The Effect of the 2009 Influenza Pandemic on Absence from Work.

In July 2009, the World Health Organization declared the first flu pandemic in nearly 40 years. Although the health effects of the pandemic have been studied, there is little research examining the labor productivity consequences. Using unique sick leave data from the Chilean private health insurance system, we estimate the effect of the pandemic on missed days of work. We estimate that the pandemic increased mean flu days missed by 0.042 days per person-month during the 2009 peak winter months (June and July), representing an 800% increase in missed days relative to the sample mean. Calculations using the estimated effect imply a minimum 0.2% reduction in Chile's labor supply. Copyright © 2017 John Wiley & Sons, Ltd.

Using cost-effectiveness analysis to support research and development portfolio prioritization for product innovations in measles vaccination.

BACKGROUND: Several potential measles vaccine innovations are in development to address the shortcomings of the current vaccine. Funders need to prioritize their scarce research and development resources. This article demonstrates the usefulness of cost-effectiveness analysis to support these decisions. METHODS: This study had 4 major components: (1) identifying potential innovations, (2) developing transmission models to assess mortality and morbidity impacts, (3) estimating the unit cost impacts, and (4) assessing aggregate cost-effectiveness in United Nations Children's Fund countries through 2049. RESULTS: Four promising technologies were evaluated: aerosol delivery, needle-free injection, inhalable dry powder, and early administration DNA vaccine. They are projected to have a small absolute impact in terms of reducing the number of measles cases in most scenarios because of already improving vaccine coverage. Three are projected to reduce unit cost per dose by $0.024 to $0.170 and would improve overall cost-effectiveness. Each will require additional investments to reach the market. Over the next 40 years, the aggregate cost savings could be substantial, ranging from $98.4 million to $689.4 million. CONCLUSIONS: Cost-effectiveness analysis can help to inform research and development portfolio prioritization decisions. Three new measles vaccination technologies under development hold promise to be cost-saving from a global perspective over the long-term, even after considering additional investment costs.

Are United States and Canadian cancer screening rates consistent with guideline information regarding the age of screening initiation?

OBJECTIVE: To understand whether US and Canadian breast, colorectal and prostate cancer screening test utilization is consistent with US and Canadian cancer screening guideline information with respect to the age of screening initiation. DESIGN: Cross-sectional, regression discontinuity. SETTING: Canada and the US. PARTICIPANTS: Canadian and American women of ages 30-60 and men of ages 40-60. INTERVENTIONS: None. Main Outcomes Measures Mammography, prostate-specific antigen (PSA) and colorectal cancer test use within the past 2 years. METHODS: We identify US and Canadian compliance with age screening information in a novel manner, by comparing test utilization rates of individuals who are immediately on either side of the guideline recommended initiation ages. RESULTS: US mammography utilization within the last 2 years increased from 33% at age 39 to 48% at age 40 and 60% at age 41. US colorectal cancer test utilization, within the last 2 years, increased from 15% at age 49 to 18% at age 50 and 28% at age 51. US PSA utilization within the last 2 years increased from 37% at age 49 to 44% at age 50 and 54% at age 51. In Canada, mammography utilization within the last 2 years increased from 47% at age 49 to 57% at age 50 and 66% at age 51. CONCLUSION: American and Canadian cancer screening utilization is generally consistent with each country's guideline recommendations regarding age. US and Canadian differences in screening due to guidelines can potentially explain cross-country differences in breast cancer mortality and affect interpretation of international comparisons of cancer statistics.

The Effect Of The Affordable Care Act On Cancer Detection Among The Near-Elderly.

During the period 2014-16 the Affordable Care Act (ACA) dramatically reduced rates of uninsurance and underinsurance in the United States. In this study we estimated the effects of these coverage increases on cancer detection among the near-elderly population (ages 60-64). Using 2010-16 Surveillance, Epidemiology, and End Results (SEER) Program data, we estimated that the ACA increased cancer detection among this population. We found that 45 percent of the jump in cancer detection that occurs when people reach Medicare eligibility age was eliminated by the ACA coverage expansions. The ACA coverage expansions had large effects on cancers with and without routine screening tests, and 68 percent of newly detected cancers were early- and middle-stage cancers. In addition, the empirical strategy used to identify the effects of the ACA on cancer detection confirmed the role of health insurance as the key mechanism to explain Medicare's effects on health care use and health outcomes as described in the prior literature. Our results highlight the importance of the ACA, Medicare, and health insurance coverage generally for disease detection.

Adherence to cancer screening guidelines across Canadian provinces: an observational study.

BACKGROUND: Cancer screening guidelines reflect the costs and benefits of population-based screening based on evidence from clinical trials. While most of the existing literature on compliance with cancer screening guidelines only measures raw screening rates in the target age groups, we used a novel approach to estimate degree of guideline compliance across Canadian provinces for breast, colorectal and prostate cancer screening. Measuring compliance as the change in age-specific screening rates at the guideline-recommended initiation age (50), we generally found screening patterns across Canadian provinces that were not consistent with guideline compliance. METHODS: We calculated age-cancer-specific screening rates for ages 40-60 using the Canadian Community Health Survey (2003 and 2005), a cross-sectional, nationally representative survey of health status, health care utilization and health determinants in the Canadian population. We estimated the degree of compliance using logistic regression to measure the change in adjusted screening rates at the guideline-recommended initiation age for each province in the sample. RESULTS: For breast cancer, after adjusting for age trends and other covariates, being above age 50 in Quebec increased the probability of being screened by 19 percentage points, from an average screening rate of 24% among 40-49 year olds. None of the other regions exhibited a statistically significant change in screening rates at age 50. Additional analyses indicated that these patterns reflect asymptomatic screening and that Quebec's breast cancer screening program enhanced the degree of guideline compliance in that province. Colorectal cancer screening practice was consistent with guidelines only in Saskatchewan, as screening rates increased at age 50 by 12 percentage points, from an average rate of 6% among 40-49 year olds. For prostate cancer, the regions examined here are not compliant with Canadian guidelines since screening rates were quite high, and there was not a discrete increase at any particular age. CONCLUSIONS: Screening practice for breast, colorectal and prostate cancer was generally not consistent with Canadian clinical guidelines. Quebec (breast) and Saskatchewan (colorectal) were exceptions to this, and the impact of Quebec's breast cancer screening program suggests a role for policy in improving screening guideline compliance.

Are U.S. cancer screening test patterns consistent with guideline recommendations with respect to the age of screening initiation?

BACKGROUND: U.S. cancer screening guidelines communicate important information regarding the ages for which screening tests are appropriate. Little attention has been given to whether breast, colorectal and prostate cancer screening test use is responsive to guideline age information regarding the age of screening initiation. METHODS: The 2006 Behavioral Risk Factor Social Survey and the 2003 National Health Interview Surveys were used to compute breast, colorectal and prostate cancer screening test rates by single year of age. Graphical and logistic regression analyses were used to compare screening rates for individuals close to and on either side of the guideline recommended screening initiation ages. RESULTS: We identified large discrete shifts in the use of screening tests precisely at the ages where guidelines recommend that screening begin. Mammography screening in the last year increased from 22% [95% CI = 20, 25] at age 39 to 36% [95% CI = 33, 39] at age 40 and 47% [95% CI = 44, 51] at age 41. Adherence to the colorectal cancer screening guidelines within the last year increased from 18% [95% CI = 15, 22] at age 49 to 19% [95% CI = 15, 23] at age 50 and 34% [95% CI = 28, 39] at age 51. Prostate specific antigen screening in the last year increased from 28% [95% CI = 25, 31] at age 49 to 33% [95% CI = 29, 36] and 42% [95% CI = 38, 46] at ages 50 and 51. These results are robust to multivariate analyses that adjust for age, sex, income, education, marital status and health insurance status. CONCLUSION: The results from this study suggest that cancer screening test utilization is consistent with guideline age information regarding the age of screening initiation. Screening test and adherence rates increased by approximately 100% at the breast and colorectal cancer guideline recommended ages compared to only a 50% increase in the screening test rate for prostate cancer screening. Since information regarding the age of cancer screening initiation varies across countries, results from this study also potentially have implications for cross-country comparisons of cancer incidence and survival statistics.

The causal effect of health insurance on utilization and outcomes in adults: a systematic review of US studies.

BACKGROUND: No current consensus exists on the causal effect of gaining or losing health insurance on health care utilization and health outcomes. OBJECTIVE: To systemically search and review available evidence of estimated causal effects of health insurance on health care utilization and/or health outcomes among nonelderly adults in the United States. RESEARCH DESIGN: A systematic search of 3 electronic databases (PubMed, JSTOR, EconLit) was performed. To be included in the review, studies had to have a publication date after 1991; a population of nonelderly adults; analyses comparing an uninsured group to an appropriate control group; and 1 of 3 study designs that account for potential reverse causality and provide estimates of causal effects (longitudinal cohort, instrumental variable analysis, or quasi-experimental design). RESULTS: A total of 9701 studies, including duplicates, were primarily screened. Fourteen studies fulfilled the criteria to be included in this review-4 longitudinal cohort studies using standard regression or fixed effects analysis, 5 longitudinal cohort studies using instrumental variable regression analysis, and 5 quasi-experimental studies. CONCLUSIONS: Results of our review of empirical studies that estimate causal relationships between health insurance and health care utilization and/or health outcomes consistently show that health insurance increases utilization and improves health. Specifically, health insurance had substantial effects on the use of physician services, preventive services, self-reported health status, and mortality conditional on injury and disease. These results both confirm and contradict comparable results from the RAND Health Insurance Experiment, the gold standard on relationships between health insurance, utilization, and health.

When Guidelines Conflict: A Case Study of Mammography Screening Initiation in the 1990s.

BACKGROUND: Cancer screening guidelines communicate important information to patients and physicians regarding the costs and benefits of screening. Currently, guideline recommendations from major organizations conflict regarding the age of mammography screening initiation. To understand current and future U.S. mammography screening patterns we study age-mammography patterns from the 1990s, another period of conflicting guideline recommendations. METHODS: We examine mammography use rates by single year of age to understand compliance with guideline-recommended initiation ages in the 1990s. Mammography test use data was taken primarily from the 1991 to 2001 Behavioral Risk Factor Surveillance System. The analytic sample included all women 35 to 54 years of age. RESULTS: We found a discrete 8.7-percentage point increase in mammography use precisely at age 40 and a much smaller 1.6-percentage point increase in mammography use at age 50. These findings varied by insurance status, with the insured experiencing a large, discrete increase primarily at age 40 and the uninsured experiencing notable discrete increases at ages 40 and 50. CONCLUSION: Physicians and patients converged primarily on the age 40 mammography screening threshold during the 1990s. Prices, along with guidelines, were key determinants of the age of screening initiation, with the insured responding to age 40 coverage and cost-sharing reductions and the uninsured affected by guidelines and public funding tied to the age 50 threshold. The policy factors underlying these results, recent ACA coverage increases, and ACA cost-sharing requirements imply that a substantial number of women will continue to receive mammography screening in their 40s.

TRICARE Applied Behavior Analysis (ABA) Benefit: Comparison with Medicaid and Commercial Benefits.

This study compared the Applied Behavior Analysis (ABA) benefit provided by TRICARE as an early intervention for autism spectrum disorder with similar benefits in Medicaid and commercial health insurance plans. The sponsor, the Office of the Under Secretary of Defense for Personnel and Readiness, was particularly interested in how a proposed TRICARE reimbursement rate decrease from $125 per hour to $68 per hour for ABA services performed by a Board Certified Behavior Analyst compared with reimbursement rates (defined as third-party payment to the service provider) in Medicaid and commercial health insurance plans. Information on ABA coverage in state Medicaid programs was collected from Medicaid state waiver databases; subsequently, Medicaid provider reimbursement data were collected from state Medicaid fee schedules. Applied Behavior Analysis provider reimbursement in the commercial health insurance system was estimated using Truven Health MarketScan® data. A weighted mean U.S. reimbursement rate was calculated for several services using cross-state information on the number of children diagnosed with autism spectrum disorder. Locations of potential provider shortages were also identified. Medicaid and commercial insurance reimbursement rates varied considerably across the United States. This project concluded that the proposed $68-per-hour reimbursement rate for services provided by a board certified analyst was more than 25 percent below the U.S. mean.

How Effective is Population-Based Cancer Screening? Regression Discontinuity Estimates from the US Guideline Screening Initiation Ages.

We estimate the marginal benefits of population-based cancer screening by comparing cancer test and detection rates on either side of US guideline-recommended initiation ages (age 40 for breast cancer and age 50 for colorectal cancer during the study period). Using a regression discontinuity design and self-reported test data from national health surveys, we find test rates for breast and colorectal cancer increase at the guideline age thresholds by 109% and 78%, respectively. Data from cancer registries in twelve US states indicate that cancer detection rates increase at the same thresholds by 50% and 49%, respectively. We estimate significant effects of screening on earlier breast cancer detection (1.2 cases/1000 screened) at age 40 and colorectal cancer detection (1.1 cases/1000 individuals screened) at age 50. Forty-eight and 73% of the increases in breast and colorectal case detection occur among middle-stage cancers (localized and regional) with most of the remainder among early-stage (in-situ). Our analysis suggests that the cost of detecting an asymptomatic case of breast cancer at age 40 via population-based screening is $107,000-134,000 and that the cost of detecting an asymptomatic case of colorectal cancer at age 50 is $473,000-485,000.

How Deployments Affect the Capacity and Utilization of Army Treatment Facilities.

The Army was concerned about how the Army Force Generation (ARFORGEN) cycle, established to provide a predictable process by which Army units deploy, reset, and train to become ready and available to deploy again, affected the lives of Army soldiers and their families. In particular, the Vice Chief of Staff of the Army asked RAND Arroyo Center to determine whether ARFORGEN resulted in ebbs and flows in the ability of Army military treatment facilities (MTFs) to provide medical care and respond to changes in family needs as soldiers and care providers deploy and return home. This concern is especially well-founded because military health research has shown that family members of service members utilize health care differently during deployment than when the soldier is at home. This study found that MTF capacity is not greatly affected when soldiers and care providers deploy, and that MTFs may be slightly less busy than when soldiers and care providers are both at home. In aggregate, family member access to health care does not appear to be impinged when soldiers deploy, and soldiers who did not deploy with their unit slightly increase their utilization of health care during those times.

The validity of dependence as a health outcome measure in Alzheimer's disease.

BACKGROUND: Relating to Alzheimer's disease (AD), dependence has been defined as the increased need for assistance due to deterioration in cognition, physical functioning, and behavior. Our objective was to evaluate the association between dependence and measures of functional impairment. METHODS: Data were compiled by the National Alzheimer's Coordinating Center. We used multinomial logistic regression to estimate the association between dependence and cognition, physical functioning, and behavior. RESULTS: The independent association with dependence was positive. Dependence was most strongly associated with physical functioning. A secondary analysis suggested a strong association of dependence with multiple impairments, as measured by the interaction terms, in more severe patients. CONCLUSIONS: We find that dependence is simultaneously associated with physical functioning, cognition, and behavior, which support the construct validity of dependence. Dependence might be a more simple measure to explain the multifaceted disease progression of AD and convey the increasing need for care.

Measuring Alzheimer disease progression with transition probabilities: estimates from NACC-UDS.

OBJECTIVES: Estimate the probabilities, for Alzheimer's disease (AD) patients, of transitioning between stages of disease severity (mild, moderate, severe, dead) and care settings (community, institutional). METHODS: Data were compiled by the National Alzheimer Coordinating Center. The main analyses were limited to 3,852 patients who were 50 years old, diagnosed with possible/probable AD and had at least two center visits. A multinomial logistic model accounting for patient and center level correlation was used to calculate transition probabilities between stages of the Clinical Dementia Rating (CDR). Separately we calculated the probabilities of being institutionalized based on CDR stage. Both analyses controlled for baseline age, time between visits, sex, marital status, whether white, whether Hispanic and number of years of education. RESULTS: The annual probabilities of dying for patients in mild, moderate and severe health states were 5.5%, 21.5% and 48.0%, respectively, while the annual probabilities for institutionalization were 1.2%, 3.4% and 6.6%, respectively. The majority of mild and moderate patients remain in the same health state after one year, 77.4% and 50.1% respectively. Progressing patients are most likely to transition one stage, but 1.3% of mild patients become severe in one year. Some patients revert to lower severity stages, 7% from moderate to mild. CONCLUSIONS: Transition probabilities to higher CDR stages and to institutionalization are lower than those published previously, but the probability of death is higher. These results are useful for understanding AD progression and can be used in simulation models to evaluate costs and compare new treatments or policies.

Workplace efforts to promote influenza vaccination among healthcare personnel and their association with uptake during the 2009 pandemic influenza A (H1N1).

BACKGROUND: Survey data suggest that, in a typical year, less than half U.S. healthcare personnel (HCP) are vaccinated for influenza. We measured workplace efforts to promote influenza vaccination among HCP in the U.S. and their association with seasonal and pandemic vaccination during the 2009-10 influenza season. METHODS: Self-reported survey data collected in June 2010 from eligible HCP (n=1714) participating in a nationally representative, online research panel. HCP eligible for participation in the survey were those reporting as patient care providers and/or working in a healthcare setting. The survey measured workplace exposure to vaccination recommendations, vaccination requirements, on-site vaccination, reminders, and/or rewards, and being vaccinated for seasonal or H1N1 influenza. RESULTS: At least two-thirds of HCP were offered worksite influenza vaccination; about one half received reminders; and 10% were required to be vaccinated. Compared to HCP in other work settings, hospital employees were most (p<0.001) likely to be the subject to efforts to promote vaccination. Vaccination requirements were associated with increases in seasonal and pandemic vaccination rates of between 31 and 49% points (p<0.005). On-site vaccination was associated with increases in seasonal and pandemic vaccination of between 13 and 29% points (p<0.05). Reminders and incentives were not associated with vaccination. CONCLUSIONS: Our findings provide empirical support for vaccination requirements as a strategy for increasing influenza vaccination among HCP. Our findings also suggest that making influenza vaccination available to HCP at work could increase uptake and highlight the need to reach beyond hospitals in promoting vaccination among HCP.