Rural-Urban Differences in Vaccination and Hesitancy Rates and Trust: US COVID-19 Trends and Impact Survey on a Social Media Platform, May 2021-April 2022.

Objectives. To analyze rural-urban differences in COVID-19 vaccination uptake, hesitancy, and trust in information sources in the United States. Methods. We used data from a large survey of Facebook users. We computed the vaccination, hesitancy, and decline rates and the trust proportions among individuals hesitant toward COVID-19 information sources for rural and urban regions in each state from May 2021 to April 2022. Results. In 48 states with adequate data, on average, two thirds of states showed statistically significant differences in monthly vaccination rates between rural and urban regions, with rural regions having a lower vaccination rate at all times. Far fewer states showed statistically significant differences when comparing monthly hesitancy and decline rates for urban versus rural regions. Doctors and health professionals received the highest level of trust. Friends and family were also among the most trusted sources in rural areas where the vaccination uptake was low. Conclusions. Rural-urban difference in hesitancy rates among those still unvaccinated was much smaller than the rural-urban difference in vaccination rates, suggesting that access to vaccines may be another contributor to the lower vaccination rates in rural areas. (Am J Public Health. 2023;113(6):680-688. https://doi.org/10.2105/AJPH.2023.307274).

The costs and value of modelling-based design in healthcare delivery: five case studies from the US.

In the nineties and noughties, Hollocks surveyed the use of Discrete Event Simulation (DES) in industry and listed (although he could not quantify the value of) benefits. This paper explores how DES is now used to design healthcare facilities and services, developing a value-for-money case with a protocol on collecting information. We present a set of five DES case studies from the US care system and, following Hollocks, focus on modelling as part of a rigorous design process, capturing as many of the benefits as possible. Healthcare offers the possibility of ascribing value to health improvement, but in these cases it is primarily the operational benefits of a better service that are reported and monetarised. By estimated the cost of modelling and the value of the operation gains, this paper contributes significantly to the literature. We conclude with a protocol for collecting information and a discussion of methods by which different types of benefit may be captured.

Systems, design and value-for-money in the NHS: mission impossible?

NHS organisations are being challenged to transform -themselves sustainably in the face of increasing demands, but they have little room for error. To manage trade-offs and risks precisely, they must integrate two very different streams of -expertise: systems approaches to service design and implementation, and economic evaluation of the type pioneered by the National Institute of Health and Care Excellence (NICE) for pharmaceuticals and interventions. Neither approach is fully embedded in NHS service transformation, while the combination as an integrated discipline is still some way away. We share three examples to show how design methods may be deployed within a value-for-money framework to plan operationally and in terms of clinical outcomes. They are real cases briefly described and the unreferenced ones are anonymised. They have been selected by one of the authors (TY) during his sabbatical research because each illustrates a commonly observed challenge. To meet these challenges, we argue that the health economics cost / quality-adjusted life year (QALY) framework promulgated by NICE provides an under-appreciated lens for thinking about trade-offs and we highlight some systems tools which have also been under-utilised in this context.

Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis.

BACKGROUND: Identifying and treating persons with human immunodeficiency virus (HIV) infection early in their disease stage is considered an effective means of reducing the impact of the disease. We compared the cost-effectiveness of HIV screening in three settings, sexually transmitted disease (STD) clinics serving men who have sex with men, hospital emergency departments (EDs), settings where patients are likely to be diagnosed early, and inpatient diagnosis based on clinical manifestations. METHODS AND FINDINGS: We developed the Progression and Transmission of HIV/AIDS model, a health state transition model that tracks index patients and their infected partners from HIV infection to death. We used program characteristics for each setting to compare the incremental cost per quality-adjusted life year gained from early versus late diagnosis and treatment. We ran the model for 10,000 index patients for each setting, examining alternative scenarios, excluding and including transmission to partners, and assuming HAART was initiated at a CD4 count of either 350 or 500 cells/µL. Screening in STD clinics and EDs was cost-effective compared with diagnosing inpatients, even when including only the benefits to the index patients. Screening patients in STD clinics, who have less-advanced disease, was cost-effective compared with ED screening when treatment with HAART was initiated at a CD4 count of 500 cells/µL. When the benefits of reduced transmission to partners from early diagnosis were included, screening in settings with less-advanced disease stages was cost-saving compared with screening later in the course of infection. The study was limited by a small number of observations on CD4 count at diagnosis and by including transmission only to first generation partners of the index patients. CONCLUSIONS: HIV prevention efforts can be advanced by screening in settings where patients present with less-advanced stages of HIV infection and by initiating treatment with HAART earlier in the course of infection.

Modeling the impact of HIV chemoprophylaxis strategies among men who have sex with men in the United States: HIV infections prevented and cost-effectiveness.

BACKGROUND AND OBJECTIVE: HIV chemoprophylaxis may be a future prevention strategy to help control the global epidemic of HIV/AIDS. Safety and efficacy trials of two agents are currently underway. We assess the expected number of HIV cases prevented and cost-effectiveness of a hypothetical HIV chemoprophylaxis program among men who have sex with men in a large US city. DESIGN AND METHODS: We developed a stochastic compartmental mathematical model using HIV/AIDS surveillance data to simulate the HIV epidemic and the impact of a 5-year chemoprophylaxis program under varying assumptions for epidemiological, behavioral, programmatic and cost parameters. We estimated program effectiveness and costs from the perspective of the US healthcare system compared with current HIV prevention practices. The main outcome measures were number of HIV infections prevented and incremental cost per quality-adjusted life-years saved. RESULTS: A chemoprophylaxis program targeting 25% of high-risk men who have sex with men in New York City could prevent 780 (4%) to 4510 (23%) of the 19 510 HIV infections predicted to occur among all men who have sex with men in New York City in 5 years. More than half of prevented infections would be among those not taking chemoprophylaxis but who benefit from reduced HIV prevalence in the community. Under base-case assumptions, incremental cost was US$ 31 970 per quality-adjusted life-years saved. The program was cost-effective under most variations in efficacy, mechanism of protection and adherence. CONCLUSION: HIV chemoprophylaxis among high-risk men who have sex with men in a major US city could prevent a significant number of HIV infections and be cost-effective.

Updated estimates of healthcare utilization and costs among perinatally HIV-infected children.

OBJECTIVES: This study examined changes in healthcare use among perinatally HIV-infected children and developed new estimates of expected lifetime treatment costs. METHODS: The study analyzed longitudinal medical record data from the Pediatric Spectrum of Disease study on perinatally HIV-infected children enrolled in 6 US sites during 1995 and 2001 for enrollee characteristics including healthcare utilization. For the year 2001, costs were assigned to hospitalization, HIV-related drug usage, and laboratory testing. To estimate lifetime treatment costs based on those categories, median survival times of 9, 15, and 25 years were assumed and average annual healthcare utilization costs were applied to each year of survival. RESULTS: From 1995 to 2001, hospitalization rates fell from 0.67 per child-year to 0.23 per child-year (P < 0.05). In 2001, the average cost of healthcare utilization per child was $12,663, including $2164 for hospitalization, $9505 for HIV-related drugs, and $994 for laboratory tests. The discounted lifetime treatment cost, based on those 3 cost categories, was $113,476 for 9 years of survival, $151,849 for 15 years, and $228,155 for 25 years. CONCLUSIONS: Hospitalizations among perinatally HIV-infected children decreased significantly from 1995 to 2001. Compared with previously published estimates, lifetime treatment costs for children perinatally infected with HIV have remained relatively stable. However, as years of survival increase for this population, lifetime costs also are likely to increase.

Cost-effectiveness of HIV rescreening during late pregnancy to prevent mother-to-child HIV transmission in South Africa and other resource-limited settings.

A decision analysis model, from a health care system perspective, was used to assess the cost-effectiveness of HIV rescreening during late pregnancy to prevent perinatal HIV transmission in South Africa, a country with high HIV prevalence and incidence among pregnant women. Because new HIV prenatal prophylactic and pediatric antiretroviral therapy (ART) regimens are becoming more widely available, the study was carried out with different combinations of the two. With an estimated HIV incidence during pregnancy of 2.3 per 100 person-years, HIV rescreening would prevent additional infant infections and result in net savings when zidovudine plus single-dose nevirapine or single-dose nevirapine is used for perinatal HIV prevention, and ART was available to treat perinatally HIV-infected children. The cost savings were robust over a wide range of parameter values when ART was available to treat perinatally HIV-infected children but were more sensitive to variations around the baseline when ART was not available. The minimum time interval between the initial and repeat screens would be from 3 to 18 weeks, depending on prophylactic and treatment regimens, for HIV rescreening to be cost saving. Overall, HIV rescreening late in pregnancy in high-prevalence, resource-limited settings such as South Africa would be a cost-effective strategy for reducing mother-to-child transmission.