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.

Educational outcomes associated with childhood obesity in the United States: cross-sectional results from the 2011-2012 National Survey of Children's Health.

BACKGROUND: Past research examining the effects of childhood obesity has largely focused on its projected effects into adulthood. However, there is emerging evidence that childhood obesity may have more immediate effects on school-related outcomes. We examine a range of educational attainment indicators to examine the possible pathway between obesity status and academic performance, while investigating the proximal effects of childhood obesity on health and utilization of health services, and whether these variables attenuate the relationship between obesity status and educational outcomes. METHODS: Data for the current study come from the 2011-2012 National Survey of Children's Health, which details the impacts of childhood obesity on a range of outcomes among a nationally representative sample of children and adolescents aged 10-17 years (N=45,255). Educational outcomes (school absences, school problems, repeating a grade and school engagement) were modeled by logistic regression as a function of BMI, overall health status, health care utilization, and a range of sociodemographic variables. RESULTS: BMI status was significantly associated with all educational outcomes (p<0.001 for all), overall health status (p<0.001), and health care utilization (p=0.016). Prior to adjustment for covariates, obese children were significantly more likely to have school absences and school problems, to repeat a grade, and to have lower school engagement than non-overweight children. After adjustment for sociodemographic and health/healthcare variables, these outcomes remained significant for all but repeating a grade. The odds of having school problems, repeating a grade, and low school engagement that were associated with obesity were attenuated by the addition of sociodemographic variables into the model, while the addition of health and health care variables in the model decreased the odds of school absences. CONCLUSIONS: This study provides evidence that increased weight status in children is associated with poorer educational outcomes. While recognizing that these are cross-sectional data, we suggest that 1) health-related and sociodemographic factors should be a focus point of intervention, and 2) a socio-structural approach including Coordinated School Health intervention is crucial to reducing childhood obesity and improving educational outcomes in this population.

Cost-effectiveness of a community-based weight control intervention targeting a low-socioeconomic-status Mexican-origin population.

INTRODUCTION: The objective of our study was to evaluate the cost-effectiveness of a community-based intervention designed to improve physical activity levels and dietary intake and to reduce diabetes risk in a largely Hispanic population residing along the U.S.-Mexico border. METHOD: We forecasted disease outcomes, quality-adjusted life-years (QALYs) gained, and lifetime costs associated with actual and projected attainment of 2% and 5% weight loss taking a societal cost perspective. We extrapolated changes in beverage calorie consumption between baseline and 6-month follow-up to attain projected weight loss measures. Outcomes were projected 5, 10, and 20 years into the future and discounted at a 3.0% rate. RESULTS: The incremental cost-effectiveness ratio was $57,430 and $61,893, respectively, per QALY gained when compared with usual care for the 2% and 5% weight loss scenarios. The intervention was particularly cost-effective for morbidly obese participants. Cost-effectiveness improves when using 3-year weight loss projections based on changes in sugar-sweetened beverage caloric consumption to $49,478 and $24,092 for the 2% and 5% weight loss scenarios. CONCLUSIONS: This analysis demonstrates that a culturally sensitive community-based weight loss and maintenance intervention can be cost-effective even when healthy weight individuals participate.

Cross-gender social normative effects for violence in middle school: do girls carry a social multiplier effect for at-risk boys?

A social multiplier effect is a social interaction in which the behavior of a person in a social network varies with the normative behavior of others in the network, also known as an endogenous interaction. Policies and intervention efforts can harness social multiplier effects because, in theory, interventions on a subset of individuals will have "spillover effects" on other individuals in the network. This study investigates potential social multiplier effects for violence in middle schools, and whether there is evidence for a social multiplier effect transmitted from girls to boys. Three years of longitudinal data (2003-2005) from Project Northland Chicago were used to investigate this question, with a sample consisting of youth in Grades 6 through 8 in 61 Chicago Public Schools (N = 4,233 at Grade 6, N = 3,771 at Grade 7, and N = 3,793 at Grade 8). The sample was 49.3% female, and primarily African American (41.9%) and Latino/a (28.7%), with smaller proportions of whites (12.9%), Asians (5.2%) and other ethnicities. Results from two sets of regression models estimating the effects of 20th (low), 50th (average), and 80th (high) percentile scores for girls and boys on levels of violence in each gender group revealed evidence for social multiplier effects. Specifically, boys and girls were both influenced by social multiplier effects within their own gender group, and boys were also affected by normative violence scores among girls, typically those of the best-behaved (20th percentile) girls. The finding that girls may have positive social influence on boys' levels of violent behavior extends prior findings of beneficial social effects of girls on boys in the domains of education and risky driving. Further, this social normative effect presents a potential opportunity to improve school-based intervention efforts for reducing violence among youth by leveraging girls as carriers of a social multiplier effect for reduced violence in the middle school environmental context, particularly among boys, who are at greater risk.

The peer to career pipeline: An observational study of peer worker trainee characteristics and training completion likelihood.

INTRODUCTION: Peer recovery support services (PRSS) for substance use disorder (SUD) are a flexible and evidence-based intervention employed across multiple settings and for a variety of populations. These services have expanded over the past two decades, but there is little research on recruitment and training of prospective peer workers - the peer to career pipeline. This study observed training outcomes for applicants to a peer worker scholarship program in Texas. METHODS: A total of 448 participants provided baseline personal history information, and a subset of participants (n = 239) completed optional psychosocial surveys. Logistic regression analysis tested associations of personal history and psychosocial variables with three training stage completion outcomes: classroom training completion, placement at an internship site, and full certification. RESULTS: The greatest decline in advancement between stages occurred in the transition between classroom training (78.1 % of participants completed) and internship placement (43.3 % of participants completed). Participants were diverse in terms of race/ethnicity and life experiences salient to the peer worker role, but Hispanic/Latinx peer workers were under-represented. Past work with a SUD peer worker, age, and having a bachelor's degree were each positively associated with training stage completion across multiple models, while having basic technological access, being a woman, and veteran status were each positively associated with training stage completion in only one model. Years since recovery initiation date, non-monosexual orientation, White race, and quality of life were each negatively associated with training stage completion in only one model. CONCLUSIONS: The existing peer workforce may be a key source of recruitment for new peer workers; thus retention of existing workers is key to ensuring continued expansion of these services. Additional support may be required to recruit and retain younger peer worker trainees, men trainees, Hispanic/Latinx trainees, trainees who lack basic technological access, or trainees without bachelor's degrees. Unanswered questions about the peer workforce remain and must be addressed to ensure that an appropriately diverse workforce is recruited, that disparities in training outcomes are minimized or prevented, and that existing peer workers are well-supported.

The cost-effectiveness of a school-based smoking prevention program in India.

Intervention programs aimed at preventing tobacco use among youth have been shown to be effective in curbing tobacco use onset and progression. However, the effects of even very successful tobacco prevention programs may not always impress policy-makers and lay audiences. Economic analysis potentially strengthens the case. In this paper, we evaluate the cost-effectiveness of a youth tobacco use prevention program which has been translated and implemented in India, a developing country. Although programs like these are inexpensive to implement in the USA, they are even less expensive in India due to low labor costs. Our results show that the costs per quality-adjusted life-year added, due to averted smoking, was $2057, even without including averted medical costs. If we ignore student time, cost-effectiveness improves by roughly 10%. To put the cost-effectiveness of this smoking prevention program into context, it is over 24 times more cost-effective than dialysis in the USA, which costs $50,000 for a life-year.

Opportunity costs associated with caring for older Mexican-Americans.

Long-term care use among older Mexican-Americans is poorly understood, despite the adverse effects on health and economic disadvantage in this vulnerable population. This study examines gender-based risk of long-term care use in 628 women and 391 men, age 70 and over in the 2000-2001 and 2004-2005 waves of the Hispanic Established Populations for Epidemiologic Studies of the Elderly. Logistic regression models are employed to assess the impact of the opportunity cost implications of family support (kin availability and co-residence) relative to health care needs (quality-adjusted life years (QALY) weighted scores and functional limitations) on women's risk of entry into a nursing home. A small percentage (~5%) of men and women had entered a long-term care facility. Women had lower weights for QALY weights and greater disability than men, but on average were more likely to live with or in closer proximity to an adult child. Higher disability rates (p < 0.01) increased the risk of institutionalization regardless of gender because disability increases time burdens. Families with fewer adult children faced higher time burdens per child in caring for elderly parents; particularly for elderly mothers. Demographic trends suggest that the number of adult children available to share the caregiving load may decrease long-term care use.

Cost-effectiveness analysis of a community health worker intervention for low-income Hispanic adults with diabetes.

INTRODUCTION: The objective of our study was to estimate the long-term cost-effectiveness of a lifestyle modification program led by community health workers (CHWs) for low-income Hispanic adults with type 2 diabetes. METHODS: We forecasted disease outcomes, quality-adjusted life years (QALYs) gained, and lifetime costs associated with attaining different hemoglobin A1c (A1c) levels. Outcomes were projected 20 years into the future and discounted at a 3.0% rate. Sensitivity analyses were conducted to assess the extent to which our results were dependent on assumptions related to program effectiveness, projected years, discount rates, and costs. RESULTS: The incremental cost-effectiveness ratio of the intervention ranged from $10,995 to $33,319 per QALY gained when compared with usual care. The intervention was particularly cost-effective for adults with high glycemic levels (A1c > 9%). The results are robust to changes in multiple parameters. CONCLUSION: The CHW program was cost-effective. This study adds to the evidence that culturally sensitive lifestyle modification programs to control diabetes can be a cost-effective way to improve health among Hispanics with diabetes, particularly among those with high A1c levels.

Missed opportunities for diagnosis and treatment of diabetes, hypertension, and hypercholesterolemia in a Mexican American population, Cameron County Hispanic Cohort, 2003-2008.

INTRODUCTION: Diabetes, hypertension, and hypercholesterolemia are common chronic diseases among Hispanics, a group projected to comprise 30% of the US population by 2050. Mexican Americans are the largest ethnically distinct subgroup among Hispanics. We assessed the prevalence of and risk factors for undiagnosed and untreated diabetes, hypertension, and hypercholesterolemia among Mexican Americans in Cameron County, Texas. METHODS: We analyzed cross-sectional baseline data collected from 2003 to 2008 in the Cameron County Hispanic Cohort, a randomly selected, community-recruited cohort of 2,000 Mexican American adults aged 18 or older, to assess prevalence of diabetes, hypertension, and hypercholesterolemia; to assess the extent to which these diseases had been previously diagnosed based on self-report; and to determine whether participants who self-reported having these diseases were receiving treatment. We also assessed social and economic factors associated with prevalence, diagnosis, and treatment. RESULTS: Approximately 70% of participants had 1 or more of the 3 chronic diseases studied. Of these, at least half had had 1 of these 3 diagnosed, and at least half of those who had had a disease diagnosed were not being treated. Having insurance coverage was positively associated with having the 3 diseases diagnosed and treated, as were higher income and education level. CONCLUSIONS: Although having insurance coverage is associated with receiving treatment, important social and cultural barriers remain. Failure to provide widespread preventive medicine at the primary care level will have costly consequences.

Physical activity, watching television, and the risk of obesity in students, Texas, 2004-2005.

INTRODUCTION: The epidemic of childhood obesity has been well-documented. Prevalence of obesity among students in Texas is higher than the US prevalence. Our objective was to understand the combined influence of physical activity and television viewing on weight status of students in Texas. METHODS: Students in grades 4, 8, and 11 participated in the School Physical Activity and Nutrition survey during the 2004-2005 academic year. Multinomial logistic regression tested the associations between both being overweight and obese (vs underweight/normal weight) and the combined influence of physical activity and watching television, adjusting for age, grade, race/ethnicity, language spoken at home, and percentage of economically disadvantaged students in the school. We used 5 physical activity indicators to describe students' physical activity. RESULTS: Girls who participated in less than 3 days of exercise per week to strengthen or tone muscles and watched 2 hours or less per day of television had increased odds of being obese (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.0) compared with girls who participated in 3 or more days per week of exercise to strengthen or tone muscles and watched 2 hours or less per day of television. Boys in our study who watched 3 or more hours per day of television and did not meet physical activity recommendations had increased odds of being obese in all of our 5 physical activity indicators. CONCLUSION: Although results varied by physical activity indicator and sex, our findings provide further evidence for the combined effect of high television watching and low physical activity engagement on the risk for obesity in children and adolescents.

Reimbursement for genetic variant reinterpretation: five questions payers should ask.

Reaching the goals set by the Health Care Payment and Learning Action Network requires an unyielding and unrelenting focus on encouraging providers to adopt advanced alternative payment models (APMs). Many of these models will continue to be voluntary because they either are in early stages or have not yet proven their effectiveness. The models that have proven their effectiveness should become permanent, comprising the new way that providers are paid in the Medicare program. Either way, getting today's high performers into those programs and keeping them engaged to continue to innovate and set new benchmarks is as important as attracting and improving the performance of poorer performers. That will require a shift in Medicare's policy on pricing and evaluating APMs.

Socioeconomic status and prevalence of obesity and diabetes in a Mexican American community, Cameron County, Texas, 2004-2007.

INTRODUCTION: Mexican Americans are at increased risk for obesity and diabetes. We established a cohort on the United States-Mexico border to determine the prevalence of obesity and diabetes in this Mexican American population and to see whether minor economic advantages had any effect on health. METHODS: We randomly selected and extensively documented 810 people aged 35 to 64 years. Weighted data were analyzed to establish prevalence of obesity and diabetes and other markers of poor health such as elevated glycated hemoglobin levels. RESULTS: Rates of obesity (body mass index > or = 30 kg/m(2)) were 57% in the first (lower) of 4 socioeconomic strata by income and were 55.5% in the third (higher). People in the higher socioeconomic stratum were significantly less likely to have undiagnosed diabetes (2% vs 9%). Among people aged 55 to 64 years, rates of diabetes were significantly higher among those in the lower socioeconomic stratum than among those in the higher stratum. Rates of undiagnosed diabetes had similar differences. Approximately three-fourths of the respondents reported having no health insurance, and we found no difference between people in different socioeconomic strata. CONCLUSION: Rates of obesity and diabetes in this border community are among the highest in the United States. Belonging to the lower socioeconomic stratum significantly increased the likelihood of having undiagnosed diabetes and, in patients too young to be eligible for Medicare, the overall risk of developing diabetes. Modest improvement in income has a beneficial effect on health in this racial/ethnic minority community.

International competition and the demand for health insurance in the US: evidence from the Texas-Mexico border region.

Conventional economic explanations for uninsurance should apply to all geographic regions in the United States. However, the border states of California, Arizona, New Mexico and Texas have the highest rates of uninsurance in the US, accounting for over 30% of the total US uninsured population. We use survey data from the fourth wave of the Border Epidemiologic Study on Aging (BESA), a survey from a predominantly Mexican American region of South Texas from 2005 to 2006, to analyze how health insurance coverage in the US is related to the use of health care services in Mexico. BESA includes data on the use of health care services in the US and Mexico. We estimate probit models to investigate the association between having insurance coverage in the US and having a regular doctor in Mexico, the independent variable of interest. Separate models are estimated with having private insurance, Medicare Part B insurance, and any type of public insurance as dependent variables. We deal with the endogeneity, due to reverse causality, of having a regular doctor in Mexico by using instrumental variables in a bivariate probit model. The instruments are dental care utilization in Mexico and a variable measuring frequently visiting Mexico. The results show that competition from Mexico lowers the demand for health insurance coverage in the US side of the border.

Persistent disparities in the use of health care along the US-Mexico border: an ecological perspective.

OBJECTIVES: We examined disparities in health care use among US-Mexico border residents, with a focus on the unique binational environment of the region, to determine factors that may influence health care use in Mexico. METHODS: Data were from 2 waves of a population-based study of 1048 Latino residents of selected Texas border counties. Logistic regression models examined predictors of health insurance coverage. Results from these models were used to examine regional patterns of health care use. RESULTS: Of the respondents younger than 65 years, 60% reported no health insurance coverage. The uninsured were 7 and 3 times more likely in waves 3 and 4, respectively, to use medical care in Mexico than were the insured. Preference for medical care in Mexico was an important predictor. CONCLUSIONS: For those who were chronically ill, old, poor, or burdened by the lengthy processing of their documents by immigration authorities, the United States provided the only source of health care. For some, Mexico may lessen the burden at the individual level, but it does not lessen the aggregate burden of providing highly priced care to the region's neediest. Health disparities will continue unless policies are enacted to expand health care accessibility in the region.

Crime rates and sedentary behavior among 4th grade Texas school children.

INTRODUCTION: Although per capita crime has generally fallen over the period which coincides with the obesity epidemic, it has not fallen uniformly across communities. It also has not fallen enough to allay fears on the part of parents. Over the past 30 years, technological changes have made the indoor alternatives to playing outside, where children are more vulnerable to criminal activity, more enjoyable (cable TV, video games, and the internet) and comfortable (the spread of air conditioning to low income neighborhoods). We determined whether indoor sedentary behavior patterns are associated with community crime statistics. 4th graders in the U.S. are typically 9 or 10 years old. METHODS: We used data from the 2004-2005 Texas School Physical Activity and Nutrition (SPAN) survey linked with U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics data for the years 2000 through 2005 and Texas State data on sexual offenders. The probability-based sample included a total of 7,907 children in grade four. Multistage probability sampling weights were used. The dependent variables included were hours of TV watching, video game playing, computer use and total indoor sedentary behavior after school. Incremental Relative Rates were computed for community crime rates including robberies, all violent crimes, murders, assaults, property crimes, rapes, burglaries, larcenies and motor vehicle thefts as well as for sexual offenders living in the neighborhood. The neighborhood refers to the areas where the students at each school live. In the case of sexual offenders, sexual offenders per capita are estimated using the per capita rate in the zip code of the school attended; all other crime statistics are estimated by the crimes per capita in the police department jurisdiction covering the school attended. After controlling for sex, age, and African-American and Hispanic, cross-sectional associations were determined using multivariate Poisson regression. RESULTS: 4th grade boys were more likely to play video games in communities with increased per 100 population rates of larceny and burglary as well as in communities with increased per capita sexual offenders; 4th grade girls were more likely to watch television in communities with increased per capita sexual offenders. While 4th grade girls were more likely to watch TV in communities with increased per capita sex offenders, they were less likely to use computers. Per capita sexual offenders were negatively related to computer use amongst 4th grade girls. CONCLUSION: By combining community crime and cross-sectional individual level data on indoor sedentary behavior, we found that there is an association between community crimes/sex offender rates and certain types of indoor sedentary behavior. The development of technologies in recent decades which makes supervising children easier indoors, where children are much less vulnerable to crime, may be contributing to the epidemic of childhood obesity.

Association between tuberculosis and diabetes in the Mexican border and non-border regions of Texas.

The association between tuberculosis and underlying risk factors was evaluated in Texas patients hospitalized in the 15 counties along the Mexico border within the remaining non-border counties. A case control analysis of the hospital discharge dataset from the Texas Health Care Information Council was performed for the years 1999-2001. A discharge diagnosis of tuberculosis identified cases (N = 4,915). Deep venous thrombosis, pulmonary embolism, and acute appendicitis conditions identified controls (N = 70,808). Risk factors associated with tuberculosis were identified by logistic regression. Diabetes patients were almost twice as likely to have tuberculosis after adjusting by sex, age, and race/ethnicity. The association was strong for the population in the Texas border region, where there are higher incidence rates of tuberculosis (odds ratio [OR](adj) = 1.82; 95% CI = 1.57-2.12) compared with non-border counties (OR(adj) = 1.51; 95% CI = 1.36-1.67).

Influence of grade-level drinking norms on individual drinking behavior.

OBJECTIVE: To investigate which points of the middle-school drinking distribution are the most influential in the social contagion of drinking across the middle-school years, in order to identify potential social multipliers. METHODS: We measured drinking intentions and behaviors by gender, school, and grade among urban middle-school students who participated in Project Northland Chicago in a longitudinal cohort design. RESULTS: Individual drinking behaviors were consistently influenced by extreme (80(th) percentile) drinking intentions and behaviors. This effect was mediated through normal or average levels of drinking, over time. CONCLUSIONS: Interventions can target extreme drinkers as the influential persons in middle-school grades.

Surveillance of bleeding disorders, Texas, 2007.

BACKGROUND: In 2007, some 1261 patients with hemophilia or other bleeding disorders were seen at federally funded hemophilia treatment centers (HTCs) in Texas. Although HTCs function as sites for passive surveillance of bleeding disorders, annual HTC visit data likely underestimate true prevalence of the disease due to the infrequent nature of healthcare utilization for this population. PURPOSE: The main aim of this study was to compare two alternative methods for estimating prevalence of hemophilia and to describe the challenges associated with making valid prevalence estimates. Each method utilized a separate data source, with the goal of validating one or both of the methods, compared to the gold standard of active case finding. METHODS: Two data sets, one describing treatment of hemophilia in an outpatient setting at HTCs and one describing treatment and care of patients in a hospital inpatient setting, were used to calculate annual prevalence estimates of hemophilia among men in Texas in 2007. The prevalence estimates resulting from each of the two methods were compared to each other and to past estimates based on active surveillance. RESULTS: Calculations based on HTC data resulted in estimated prevalence rates of 8.9 and 2.1/100,000 male population for hemophilia A and B, respectively. Prevalence estimates based on hospital discharge data yielded rates of 12.3 and 2.9/100,000 males for hemophilia A and B, respectively. CONCLUSIONS: Hemophilia is a rare, chronic disease with high treatment costs. Prevalence estimates based on HTC and hospital discharge data were similar to each other as well as to active surveillance prevalence estimates in published literature.