Economic Evaluation of Wastewater Surveillance Combined with Clinical COVID-19 Screening Tests, Japan.

The COVID-19 pandemic has imposed substantial burdens on the global society. To find an optimal combination of wastewater surveillance and clinical testing for tracking COVID-19, we evaluated the economic efficiency of hypothetical screening options at a single facility in Japan. To conduct cost-benefit analyses, we developed standard decision models in which we assumed model parameters from literature and primary data, such as screening policies used at the Tokyo Olympic and Paralympic Village in 2021. We compared hypothetical 2-step screening options that used clinical PCR to diagnose COVID-19 after a positive result from primary screening using antigen tests (option 1) or wastewater surveillance (option 2). Our simulation results indicated that option 2 likely would be economically more justifiable than option 1, particularly at lower incidence levels. Our findings could help justify and promote the use of wastewater surveillance as a primary screening at a facility level for COVID-19 and other infectious diseases.

Economic Evaluation of Telemedicine Consultations to Reduce Unnecessary Neonatal Care Transfers.

OBJECTIVES: To perform an economic evaluation to estimate the return on investment (ROI) of making available telemedicine consultations from a healthcare payer perspective, and to estimate the economic impacts of telemedicine under a hypothetical scenario in which all rural hospitals providing level I neonatal care in California had access to telemedicine consultations from neonatologists at level III and level IV neonatal intensive care units (NICUs). STUDY DESIGN: We developed standard decision models with assumptions derived from primary data and the literature. Telemedicine costs included equipment installation and operation costs. Probabilistic analysis with Monte Carlo simulation was performed to address model uncertainties and to estimate 95% probabilistic confidence intervals (PCIs). All costs were adjusted to 2017 US dollars using the Consumer Price Index. RESULTS: Our probabilistic analysis estimated the ROI to have a mean value of 2.23 (95% PCI, -0.7 to 6.0). That is, a $1 investment in this telemedicine model would yield a net medical expenditure saving of $1.23. "Cost saving" was observed for 75% of the hypothetical 1000 Monte Carlo simulations. For the state of California, the estimated mean annual net savings was $661 000. CONCLUSIONS: Providing telemedicine and making available consultations to rural hospitals providing level I neonatal care are likely to reduce medical expenditures by reducing potentially avoidable transfers of newborns to level III and IV NICUs, offsetting all telemedicine-related costs.

Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial.

BACKGROUND: Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking. OBJECTIVE: This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method. METHODS: Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months. RESULTS: For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention. CONCLUSIONS: This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

Can income-based co-payment rates improve disparity? The case of the choice between brand-name and generic drugs.

BACKGROUND: Higher income population tend to prefer brand-name to generic drugs, which may cause disparity in access to brand-name drugs among income groups. A potential policy that can resolve such disparity is imposing a greater co-payment rate on high-income enrollees. However, the effects of such policy are unknown. We examined how patients' choice between brand-name and generic drugs are affected by the unique income-based co-payment rates in Japan; 10% for general enrollees and 30% for those with high income among the elderly aged 75 and over. METHODS: We drew on cross-sectional price variation among commonly prescribed 311 drugs using health insurance claims data from a large prefecture in Japan between October 2013 and September 2014 to identify between-income-group differences in responses to differentiated payments. RESULTS: Running 311 multivariate logistic regression models controlling individual demographics, the median estimate indicated that high-income group was 3% (odds ratio = 0.97) less likely to choose a generic drug than the general-income group and the interquartile estimates ranged 0.92-1.02. The multivariate feasible generalized least squares model indicated high-income group's higher likelihood to choose brand-name drugs than the general-income group without co-payment rate differentiation (p < 0.001). Such gap in the likelihood was attenuated by 0.4% (p = 0.027) with an US$1 increase in the difference in additional payment/month for brand-name drugs between income groups - no gap with US$10 additional payment/month. This attenuation was observed in drugs for chronic diseases only, not for acute diseases. CONCLUSIONS: Income-based co-payment rates appeared to reduce disparity in access to brand-name drugs across income groups, in addition to reducing total medical expenditure among high-income group who shifted from brand-name drugs to generic ones due to larger drug price differences.

School-Located Influenza Vaccination: Do Vaccine Clinics at School Raise Vaccination Rates?

BACKGROUND: Only half of US schoolchildren receive influenza vaccine. School-located influenza vaccination (SLIV) might raise vaccination rates but conducting flu vaccine clinics at schools is challenging to implement. We compared 2 school-based programs designed to raise influenza vaccination rates: parent reminder/educational messages sent to parents from schools which is a low-intensity intervention vs the combination of reminder/educational messages plus SLIV clinics which is a high-intensity intervention. METHODS: We assigned 36 schools (6 school districts, 2 per group) to 3 groups: (1) control, ie, no SLIV and no parent reminder/education, (2) parent reminder/education emailed by schools, and (3) parent reminder/education plus SLIV clinics. Some schools had SLIV clinics in prior years. Health department nurses conducted SLIV clinics. RESULTS: Among 24,832 children at 36 schools, vaccination rates were control (51.3%), parent reminder/education-only (41.2%), and reminder/education + SLIV (58.7%). On multivariate analyses which controlled for vaccination in prior seasons, children in reminder/education + SLIV schools had higher vaccination rates (OR 1.27, 95% CI 1.10-1.47), but children in reminder/education-only schools had lower rates (OR 0.87, 95% CI 0.75-1.00) than children in control schools. CONCLUSIONS: Parent reminder/education combined with SLIV clinics raise vaccination rates, but parent reminder/education alone does not.

Cost effectiveness of school-located influenza vaccination programs for elementary and secondary school children.

BACKGROUND: Studies have noted variations in the cost-effectiveness of school-located influenza vaccination (SLIV), but little is known about how SLIV's cost-effectiveness may vary by targeted age group (e.g., elementary or secondary school students), or vaccine consent process (paper-based or web-based). Further, SLIV's cost-effectiveness may be impacted by its spillover effect on practice-based vaccination; prior studies have not addressed this issue. METHODS: We performed a cost-effectiveness analysis on two SLIV programs in upstate New York in 2015-2016: (a) elementary school SLIV using a stepped wedge design with schools as clusters (24 suburban and 18 urban schools) and (b) secondary school SLIV using a cluster randomized trial (16 suburban and 4 urban schools). The cost-per-additionally-vaccinated child (i.e., incremental cost-effectiveness ratio (ICER)) was estimated by dividing the incremental SLIV intervention cost by the incremental effectiveness (i.e., the additional number of vaccinated students in intervention schools compared to control schools). We performed deterministic analyses, one-way sensitivity analyses, and probabilistic analyses. RESULTS: The overall effectiveness measure (proportion of children vaccinated) was 5.7 and 5.5 percentage points higher, respectively, in intervention elementary (52.8%) and secondary schools (48.2%) than grade-matched control schools. SLIV programs vaccinated a small proportion of children in intervention elementary (5.2%) and secondary schools (2.5%). In elementary and secondary schools, the ICER excluding vaccine purchase was $85.71 and $86.51 per-additionally-vaccinated-child, respectively. When additionally accounting for observed spillover impact on practice-based vaccination, the ICER decreased to $80.53 in elementary schools -- decreasing substantially in secondary schools. (to $53.40). These estimates were higher than the published practice-based vaccination cost (median = $25.50, mean = $45.48). Also, these estimates were higher than our 2009-2011 urban SLIV program mean costs ($65) due to additional costs for use of a new web-based consent system ($12.97 per-additionally-vaccinated-child) and higher project coordination costs in 2015-2016. One-way sensitivity analyses showed that ICER estimates were most sensitive to the SLIV effectiveness. CONCLUSIONS: SLIV raises vaccination rates and may increase practice-based vaccination in primary care practices. While these SLIV programs are effective, to be as cost-effective as practice-based vaccination our SLIV programs would need to vaccinate more students and/or lower the costs for consent systems and project coordination. TRIAL REGISTRATION: ClinicalTrials.gov NCT02227186 (August 25, 2014), updated NCT03137667 (May 2, 2017).

Text Message Reminders for Child Influenza Vaccination in the Setting of School-Located Influenza Vaccination: A Randomized Clinical Trial.

Half of US school children receive influenza vaccine. In our previous trials, school-located influenza vaccination (SLIV) raised vaccination rates by 5 to 8 percentage points. We assessed whether text message reminders to parents could raise vaccination rates above those observed with SLIV. Within urban elementary schools we randomized families into text message + SLIV (intervention) versus SLIV alone (comparison). All parents were sent 2 backpack notifications plus 2 autodialer phone reminders about SLIV at a single SLIV clinic. Intervention group parents also were sent 3 text messages from the school nurse encouraging flu vaccination via either primary care or SLIV. Among 15 768 children at 32 schools, vaccination rates were text + SLIV (40%) and SLIV control (40%); 4% of students per group received influenza vaccination at SLIV. Text message reminders did not raise influenza vaccination rates above those observed with SLIV alone. More intensive interventions are needed to raise influenza vaccination rates.

Impact of a direct-to-consumer information campaign on prescription patterns for overactive bladder.

BACKGROUND: Direct-to-consumer information (DTCI) campaign is a new medium to inform and empower patients in their decision-making without directly promoting specific drugs. However, little is known about the impact of DTCI campaigns, expanding rapidly in developed countries, on changes in prescription patterns. We sought to determine whether a DTCI campaign on overactive bladder increases the prescription rate for overactive bladder treatment drugs. METHODS: We performed a 3-year retrospective cohort study of 1332 participants who were diagnosed overactive bladder but not prescribed treatment drugs prior to the examined DTCI campaign (exposure), using the health insurance claims dataset of the Japan Medical Data Center (November 19, 2010 to November 18, 2013). The DTCI campaign for overactive bladder included television, Internet, and print advertising (November 19, 2011 to December 22, 2011). We divided the study period into Pre-Campaign Year (2010-2011), Year 1 (2011-2012), and Year 2 (2012-2013). Each year began on November 19 and included Period 1 (weeks 1-5) through Period 10 (weeks 46-50). The main outcome was first-time prescription of the treatment drug for each patient, measured by 5-week periods. Using Period 10 in the Pre-Campaign Year as the referent period, we applied the Cox proportional hazard model for each period. Additionally, we performed the interrupted time series analysis (ITSA) for the first-time prescription rate per 5-week period. RESULTS: Following the DTCI campaign, patients were about seven times more likely to receive a first prescription of a treatment drug during Period 4 in Year 1 (hazard ratio 7.09; 95% CI, 2.11-23.8; p-value<.01) compared with the reference period. Similar increases were also observed for subsequent Periods 5 and 6 in Year 1. The ITSA confirmed the DTCI campaign impact on the level of prescription rate (one-time increase in the regression-intercept) that increased by 1128.1 [per standardized 100,000 persons] (p < .05) during Period 4 in Year 1. CONCLUSIONS: The examined DTCI campaign appeared to increase the prescription rate among patients with overactive bladder for 15 weeks with a 15-week delay. Clinical outcomes of the patients with targeted diseases need to be monitored after DTCI campaigns by a future study.

Impact of elementary school-located influenza vaccinations: A stepped wedge trial across a community.

BACKGROUND: Influenza vaccination rates among children are low and novel strategies are needed to raise coverage. We measured the impact of school-located influenza vaccination (SLIV) on coverage, examined whether SLIV substitutes for practice-based influenza vaccination ("substitution"), and estimated whether a second year of experience with SLIV increases its impact. METHODS: We implemented a stepped wedge study design with schools as clusters. In Year 1, we randomly allocated schools to SLIV or control. In Year 2, all schools performed SLIV. We used emails (suburban schools) or backpack fliers (both urban and suburban schools) to notify parents, and offered web-based (suburban) or paper-based vaccination (urban) consent forms. Local health department nurses administered SLIV vaccinations and billed insurers. We analyzed state immunization registry data to measure influenza vaccination rates. RESULTS: 42 schools (38,078 children) participated over 2 years. Overall vaccination rates were 5 and 7 percentage points higher among SLIV- school children versus control-school children in suburban (aOR 1.36, 95% CI 1.25-1.49 in Years 1-2 SLIV vs. Year 1 control schools) and urban schools (aOR 1.22, 95% CI 1.10-1.36), respectively, adjusting for prior year's vaccination and other covariates. While no substitution occurred among children attending suburban schools, some substitution occurred among children attending urban schools, although overall vaccination rates were still higher in urban schools due to SLIV. Compared to an initial year of SLIV, more children were vaccinated in a second year of SLIV at urban (8.3% vs. 6.8%, aOR 1.24, 95% CI 1.04-1.47) but not suburban schools (3.5% vs. 2.7%, aOR 1.24, 95% CI 0.98-1.57). CONCLUSIONS: In this stepped wedge trial, SLIV increased overall influenza vaccination rates in suburban and urban schools. Some substitution for primary care vaccination occurred in urban settings. A second year of SLIV expanded its reach slightly in urban schools.

Selected Use of Telemedicine in Intensive Care Units Based on Severity of Illness Improves Cost-Effectiveness.

BACKGROUND: Telemedicine in the intensive care unit (tele-ICU) is expected to address geographic health disparities through more efficient resource allocation. Our previous economic evaluation demonstrated tele-ICU to be cost-effective in most cases and cost saving in some cases, compared to conventional intensive care unit (ICU) care without adequate intensivist coverage. INTRODUCTION: This study's objective is to examine how to optimize the cost-effectiveness of tele-ICU use by selecting highest risk (i.e., both highest mortality and highest cost) subpopulations. We also explore potential cost savings. MATERIALS AND METHODS: We conducted simulation analyses among a hypothetical adult ICU patient cohort defined by the literature, distinguishing four types of hospitals: urban tertiary (primary analysis), urban community, rural tertiary, and rural community. The selected tele-ICU use was assumed to affect per-patient ICU cost and hospital mortality among highest risk subpopulations (10-100% of all ICU patients), defined by an established illness-severity measure. RESULTS: We found a U-shaped relationship between the economic efficiency and selected tele-ICU use among all 4 hospital types. Optimal cost-effectiveness was achieved when tele-ICU was applied to the 30-40% highest risk patients among all ICU patients (incremental cost-effectiveness ratio = $25,392 [2014 U.S. dollars] per extending a quality-adjusted life year) in urban tertiary hospitals (primary analysis). Our break-even analyses indicated that cost saving seems more feasible when reducing ICU medical care cost, rather than lowering the cost to operate telemedicine alone. DISCUSSION AND CONCLUSIONS: A selected use of tele-ICU based on severity of illness is likely to improve tele-ICU cost-effectiveness. To achieve cost saving, tele-ICU must reduce more than just telemedicine-related cost.

School-located Influenza Vaccinations for Adolescents: A Randomized Controlled Trial.

PURPOSE: We aimed to evaluate the effect of school-located influenza vaccination (SLIV) on adolescents' influenza vaccination rates. METHODS: In 2015-2016, we performed a cluster-randomized trial of adolescent SLIV in middle/high schools. We selected 10 pairs of schools (identical grades within pairs) and randomly allocated schools within pairs to SLIV or usual care control. At eight suburban SLIV schools, we sent parents e-mail notifications about upcoming SLIV clinics and promoted online immunization consent. At two urban SLIV schools, we sent parents (via student backpack fliers) paper immunization consent forms and information about SLIV. E-mails were unavailable at these schools. Local health department nurses administered nasal or injectable influenza vaccine at dedicated SLIV clinics and billed insurers. We compared influenza vaccination rates at SLIV versus control schools using school directories to identify the student sample in each school. We used the state immunization registry to determine receipt of influenza vaccination. RESULTS: The final sample comprised 17,650 students enrolled in the 20 schools. Adolescents at suburban SLIV schools had higher overall influenza vaccination rates than did adolescents at control schools (51% vs. 46%, p < .001; adjusted odds ratio = 1.27, 95% confidence interval 1.18-1.38, controlling for vaccination during the prior two seasons). No effect of SLIV was noted among urbanschools on multivariate analysis. SLIV did not substitute for vaccinations in primary care or other settings; in suburban settings, SLIV was associated with increased vaccinations in primary care or other settings (adjusted odds ratio = 1.10, 95% confidence interval 1.02-1.19). CONCLUSIONS: SLIV in this community increased influenza vaccination rates among adolescents attending suburban schools.

Pilot survey of a novel incentive to promote healthy behavior among school children and their parents.

Reversing the obesity epidemic has been a persistent global public health challenge, particularly among low socioeconomic status populations and racial/ethnic minorities. We developed a novel concept of community-based incentives to approach this problem in such communities. Applying this concept, we proposed a school intervention to promote obesity prevention in the U.S. We conducted a pilot survey to explore attitudes towards this future intervention. The survey was collected as a nonprobability sample (N = 137 school-aged children (5-12 years)) in northern California in July 2013. We implemented multivariable logistic regression analyses where the dependent variable indicated the intention to participate in the future intervention. The covariates included the body mass index (BMI) based weight categories, demographics, and others. We found that the future intervention is expected to motivate generally-high-risk populations (such as children and parents who have never joined a past health-improvement program compared to those who have completed a past health-improvement program (the odds-ratio (OR) = 5.84, p < 0.05) and children with an obese/overweight parent (OR = 2.72, p < 0.05 compared to those without one)) to participate in future obesity-prevention activities. Our analyses also showed that some subgroups of high-risk populations, such as Hispanic children (OR = 0.27, p < 0.05) and children eligible for a free or reduced price meal program (OR = 0.37, p < 0.06), remain difficult to reach and need an intensive outreach activity for the future intervention. The survey indicated high interest in the future school intervention among high-risk parents who have never joined a past health-improvement program or are obese/overweight. These findings will help design and implement a future intervention.

Program Evaluation of a Nursing Workforce Intervention: The Maryland Nurse Support Program II.

A nursing workforce initiative in Maryland sought to graduate additional nursing students to become registered nurses and to increase the number and preparation levels of nursing faculty. Between FY 2006 and FY 2015, nearly $100 million was awarded through 109 competitive institutional grants at 27 nursing programs across the state; 950 faculty received awards through fellowships, scholarships, and grants. Maryland's nursing workforce intervention increased the number of graduates by 27% through this decade-long program. Although Maryland outperformed the nation in the rate of increase of registered nurses, there is still a projected state shortfall of 12,100 nurses by 2025. It is imperative for nurse researchers and nurse leaders to address the future nursing and nurse faculty workforce shortage using effective strategies based on empirical evidence and evaluation of outcomes. This program evaluation informed the decision to continue investments in the nursing and faculty workforce (up to $75 million) for an additional 5 years.

The Impact of Economic Recession On Registered Nurse Workforce Supply in California.

The severe economic recession from December 2007 to December 2010 substantially affected registered nurse (RN) employment. The objective of this study was to determine if the association between RN workforce supply and its potential determinants differed during the period from 2008 to 2012. Older, experienced RNs were more likely to work in 2010, compared to 2008, but less likely to work in 2012 compared to 2010. RNs were less sensitive to financial factors in 2010 than in 2008, but were more sensitive in 2012 than in 2010. These recession-driven changes in employment may have had impacts on the labor market for newly graduating RNs.

School-Located Influenza Vaccinations: A Randomized Trial.

OBJECTIVE: Assess impact of offering school-located influenza vaccination (SLIV) clinics using both Web-based and paper consent upon overall influenza vaccination rates among elementary school children. METHODS: We conducted a cluster-randomized trial (stratified by suburban/urban districts) in upstate New York in 2014-2015. We randomized 44 elementary schools, selected similar pairs of schools within districts, and allocated schools to SLIV versus usual care (control). Parents of children at SLIV schools were sent information and vaccination consent forms via e-mail, backpack fliers, or both (depending on school preferences) regarding school vaccine clinics. Health department nurses conducted vaccine clinics and billed insurers. For all children registered at SLIV/control schools, we compared receipt of influenza vaccination anywhere (primary outcome). RESULTS: The 44 schools served 19 776 eligible children in 2014-2015. Children in SLIV schools had higher influenza vaccination rates than children in control schools county-wide (54.1% vs 47.4%, P < .001) and in suburban (61.9% vs 53.6%, P < .001) and urban schools (43.9% vs 39.2%; P < .001). Multivariate analyses (controlling for age, grade, vaccination in previous season) confirmed bivariate findings. Among parents who consented for SLIV, nearly half of those notified by backpack fliers and four-fifths of those notified by e-mail consented online. In suburban districts, SLIV did not substitute for primary care influenza vaccination. In urban schools, some substitution occurred. CONCLUSIONS: SLIV raised seasonal influenza vaccination rates county-wide and in both suburban and urban settings. SLIV did not substitute for primary care vaccinations in suburban settings where pediatricians often preorder influenza vaccine but did substitute somewhat in urban settings.

A Systematic Review of the Economic Evaluation of Telemedicine in Japan.

OBJECTIVES: There is no systematic review on economic evaluations of telemedicine in Japan, despite over 1000 trials implemented. Our systematic review aims to examine whether Japan's telemedicine is cost-saving or cost-effective, examine the methodological rigorousness of the economic evaluations, and discuss future studies needed to improve telemedicine's financial sustainability. METHODS: We searched five databases, including two Japanese databases, to find peer-reviewed articles published between January 1, 2000 and December 31, 2014 in English and Japanese that performed economic evaluations of Japan's telemedicine programs. The methodological rigorousness of the economic analyses was assessed with a well-established checklist. We calculated the benefit-to-cost ratio (BCR) when a reviewed study reported related data but did not report the BCR. All cost values were adjusted to 2014 US dollars. RESULTS: Among the 17 articles identified, six studies reported on settings connecting physicians for specialist consultations, and eleven studies on settings connecting healthcare providers and patients at home. There are three cost-benefit analyses and three cost-minimization analyses. The remaining studies measured the benefit of telemedicine only, using medical expenditure saved or users' willingness-to-pay. There was substantial diversity in the methodological rigorousness. Studies on teledermatology and teleradiology indicated a favorable level of economic efficiency. Studies on telehomecare gave mixed results. One cost-benefit analysis on telehomecare indicated a low economic efficiency, partly due to public subsidy rules, e.g., a too short budget period. CONCLUSIONS: Overall, telemedicine programs in Japan were indicated to have a favorable level of economic efficiency. However, the scarcity of the economic literature indicates the need for further rigorous economic evaluation studies.

The effect of prior healthcare employment on the wages of registered nurses.

BACKGROUND: The proportion of registered nurses (RNs) with employment in health-related positions before their initial RN education has increased in the past two decades. Previous research found that prior health-related employment is positively associated with RN workforce supply, potentially due to the wage differences based on different career paths. This study's objective is to test the hypotheses that prior health-related employment is associated with differences in starting wages and with different rates of wage growth for experience as an RN. METHODS: We conducted a cross-sectional analysis using the 2008 National Sample Survey of Registered Nurses (NSSRN) linked with county-level variables from the Area Health Resource File. We estimated a Heckman model where the second-stage equation's outcome variable was the logarithm of the RN hourly wage, accounting for the self-selection of working or not working as an RN (i.e., the first-stage equation's outcome variable). Key covariates included interaction terms between years of experience, experience squared, and six categories of prior health-related employment (manager, LPN/LVN, allied health, nursing aide, clerk, and all other healthcare positions). Additional covariates included demographics, weekly working hours, marital status, highest nursing degree, and county-level variables (e.g., unemployment rate). We estimated the marginal effect of experience on wage for each type of prior health-related employment, conducting separate analyses for RNs whose initial education was a Bachelor of Science in Nursing (BSN) (unweighted N = 10,345/weighted N = 945,429), RNs whose initial education was an Associate degree (unweighted N = 13,791/weighted N = 1,296,809), and total population combining the former groups (unweighted N = 24,136/weighted N = 2,242,238). RESULTS: Prior health-related employment was associated with higher wages, with the strongest wage differences among BSN-educated RNs. Among BSN-educated RNs, previous employment as a health care manager, LPN/LVN, or nursing aide produced statistically higher starting wages ($1.72-$3.86 per hour; $3400-$7700 per year; p = 0.006-0.08). However, experience-based wage growth was lower for BSN-educated RNs previously employed as allied health workers, LPN/LVNs, or nursing aides. Among Associate degree-educated RNs, wage difference was not observed except for higher initial wage for RNs with previous employment as LPN/LVNs. CONCLUSIONS: Prior employment in health-related positions was associated with both starting salary and experience-based wage growth among BSN-educated RNs. The higher wage return for those with a BSN may motivate non-RN healthcare workers to seek a BSN in their transition to RN jobs, which could help advancement toward the 80 % BSN workforce recommended by the U.S. Institute of Medicine.

Economic Evaluation of Telemedicine for Patients in ICUs.

OBJECTIVE: Despite telemedicine's potential to improve patients' health outcomes and reduce costs in the ICU, hospitals have been slow to introduce telemedicine in the ICU due to high up-front costs and mixed evidence on effectiveness. This study's first aim was to conduct a cost-effectiveness analysis to estimate the incremental cost-effectiveness ratio of telemedicine in the ICU, compared with ICU without telemedicine, from the healthcare system perspective. The second aim was to examine potential cost saving of telemedicine in the ICU through probabilistic analyses and break-even analyses. DESIGN: Simulation analyses performed by standard decision models. SETTING: Hypothetical ICU defined by the U.S. literature. PATIENTS: Hypothetical adult patients in ICU defined by the U.S. literature. INTERVENTIONS: The intervention was the introduction of telemedicine in the ICU, which was assumed to affect per-patient per-hospital-stay ICU cost and hospital mortality. Telemedicine in the ICU operation costs included the telemedicine equipment-installation (start-up) costs with 5-year depreciation, maintenance costs, and clinician staffing costs. Telemedicine in the ICU effectiveness was measured by cumulative quality-adjusted life years for 5 years after ICU discharge. MEASUREMENTS AND MAIN RESULTS: The base case cost-effectiveness analysis estimated telemedicine in the ICU to extend 0.011 quality-adjusted life years with an incremental cost of $516 per patient compared with ICU without telemedicine, resulting in an incremental cost-effectiveness ratio of $45,320 per additional quality-adjusted life year (= $516/0.011). The probabilistic cost-effectiveness analysis estimated an incremental cost-effectiveness ratio of $50,265 with a wide 95% CI from a negative value (suggesting cost savings) to $375,870. These probabilistic analyses projected that cost saving is achieved 37% of 1,000 iterations. Cost saving is also feasible if the per-patient per-hospital-stay operational cost and physician cost were less than $422 and less than $155, respectively, based on break-even analyses. CONCLUSIONS: Our analyses suggest that telemedicine in the ICU is cost-effective in most cases and cost saving in some cases. The thresholds of cost and effectiveness, estimated by break-even analyses, help hospitals determine the impact of telemedicine in the ICU and potential cost saving.

Cost effectiveness analysis of Year 2 of an elementary school-located influenza vaccination program-Results from a randomized controlled trial.

BACKGROUND: School-located vaccination against influenza (SLV-I) has the potential to improve current suboptimal influenza immunization coverage for U.S. school-aged children. However, little is known about SLV-I's cost-effectiveness. The objective of this study is to establish the cost-effectiveness of SLV-I based on a two-year community-based randomized controlled trial (Year 1: 2009-2010 vaccination season, an unusual H1N1 pandemic influenza season, and Year 2: 2010-2011, a more typical influenza season). METHODS: We performed a cost-effectiveness analysis on a two-year randomized controlled trial of a Western New York SLV-I program. SLV-I clinics were offered in 21 intervention elementary schools (Year 1 n = 9,027; Year 2 n = 9,145 children) with standard-of-care (no SLV-I) in control schools (Year 1 n = 4,534 (10 schools); Year 2 n = 4,796 children (11 schools)). We estimated the cost-per-vaccinated child, by dividing the incremental cost of the intervention by the incremental effectiveness (i.e., the number of additionally vaccinated students in intervention schools compared to control schools). RESULTS: In Years 1 and 2, respectively, the effectiveness measure (proportion of children vaccinated) was 11.2 and 12.0 percentage points higher in intervention (40.7 % and 40.4 %) than control schools. In year 2, the cost-per-vaccinated child excluding vaccine purchase ($59.88 in 2010 US $) consisted of three component costs: (A) the school costs ($8.25); (B) the project coordination costs ($32.33); and (C) the vendor costs excluding vaccine purchase ($16.68), summed through Monte Carlo simulation. Compared to Year 1, the two component costs (A) and (C) decreased, while the component cost (B) increased in Year 2. The cost-per-vaccinated child, excluding vaccine purchase, was $59.73 (Year 1) and $59.88 (Year 2, statistically indistinguishable from Year 1), higher than the published cost of providing influenza vaccination in medical practices ($39.54). However, taking indirect costs (e.g., averted parental costs to visit medical practices) into account, vaccination was less costly in SLV-I ($23.96 in Year 1, $24.07 in Year 2) than in medical practices. CONCLUSIONS: Our two-year trial's findings reinforced the evidence to support SLV-I as a potentially favorable system to increase childhood influenza vaccination rates in a cost-efficient way. Increased efficiencies in SLV-I are needed for a sustainable and scalable SLV-I program.