Vaccine, 3) Vaccination with Adenovirus Vector Vaccine. Main Measures. Quality-adjusted life years (QALYs). Key Results. Base case-for a healthy 65-year-old patient, both vaccines yield virtually equivalent results (difference of 0.0028 QALYs). In sensitivity analyses, receiving the AVV is preferred if the short-term morbidity associated with each vaccine dose exceeds 1.8 days. Both vaccines afford an even greater benefit compared with Do Not Vaccinate if the pandemic is in a surge phase with a rising incidence of infection or if the current 7-day incidence is greater than the base case estimate of 105 cases per 100,000. Conclusions. Preferred vaccination strategies change under differing assumptions, but differences in outcomes are negligible. The best advice for patients is to get vaccinated against COVID-19 disease with whatever vaccine is available first. Providing mRNA vaccine to the remaining eligible US population would result in an aggregate gain of 3.92 million QALYs.

Where population health misses the mark: breaking the 80/20 rule.

Conventional population management theory, predicated on prevention and keeping the healthy majority healthy, fails to address the root cause of the unsustainable health care spending trajectory in the United States. The national health care agenda has been heavily influenced by the assumptions that disease prevention and the general promotion of "population health" will be sufficient to reduce health care spending to a sustainable level. However, a very small subset of the population with chronic and complex conditions account for a disproportionate share of health care spending, and unnecessary variation in the care of those chronic and complex episodes wastes 20% to 30% of the episodic spending. Health care spending follows what is known as "the 80/20 rule," with 80% of all spending being incurred by only 20% of the population. Whether a population is defined as a company, a county, or a country, the overwhelming majority of their health care spending comes from a small minority of the individuals, and the bulk of that spending is associated with either largely unavoidable and unpredictable single events or complex episodes of care. Achieving an economically sustainable health care system will require more efficient and effective delivery of those complex episodes of care.

Challenges of becoming a regional referral system: the University of Kentucky as a case study.

The U.S. health care system must change because of unsustainable costs and limited access to care. Health care legislation and the recognition that health care costs must be curbed have accelerated the change process. How should academic medical centers (AMCs) respond? Teaching hospitals are a heterogeneous group, and the leaders of each must understand their institution's goals and the necessary resources to achieve them. Clinical leaders and staff at one AMC, the University of Kentucky (UK), committed to transforming the AMC into a regional referral center. To achieve this goal, UK leaders integrated the clinical enterprise, focused recruitment on advanced subspecialists, and initiated productive relationships with other providers. Attracting adequate numbers of destination patients with complex illnesses required UK to have a "market space" of five to seven million people. The resources required to effect such progress have been daunting. Relationships with providers and payers have been necessary to forge a network. These relationships have been challenging to establish and manage and have evolved over time. Most AMCs are not-for-profit public good entities that nevertheless exist in an industry driven by competition in quality and cost, and therefore scale and access to capital are paramount. AMC leaders must understand their institutions as both part of an industry and as a public good in order to adapt to the changing health care system. Although the experience of any particular AMC is inherently unique, UK's journey provides a useful case study in establishing institutional goals, outlining a strategy, and identifying required resources.

Commentary: choice--the need for a thorough and open discussion: implications for academic health centers.

The reality is that choice in health care may be limited or substantially curtailed in the future. To imply that the U.S. health care system can achieve the needed cost savings without such restrictions is not productive and may be potentially deceptive. Continued unfiltered, unlimited choice will only continue to drive more utilization and costs. Academic health centers (AHCs) should take a leadership role in expanding the public dialogue regarding health care reform and its likely need to limit choice at some level while preparing for the inevitable related evolution of AHCs' core clinical programs, relationships, and strategies.

Commentary: Institutes versus traditional administrative academic health center structures.

In the Point-Counterpoint section of this issue, Kastor discusses the pros and cons of a new, institute-based administrative structure that was developed at the Cleveland Clinic in 2008, ostensibly to improve the quality and efficiency of patient care. The real issue underlying this organizational transformation is not whether the institute model is better than the traditional model; instead, the issue is whether the traditional academic health center (AHC) structure is viable or whether it must evolve. The traditional academic model, in which the department and chair retain a great deal of autonomy and authority, and in which decision-making processes are legislative in nature, is too tedious and laborious to effectively compete in today's health care market. The current health care market is demanding greater efficiencies, lower costs, and thus greater integration, as well as more transparency and accountability. Improvements in both quality and efficiency will demand coordination and integration. Focusing on quality and efficiency requires organizational structures that facilitate cohesion and teamwork, and traditional organizational models will not suffice. These new structures must and will replace the loose amalgamation of the traditional AHC to develop the focus and cohesion to address the pressures of an evolving health care system. Because these new structures should lead to more successful clinical enterprises, they will, in fact, support the traditional academic missions of research and education more successfully than traditional organizational models can.

Commentary: Health care reform and primary care: training physicians for tomorrow's challenges.

Although Congress recently passed health insurance reform legislation, the real catalyst for change in the health care delivery system, the author's argue, will be changes to the reimbursement model. To rein in increasing costs, the Centers for Medicare and Medicaid aims to move Medicare from the current fee-for-service model to a reimbursement approach that shifts the risk to providers and encourages greater accountability both for the cost and the quality of care. This level of increased accountability can only be achieved by clinical integration among health care providers. Central to this reorganized delivery model are primary care providers who coordinate and organize the care of their patients, using best practices and evidence-based medicine while respecting the patient's values, wishes, and dictates. Thus, the authors ask whether primary care physicians will be available in sufficient numbers and if they will be adequately and appropriately trained to take on this role. Most workforce researchers report inadequate numbers of primary care doctors today, a shortage that will only be exacerbated in the future. Even more ominously, the authors argue that primary care physicians being trained today will not have the requisite skills to fulfill their contemplated responsibilities because of a variety of factors that encourage fragmentation of care. If this training issue is not debated vigorously to determine new and appropriate training approaches, the future workforce may eventually have the appropriate number of physicians but inadequately trained individuals, a situation that would doom any effort at system reform.

The evolution of a Department of Internal Medicine under an integrated clinical enterprise model: the University of Kentucky experience.

The impact on the Department of Internal Medicine of the emergence of the University of Kentucky Healthcare Enterprise as an integrated clinical model has been enormous. In fiscal year 2004, the department was financially insolvent and on the verge of implementing plans to decrease faculty from 127 to 65. Since that time, the department has changed dramatically with a corresponding improvement in its clinical, academic, and financial activity. The department has grown to 175 faculty, with a healthy financial outlook and a shared vision with the clinical enterprise. Departmental clinical growth has been accompanied by growth in extramural research funding. The clinical growth of the department, in turn, supported the growth of the integrated clinical enterprise overall.The purpose of this article is to present a case history of the impact of transition to an integrated clinical enterprise financial model on the clinical, research, and educational functions of a department of internal medicine, and the opportunities and lessons learned from this transition. The implementation of an enterprise model allowed revival and expansion of the clinical programs of the department. This expansion did not occur at the expense of the research and educational missions of the department but, rather, was associated with improved performance in these areas. The processes which were established during the conversion to the enterprise model, which involve strategic planning, monitoring of plan implementation, recalibration of objectives, financial transparency, and accountability of leadership and faculty, may better prepare the institution to face the challenges of the rapidly changing economic environment.

Commentary: Health care reform and its potential impact on academic medical centers.

President Obama's administration has committed to significant changes in the current health care system to address three issues: access, cost, and quality. Leaders at academic medical centers (AMCs) must acknowledge the root cause of the problems within the current system, recognize potential change initiatives, contemplate the changing role that AMCs will play in the health care system of the future, and begin to adapt and respond. The underlying root cause of the problem with our health care system is excessive costs. Although many factors contribute to excess costs, the most important factor is overuse of expensive modalities. The administration will try to impact change by stressing preventive care, improving medical practice with the purpose of achieving greater value, and changing the reimbursement system from fee for service to other reimbursement approaches that provide greater incentives for more coordinated and integrated systems of care. It is argued in this commentary that ultimately reform will lead to some form of a managed care model with limits on spending. Highly integrated health care systems will be in the best position to produce more efficient care that provides value. The authors posit that AMCs have the unique opportunity of shaping integration in many regions of the country and highlight efforts at the University of Kentucky to develop a health care system to serve the commonwealth. Change is inevitable. Being proactive rather than reactive may be important to secure the future of AMCs.

Defining the role of University of Kentucky HealthCare in its medical market--how strategic planning creates the intersection of good public policy and good business practices.

In response both to national pressures to reduce costs and improve health care access and outcomes and to local pressures to become a top-20 public research university, the University of Kentucky moved toward an integrated clinical enterprise, UK HealthCare, to create a common vision, shared goals, and an effective decision-making process. The leadership formed the vision and then embarked on a comprehensive and coordinated planning process that addressed financial, clinical, academic, and operational issues. The authors describe in depth the strategic planning process and specifically the definition of UK HealthCare's role in its medical marketplace. They began a rigorous process to assess and develop goals for the clinical programs and followed the progress of these programs through meetings driven by data and attended by the organization's senior leadership. They describe their approach to working with rural and community hospitals throughout central, eastern, and southern Kentucky to support the health care infrastructure of the state. They review the early successes of their strategic approach and describe the lessons they learned. The clinical successes have led to academic gains. The experience of UK HealthCare suggests that good business practices and good public policy are synergistic.

Creating an integrated clinical enterprise at the University of Kentucky: the emergence of UK HealthCare.

If the medical system in the United States is to change, as has been recommended, academic medical centers must, in fact, lead this change process. To prepare for the future, the University of Kentucky decided to move aggressively toward developing an integrated clinical enterprise branded as UK HealthCare, where leadership of the various components of the academic medical center make strategic and financial decisions together to achieve common organizational goals. The authors discuss senior leadership's development of the vision for the enterprise and the governance structure that was established to engage board members and faculty of the institution. They examine the rigorous strategic, facilities, financial, and academic planning that ensued, and the early successes achieved. The authors introduce some of the lessons learned by the organization during the emergence of UK HealthCare and describe the corporate structure and senior management team that was established to support the quick and efficient implementation of the planning strategies. It was this corporate structure and senior management team which has proven to be an effective agent of change and a key to the successful development of a truly integrated clinical enterprise.

An institutional process to improve inpatient glycemic control.

Many institutions are evaluating their inpatient patterns of care for patients with diabetes mellitus and hyperglycemia, based upon compelling evidence that strict glycemic control improves outcomes in a variety of hospital settings. In 2005, a multidisciplinary task force was established at the University of Kentucky Chandler Medical Center in Lexington, Kentucky, to guide a process to improve the quality and safety of inpatients with hyperglycemia. This article describes the stepwise process including an examination of our procedures, adoption of standards, and establishment of common protocols and procedures. Successful implementation of the protocols was preceded by extensive educational efforts. Refinement of the protocols based on early experience and feedback from staff has resulted in improvements in glycemic parameters and less reliance on sliding scale insulin regimens.

The U.S. health care system is in crisis: implications for academic medical centers and their missions.

The medical care system in the United States is in crisis. Health care costs are escalating and threatening coverage for millions of people. Concerns about the quality of care and patient safety are heightening; patients and payers now publicly share these concerns and want to make providers more accountable. Traditionally, the response to rising health care costs has been to modify reimbursement models and incentives. Currently there is a movement to shift the responsibility of cost containment to the patients. The authors express doubts about the overall effectiveness of this strategy and propose reengineering the health care system to improve quality and efficiency. Leaders of academic medical centers must understand the forces and dynamics of change, and the potential institutional response to improve the quality and efficiency of their delivery systems and to preserve their missions: clinical care, education, research, and community service. As they suggest the operational changes needed to respond to this evolving health care environment, the authors discuss the implications for the various missions. The graduates of training programs must be prepared to function within multidisciplinary teams and constantly seek ways to improve quality and efficiency to ensure that care is accessible, affordable, and safe. Academic medical centers need to expand their research agenda to develop more expertise in quality and process improvement research. Additionally, they must provide the leadership to foster the transition from an era of "managed care" to an era of "organized systems of care."

Is antibiotic prophylaxis for bacterial endocarditis cost-effective?

BACKGROUND: Antibiotic prophylaxis for bacterial endocarditis is recommended by the American Heart Association (AHA) before undergoing certain dental procedures. Whether such antibiotic prophylaxis is cost-effective is not clear. The authors' objective is to estimate the cost-effectiveness of predental antibiotic prophylaxis in patients with underlying heart disease. METHODS: The authors conducted a cost-effectiveness analysis using a Markov model to compare cost-effectiveness of 7 antibiotic regimens per AHA guidelines and a no prophylaxis strategy. The study population consisted of a hypothetical cohort of 10 million patients with either a high or moderate risk for developing endocarditis. RESULTS: Prophylaxis for patients with moderate or high risk for endocarditis cost $88,007/quality-adjusted life years saved if clarithromycin was used. Prophylaxis with amoxicillin and ampicillin resulted in a net loss of lives. All other regimens were less cost-effective than clarithromycin. For 10 million persons, clarithromycin prophylaxis prevented 119 endocarditis cases and saved 19 lives. CONCLUSION: Predental antibiotic prophylaxis is cost-effective only for persons with moderate or high risk of developing endocarditis. Contrary to current recommendations, our data demonstrate that amoxicillin and ampicillin are not cost-effective and should not be considered the agents of choice. Clarithromycin should be considered the drug of choice and cephalexin as an alternative drug of choice. The current published guidelines and recommendations should be revised.