Estimated Costs of 4-Month Pulmonary Tuberculosis Treatment Regimen, United States.

We estimated direct costs of a 4-month or 6-month regimen for drug-susceptible pulmonary tuberculosis treatment in the United States. Costs were $23,000 per person treated. Actual treatment costs will vary depending on examination and medication charges, as well as expenses associated with directly observed therapy.

Tuberculosis Test Usage and Medical Expenditures from Outpatient Insurance Claims Data, 2013.

OBJECTIVE: To evaluate TB test usage and associated direct medical expenditures from 2013 private insurance claims data in the United States (US). METHODS: We extracted outpatient claims for TB-specific and nonspecific tests from the 2013 MarketScan® commercial database. We estimated average expenditures (adjusted for claim and patient characteristics) using semilog regression analyses and compared them to the Centers for Medicare and Medicaid Services (CMS) national reimbursement limits. RESULTS: Among the TB-specific tests, 1.4% of the enrollees had at least one claim, of which the tuberculin skin test was most common (86%) and least expensive ($9). The T-SPOT® was the most expensive among the TB-specific tests ($106). Among nonspecific TB tests, the chest radiograph was the most used test (78%), while chest computerized tomography was the most expensive ($251). Adjusted average expenditures for the majority of tests (≈74%) were above CMS limits. We estimated that total United States medical expenditures for the employer-based privately insured population for TB-specific tests were $53.0 million in 2013, of which enrollees paid 17% ($9 million). CONCLUSIONS: We found substantial differences in TB test usage and expenditures. Additionally, employer-based private insurers and enrollees paid more than CMS limits for most TB tests.

A national study of socioeconomic status and tuberculosis rates by country of birth, United States, 1996-2005.

BACKGROUND: Tuberculosis (TB) in developed countries has historically been associated with poverty and low socioeconomic status (SES). In the past quarter century, TB in the United States has changed from primarily a disease of native-born to primarily a disease of foreign-born persons, who accounted for more than 60% of newly-diagnosed TB cases in 2010. The purpose of this study was to assess the association of SES with rates of TB in U.S.-born and foreign-born persons in the United States, overall and for the five most common foreign countries of origin. METHODS: National TB surveillance data for 1996-2005 was linked with ZIP Code-level measures of SES (crowding, unemployment, education, and income) from U.S. Census 2000. ZIP Codes were grouped into quartiles from low SES to high SES and TB rates were calculated for foreign-born and U.S.-born populations in each quartile. RESULTS: TB rates were highest in the quartiles with low SES for both U.S.-born and foreign-born populations. However, while TB rates increased five-fold or more from the two highest to the two lowest SES quartiles among the U.S.-born, they increased only by a factor of 1.3 among the foreign-born. CONCLUSIONS: Low SES is only weakly associated with TB among foreign-born persons in the United States. The traditional associations of TB with poverty are not sufficient to explain the epidemiology of TB among foreign-born persons in this country and perhaps in other developed countries. TB outreach and research efforts that focus only on low SES will miss an important segment of the foreign-born population.

Unexpected decline in tuberculosis cases coincident with economic recession - United States, 2009.

BACKGROUND: Since 1953, through the cooperation of state and local health departments, the U.S. Centers for Disease Control and Prevention (CDC) has collected information on incident cases of tuberculosis (TB) disease in the United States. In 2009, TB case rates declined -11.4%, compared to an average annual -3.8% decline since 2000. The unexpectedly large decline raised concerns that TB cases may have gone unreported. To address the unexpected decline, we examined trends from multiple sources on TB treatment initiation, medication sales, and laboratory and genotyping data on culture-positive TB. METHODS: We analyzed 142,174 incident TB cases reported to the U. S. National Tuberculosis Surveillance System (NTSS) during January 1, 2000-December 31, 2009; TB control program data from 59 public health reporting areas; self-reported data from 50 CDC-funded public health laboratories; monthly electronic prescription claims for new TB therapy prescriptions; and complete genotyping results available for NTSS cases. Accounting for prior trends using regression and time-series analyses, we calculated the deviation between observed and expected TB cases in 2009 according to patient and clinical characteristics, and assessed at what point in time the deviation occurred. RESULTS: The overall deviation in TB cases in 2009 was -7.9%, with -994 fewer cases reported than expected (P < .001). We ruled out evidence of surveillance underreporting since declines were seen in states that used new software for case reporting in 2009 as well as states that did not, and we found no cases unreported to CDC in our examination of over 5400 individual line-listed reports in 11 areas. TB cases decreased substantially among both foreign-born and U.S.-born persons. The unexpected decline began in late 2008 or early 2009, and may have begun to reverse in late 2009. The decline was greater in terms of case counts among foreign-born than U.S.-born persons; among the foreign-born, the declines were greatest in terms of percentage deviation from expected among persons who had been in the United States less than 2 years. Among U.S.-born persons, the declines in percentage deviation from expected were greatest among homeless persons and substance users. Independent information systems (NTSS, TB prescription claims, and public health laboratories) reported similar patterns of declines. Genotyping data did not suggest sudden decreases in recent transmission. CONCLUSIONS: Our assessments show that the decline in reported TB was not an artifact of changes in surveillance methods; rather, similar declines were found through multiple data sources. While the steady decline of TB cases before 2009 suggests ongoing improvement in TB control, we were not able to identify any substantial change in TB control activities or TB transmission that would account for the abrupt decline in 2009. It is possible that other multiple causes coincident with economic recession in the United States, including decreased immigration and delayed access to medical care, could be related to TB declines. Our findings underscore important needs in addressing health disparities as we move towards TB elimination in the United States.

Health care utilization for pneumonia in young children after routine pneumococcal conjugate vaccine use in the United States.

OBJECTIVE: To estimate the effect of 7-valent pneumococcal conjugate vaccine (PCV7) on rates of pneumonia-related health care utilization and costs in children younger than 2 years. DESIGN: Retrospective population study. SETTING: Approximately 40 large employers each year, from 1997 to 2004. PARTICIPANTS: Enrollees in the MarketScan databases collected by Thomson Medstat. MAIN EXPOSURE: Pneumococcal conjugate vaccine immunization program. MAIN OUTCOME MEASURES: Rates of International Classification of Diseases, Ninth Revision-coded hospitalizations and ambulatory visits due to all-cause and pneumococcal pneumonia and their medical expenditures. RESULTS: Comparing the rates in 2004 with those in the baseline period of 1997 to 1999 among children younger than 2 years, hospitalizations due to all-cause pneumonia declined from 11.5 to 5.5 per 1000 children (52.4% decline; P < .001) and ambulatory visits due to all-cause pneumonia declined from 99.3 to 58.5 per 1000 children (41.1% decline; P < .001). Rates of hospitalizations due to pneumococcal pneumonia declined from 0.6 to 0.3 per 1000 children (57.6% decline; P < .001) and rates of ambulatory visits declined from 1.7 to 0.9 per 1000 children (46.9% decline; P < .001). Projecting from these data to the US population, the total estimated direct medical expenditures for all-cause pneumonia-related hospitalizations and ambulatory visits in young children were reduced from an annual average of $688.2 million during the period of 1997 to 1999 to $376.7 million in 2004 (45.3% decline and approximately $310 million decrease). CONCLUSIONS: In children younger than 2 years, the age group targeted for vaccination, pneumonia-related health care utilization in a privately insured population declined substantially following PCV7 introduction. These results suggest that PCV7 may play an important role in reducing the burden of pneumonia, resulting in major savings in medical care cost.

Increasing pneumococcal vaccination in managed care through telephone outreach.

OBJECTIVES: To determine the effectiveness of a telephone reminder to increase pneumococcal vaccination in a population that had received mailed reminders and to evaluate whether the intervention effect is similar for clinics serving primarily non-Hispanic black or non-Hispanic white patient populations. STUDY DESIGN: Randomized trial within a managed care network. METHODS: All unvaccinated patients 18 years and older with chronic medical conditions and 65 years and older without chronic medical conditions (N = 6106) were randomized to receive telephone intervention or standard care and followed up for 6-month vaccination status. The intervention was a telephone call initiated by a nurse to inform patients that pneumococcal vaccination was recommended and was a covered benefit of their insurance. RESULTS: Intervention patients were 2.3 times as likely to be vaccinated during the study period than control patients (P < .001). The success of telephone intervention versus control was similar across clinics (P = .16) and across the chronic disease and elderly groups (P = .14). In subanalyses of individuals reached by telephone intervention, unvaccinated black subjects were less likely to be vaccinated during the study than unvaccinated white subjects (34% vs 25%, P = .03). Nurse staff time for telephone intervention cost $147.35 per additional patient vaccinated. CONCLUSIONS: Telephone intervention was successful at increasing vaccination rates in a diverse managed care population that had already received mailed reminders. Tailored messaging for pneumococcal vaccination through telephone reminders increases patient demand for vaccination and should be implemented by managed care organizations seeking to increase their vaccination rates.

The role of attitudes in understanding disparities in adult influenza vaccination.

BACKGROUND: Racial/ethnic disparities in influenza vaccine coverage of adults aged 65 years and older persist even after controlling for access, healthcare utilization, and socioeconomic status. Differences in attitudes toward vaccination may help explain these disparities. The purpose of this study was to describe patient characteristics and attitudes toward influenza vaccination among whites and African Americans aged 65 years and older, and to examine their effect on racial disparities in vaccination coverage. METHODS: A cross-sectional telephone survey of Medicare beneficiaries in five U.S. sites, sampled on race/ethnicity and ZIP code. Multivariate analysis controlling for demographics, healthcare utilization, and attitudes toward influenza vaccination was conducted in 2005 to assess racial disparities in vaccine coverage during the 2003-2004 season. RESULTS: The analysis included 1859 white and 1685 African-American respondents; 79% of whites versus 50% of African Americans reported influenza vaccination in the past year (p < 0.00001). Both vaccinated and unvaccinated African Americans were significantly less likely than whites to report positive attitudes toward influenza vaccination. Even among respondents with provider recommendations, respondents with positive attitudes were more likely to be vaccinated than those with negative attitudes. After multivariate adjustment, African Americans had significantly lower odds of influenza vaccination than whites (odds ratio = 0.55, 95% confidence interval = 0.42-0.72). CONCLUSIONS: A significant gap in vaccination coverage between African Americans and whites persisted even after controlling for specific respondent attitudes. Future research should focus on other factors such as vaccine-seeking behavior.

A comprehensive patient assessment and physician reminder tool for adult immunization: effect on vaccine administration.

We determined if a patient-self assessment/provider reminder tool (A/R) would increase administration of the eight vaccines that may be indicated for adults. In three family practice clinics, the A/R was completed by intervention patients and given to their provider. Control patients received an exercise reminder. On the day of the intervention, influenza, pneumococcal polysaccharide, and tetanus-diphtheria (Td) vaccines vaccine were administered significantly (P<0.01) more commonly to intervention patients in one clinic, Td in the second, and none in the third. There were no additional significant differences during one year of follow-up. A number of barriers to comprehensive vaccination were encountered.

Factors associated with vaccination of medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003.

OBJECTIVES: To examine vaccination in seniors in the five U.S. communities of the Racial and Ethnic Adult Disparities in Immunization Initiative. DESIGN: Cross-sectional telephone survey in spring 2003 using stratified sampling by ZIP code and race/ethnicity. SETTING: New York, Texas, Wisconsin, Illinois, and Mississippi. PARTICIPANTS: Four thousand five hundred seventy-seven Medicare beneficiaries. MEASUREMENTS: Outcomes were pneumococcal vaccination ever and influenza vaccination in 2002/03 and were determined according to race/ethnicity, awareness of vaccination, and provider recommendation. Survey questions also asked about future plans for vaccination, whether respondents believed they had become sick from prior influenza vaccination, and whether unvaccinated respondents would be vaccinated if a health professional recommended it. RESULTS: Pneumococcal vaccination coverage was 70.3% for whites, 40.8% for blacks, and 53.2% for Hispanics, and the proportion reporting provider recommendation for vaccination differed significantly according to race/ethnicity. In multivariate regression, provider recommendation (risk ratio (RR) = 2.32, 95% confidence intervals (CI) = 2.10-2.57) and awareness of vaccination (RR = 1.60, 95% CI = 1.40-1.82) were associated with greater pneumococcal vaccination. Influenza vaccination coverage was 76.2% for whites, 50.7% for blacks, and 65.7% for Hispanics. A little more than half of respondents reported provider recommendation for influenza vaccination, with no differences according to race/ethnicity. Provider recommendation was associated with influenza vaccination (RR = 1.31, 95% CI = 1.25-1.38). More blacks and Hispanics believed they had become sick from prior influenza vaccination than whites, and this belief was associated with lower vaccination rates. CONCLUSION: This survey details vaccination patterns in an ethnically and geographically diverse sample of seniors and identifies some differences between blacks, Hispanics, and whites that may contribute to disparities in vaccination coverage. Survey findings highlight the importance of provider vaccination recommendations.

Impact of varicella vaccination on health care utilization.

CONTEXT: Since varicella vaccine was first recommended for routine immunization in the United States in 1995, the incidence of disease has dropped substantially. However, national surveillance data are incomplete, and comprehensive data regarding outpatient as well as hospital utilization have not been reported. OBJECTIVE: To examine the impact of the varicella vaccination program on medical visits and associated expenditures. DESIGN, SETTING, AND PATIENTS: Retrospective population-based study examining the trends in varicella health care utilization, based on data from the MarketScan databases, which include enrollees (children and adults) of more than 100 health insurance plans of approximately 40 large US employers, from 1994 to 2002. MAIN OUTCOME MEASURES: Trends in rates of varicella-related hospitalizations and ambulatory visits and direct medical expenditures for hospitalizations and ambulatory visits, analyzed using 1994 and 1995 as the prevaccination baseline. RESULTS: From the prevaccination period to 2002, hospitalizations due to varicella declined by 88% (from 2.3 to 0.3 per 100,000 population) and ambulatory visits declined by 59% (from 215 to 89 per 100,000 population). Hospitalizations and ambulatory visits declined in all age groups, with the greatest declines among infants younger than 1 year. Total estimated direct medical expenditures for varicella hospitalizations and ambulatory visits declined by 74%, from an average of 84.9 million dollars in 1994 and 1995 to 22.1 million dollars in 2002. CONCLUSION: Since the introduction of the varicella vaccination program, varicella hospitalizations, ambulatory visits, and their associated expenditures have declined dramatically among all age groups in the United States.

Public health application comparing multilevel analysis with logistic regression: immunization coverage among long-term care facility residents.

PURPOSE: Public health studies often sample populations using nested sampling plans. When the variance of the residual errors is correlated between individual observations as a result of these nested structures, traditional logistic regression is inappropriate. We used nested nursing home patient data to show that one-level logistic regression and hierarchical multilevel regression can yield different results. METHODS: We performed logistic and multilevel regression to determine nursing home resident characteristics associated with receiving pneumococcal immunizations. Nursing home characteristics such as type of ownership, immunization program type, and certification were collected from a sample of 249 nursing homes in 14 selected states. Nursing home resident data including demographics, receipt of immunizations, cognitive patterns, and physical functioning were collected on 100 randomly selected residents from each facility. RESULTS: Factors associated with receipt of pneumococcal vaccination using logistic regression were similar to those found using multilevel regression model with some exceptions. Predictors using logistic regression that were not significant using multilevel regression included race, speech problems, infections, renal failure, legal responsibility for oneself, and affiliation with a chain. Unstable health conditions were significant only in the multilevel model. CONCLUSIONS: When correlation of resident outcomes within nursing home facilities was not considered, statistically significant associations were likely due to residual correlation effects. To control the probability of type I error, epidemiologists evaluating public health data on nested populations should use methods that account for correlation among observations.