Medical Costs of Respiratory Syncytial Virus-Associated Hospitalizations and Emergency Department Visits in Children Aged Younger Than 5 Years: Observational Findings from the New Vaccine Surveillance Network, 2016-2019.

OBJECTIVE: To assess medical costs of hospitalizations and emergency department (ED) care associated with respiratory syncytial virus (RSV) disease in children enrolled in the New Vaccine Surveillance Network. STUDY DESIGN: We used accounting and prospective surveillance data from 6 pediatric health systems to assess direct medical costs from laboratory-confirmed RSV-associated hospitalizations (n = 2007) and ED visits (n = 1267) from 2016 through 2019 among children aged <5 years. We grouped costs into categories relevant to clinical care and administrative billing practices. We examined RSV-associated medical costs by care setting using descriptive and bivariate analyses. We assessed associations between known RSV risk factors and hospitalization costs and length of stay using χ2 tests of association. RESULTS: The median cost was $7100 (IQR $4006-$13 355) per hospitalized child and $503 (IQR $387-$930) per ED visit. Eighty percent (n = 2628) of our final sample were children aged younger than 2 years. Fewer weeks' gestational age was associated with greater median costs in hospitalized children (P < .001, ≥37 weeks of gestational age: $6840 [$3905-$12 450]; 29-36 weeks of gestational age: $7721 [$4362-$15 274]; <29 weeks of gestational age: $9131 [$4518-$19 924]). Infants born full term accounted for 70% of the total expenditures in our sample. Almost three quarters of the health care dollars spent originated in children younger than 12 months of age, the primary age group targeted by recommended RSV prophylactics. CONCLUSIONS: Reducing the cost burden for RSV-associated medical care in young children will require prevention of RSV in all young children, not just high-risk infants. Newly available maternal vaccine and immunoprophylaxis products could substantially reduce RSV-associated medical costs.

Evaluating Partial Series Childhood Vaccination Services in a Mobile Clinic Setting.

This study aims to evaluate the cost-benefit of vaccination services, mostly partial series administration, provided by a mobile clinic program (MCP) in Houston for children of transient and low-income families. The study included 469 patients who visited the mobile clinics on regular service days in 2 study periods in 2014 and 836 patients who attended vaccination events in the summer of 2014. The benefit of partial series vaccination was estimated based on vaccine efficacy/effectiveness data. Our conservative cost-benefit estimates show that, compared with office-based settings, every dollar spent on vaccination by the MCP would result in $0.9 societal cost averted as an incremental benefit in regular service days and $3.7 during vaccination-only events. To further improve the cost-benefit of vaccination services in the MCP, decision-makers and stakeholders may consider improving work efficiency during regular service days or hosting more vaccination events.

Validation of Acute Gastroenteritis-related International Classification of Diseases, Clinical Modification Codes in Pediatric and Adult US Populations.

International Classification of Diseases diagnostic codes are used to estimate acute gastroenteritis (AGE) disease burden. We validated AGE-related codes in pediatric and adult populations using 2 multiregional active surveillance platforms. The sensitivity of AGE codes was similar (54% and 58%) in both populations and increased with addition of vomiting-specific codes.

Evidence for Household Transmission of Rotavirus in the United States, 2011-2016.

BACKGROUND: Rotavirus is a leading cause of acute gastroenteritis (AGE) in children and is highly transmissible. In this study, we assessed the presence of AGE in household contacts (HHCs) of pediatric patients with laboratory-confirmed rotavirus. METHODS: Between December 2011 and June 2016, children aged 14 days to 11 years with AGE were enrolled at 1 of 7 hospitals or emergency departments as part of the New Vaccine Surveillance Network. Parental interviews, medical and vaccination records, and stool specimens were collected at enrollment. Stool was tested for rotavirus by an enzyme immunoassay and confirmed by real-time or conventional reverse transcription-polymerase chain reaction assay or repeated enzyme immunoassay. Follow-up telephone interviews were conducted to assess AGE in HHCs the week after the enrolled child's illness. A mixed-effects multivariate model was used to calculate odds ratios. RESULTS: Overall, 829 rotavirus-positive subjects and 8858 rotavirus-negative subjects were enrolled. Households of rotavirus-positive subjects were more likely to report AGE illness in ≥1 HHC than were rotavirus-negative households (35% vs 20%, respectively; P < .0001). A total of 466 (16%) HHCs of rotavirus-positive subjects reported AGE illness. Of the 466 ill HHCs, 107 (23%) sought healthcare; 6 (6%) of these encounters resulted in hospitalization. HHCs who were <5 years old (odds ratio, 2.2 [P = .004]) were more likely to report AGE illness than those in other age groups. In addition, 144 households reported out-of-pocket expenses (median, $20; range, $2-$640) necessary to care for an ill HHC. CONCLUSIONS: Rotavirus-associated AGE in children can lead to significant disease burden in HHCs, especially in children aged <5 years. Prevention of pediatric rotavirus illness, notably through vaccination, can prevent additional illnesses in HHCs.

Early Usability Assessment of a Conversational Agent for HPV Vaccination.

With the emerging use of speech technology in consumer goods, we experimented with the application of conversational agents for the communication of health information relating to HPV vaccine. Research have stated that one-to-one contact between providers and patients have a variety of positive influences on patients' perception towards vaccines, even leading to uptake, compared to paper-based methods. We implemented a Wizard of Oz experiment that counsels adults with children (n=18) on the HPV vaccine, using an iPad tablet and dialogue script developed by public health collaborators, and for early testing of a prospective conversational agent in this area. Our early results show that non-vaccine hesitant parents believed that agent was easy to use and had capabilities needed, despite the desire for additional features. Our future work will involve developing a dialogue engine to provide automated dialogue interaction and future improvements and experimentation for the speech interface.

Understanding the Financial Implications of Immunization Reminder/Recall in a Multipractice Pediatric Group.

OBJECTIVE: Immunization reminder/recall is widely recommended as an effective strategy for increasing vaccination rates. We examined the revenue generated from well-child visits scheduled as a result of reminder/recall activities implemented in a multipractice pediatric organization. METHODS: Patients aged 19 to 35 months who were due or overdue for vaccines were identified from participating practices and assigned to either standard or enhanced reminder/recall activities. Participants who received standard reminder/recall were observed for the 6-week study period, and the number of appointments in which vaccines were administered was tracked. Participants who received enhanced reminder/recall were contacted up to 3 times and received a letter followed by up to 2 phone calls. Financial information associated with appointments scheduled during the study period was obtained, and revenue was calculated for each dose of vaccine administered. Reminder/recall costs were calculated and overall revenue generated was calculated. RESULTS: We identified 3916 children who were potentially due or overdue for immunizations. After review and manual uploading of missing historical vaccines, a total of 1892 participants received the reminder/recall initiative; 942 received standard reminder/recall, and 950 received enhanced reminder/recall. One hundred eighty-two (19%) standard and 277 (29%) enhanced reminder/recall participants scheduled an appointment by the end of the study period (P < .001). After subtracting the cost of reminder/recall activities, an additional $20,066 and $20,235 were generated by standard and enhanced reminder/recall, respectively. CONCLUSIONS: We show that conducting reminder/recall is at a minimum financially neutral, and might increase revenue generated by vaccine administration.

The Texas Children's Hospital immunization forecaster: conceptualization to implementation.

OBJECTIVES: Immunization forecasting systems evaluate patient vaccination histories and recommend the dates and vaccines that should be administered. We described the conceptualization, development, implementation, and distribution of a novel immunization forecaster, the Texas Children's Hospital (TCH) Forecaster. METHODS: In 2007, TCH convened an internal expert team that included a pediatrician, immunization nurse, software engineer, and immunization subject matter experts to develop the TCH Forecaster. Our team developed the design of the model, wrote the software, populated the Excel tables, integrated the software, and tested the Forecaster. We created a table of rules that contained each vaccine's recommendations, minimum ages and intervals, and contraindications, which served as the basis for the TCH Forecaster. RESULTS: We created 15 vaccine tables that incorporated 79 unique dose states and 84 vaccine types to operationalize the entire United States recommended immunization schedule. The TCH Forecaster was implemented throughout the TCH system, the Indian Health Service, and the Virginia Department of Health. The TCH Forecast Tester is currently being used nationally. CONCLUSIONS: Immunization forecasting systems might positively affect adherence to vaccine recommendations. Efforts to support health care provider utilization of immunization forecasting systems and to evaluate their impact on patient care are needed.

Immunization information system opt-in consent: at what cost?

Immunization information systems (IISs) are confidential, population-based systems that contain immunization data for children, and, in some cases, adults, within a geographic area. There are generally two models for participation in an IIS, termed voluntary exclusion or "opt-out" and voluntary inclusion or "opt-in." Using the Texas opt-in consent system and statewide IIS (ImmTrac), we describe the costs associated with obtaining opt-in consent in hospitals as part of the birth registration process and in provider offices for children without prior consent. We also estimate the costs associated with a hypothetical opt-out system. Between October 2006 and August 2007, project staff conducted on-site time studies for patients in 8 birthing hospitals (n = 281), 16 provider offices (n = 131), and ImmTrac state offices in Austin, Texas (n = 100). Total costs per child and costs per year were estimated using a time-and-motion study in which the time associated with discussing ImmTrac and obtaining ImmTrac consent was measured. The annual costs associated with obtaining consent for Texas' opt-in IIS are estimated at $1 389 804.61. The average per child cost associated with ImmTrac consent completed at birth is $2.00, whereas the per child cost for consent completed in provider offices is $2.64. The annual costs of operating an alternative, opt-out system are estimated at $110 714.03, or $0.29 per child. This cost analysis demonstrated that the proposed opt-out costs were substantially less than the actual opt-in model currently utilized. Changing to an opt-out system could redirect limited healthcare funding to more critical areas such as vaccine purchasing and administration.

Investigation of obstacles to accessing information regarding private medical insurance coverage and physician reimbursement for adolescent vaccination.

PURPOSE: To investigate accessing insurance company vaccine reimbursement and coverage information. METHOD: A telephone survey was conducted from June 2006 to August 2006. Participating organizations were insurance companies in the states of New York, Oregon, and Texas. The main outcome measure was the obstacles encountered while trying to obtain information on vaccine costs and reimbursement. RESULTS: Obstacles identified included the predominance of automated answering systems and the necessity of leaving voicemail messages, company nonresponse, and refusal to participate. CONCLUSIONS: Obstacles result in difficulty obtaining vaccine reimbursement and coverage information by phone. Greater transparency is necessary to enable stakeholders to make informed decisions about immunizations.

Cost-effectiveness analysis of a practice-based immunization education intervention.

OBJECTIVE: To evaluate the cost-effectiveness of academic detailing programs to improve immunization coverage in communities through implementation and evaluation of the Raising Immunizations Thru Education (RITE) program in the Greater Houston area. METHODS: RITE was a preintervention and postintervention pilot study with randomized intervention and control sites implemented in private practices in pediatrics and family medicine. Changes in self-reported provider behaviors (n = 186) and comparisons of immunization coverage levels between intervention (n = 61) and control (n = 62) practices were evaluated. Intervention costs, computed from the perspective of an agency wanting to replicate the intervention, included direct expenses and time costs, based on time logs and compensation. Sensitivity analysis describes variations in costs. The cost-effectiveness ratio was computed as dollars per additional outcome unit. RESULTS: The RITE intervention improved self-reported provider behavior. The immunization rates in the intervention group increased by 1 per cent, whereas immunization rates in the control group decreased by 2 per cent -3 per cent, but the 3 per cent - 4 per cent difference was not significant. A 1 per cent increase in practice immunization rates costs $424-$550, depending on the up-to-date criteria used and the targeted age group. CONCLUSIONS: The costs for 1 additional child with up-to-date immunization status are higher than potential societal savings, as reported in the literature. This intervention does not have a favorable cost-benefit ratio.