Influence of a COVID-19 vaccine's effectiveness and safety profile on vaccination acceptance.

Although a safe and effective vaccine holds the greatest promise for resolving the COVID-19 pandemic, hesitancy to accept vaccines remains common. To explore vaccine acceptance decisions, we conducted a national survey of 1,000 people from all US states in August of 2020 and a replication in December of 2020. Using a 3 × 3 × 3 factorial experimental design, we estimated the impact of three factors: probability of 1) protection against COVID-19, 2) minor side effects, and 3) a serious adverse reactions. The outcome was respondents' reported likelihood of receiving a vaccine for the coronavirus. Probability of vaccine efficacy (50%, 70%, or 90%) had the largest effect among the three factors. The probability of minor side effects (50%, 75%, 90%) including fever and sore arm, did not significantly influence likelihood of receiving the vaccine. The chances of a serious adverse reaction, such as temporary or permanent paralysis, had a small but significant effect. A serious adverse reaction rate of 1/100,000 was more likely to discourage vaccine use in comparison to rates of 1/million or 1/100 million. All interactions between the factors were nonsignificant. A replication following the announcement that vaccines were 95% effective showed small, but significant increases in the likelihood of taking a vaccine. The main effects and interactions in the model remained unchanged. Expected benefit was more influential in respondents' decision making than expected side effects. The absence of interaction effects suggests that respondents consider the side effects and benefits independently.

Caring for People With Depression: Costs Among 43 Million Commercially Insured Patients With or Without Comorbid Illnesses.

BACKGROUND: Depression is a common comorbidity for patients with chronic medical conditions. Although the costs of treating chronic medical illness in combination with depression are believed to be significantly higher than the costs of treating each condition independently, few studies have formally modeled the cost consequences of mental health comorbidity. PURPOSE: To estimate the relative magnitude of the independent and synergistic contributions to health care costs from depression diagnosis and other chronic physical health conditions. METHODS: Cross-sectional, observational study using all individuals >18 years of age in the national Blue Cross Blue Shield (BCBS) Axis claims database (N = 43,872,144) from calendar year 2018. General linear models with and without interaction terms were used to assess the relative magnitude of independent and synergistic contributions to total annual health care costs of depression alone and in combination with coronary heart disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes (both types 1 and 2), hypertension, and arthritis. RESULTS: The incremental annual cost associated with having a diagnosis of depression was $2,951 compared to $1,986-$6,251 for the other chronic physical conditions. The interaction between depression and chronic conditions accounted for less than one-hundredth of the amount of variation in costs explained by the main effects of depression and each chronic physical condition. CONCLUSIONS: The independent increase in total annual health care costs associated with a depression diagnosis was comparable to that of many common physical chronic conditions. This finding underscores the importance of health care service and payment models that acknowledge depression as an equal contributor to overall health care costs. The combination of depression and another chronic condition did not synergistically increase total annual health care costs beyond the increases in costs associated with each condition independently. This finding has implications for simplifying risk adjustment models.

It is widely believed that depression, when combined with other chronic physical conditions, systematically inflates health care costs. For example, it is assumed that the costs of caring for a patient with both depression and heart disease are higher than the costs of caring for each condition independently. Using a database that included 43 million commercially insured people in the United States, we found that the costs of care for patients with depression were comparable to the costs for patients with other chronic medical conditions. This result supports the need for mental health parity and for trained mental health care providers in medical settings. We then considered the costs of caring for people with depression with or with or without one of seven common chronic physical condition. Contrary to expectation, the combination of depression and any of the diagnoses appeared to have largely independent relationships with health care costs. The results contradict the suggestion that depression and chronic condition diagnoses act synergistically to inflate health care expenditures.

Sickening: who is protecting pharma consumers?

In 2022, John Abramson published Sickening: How Big Pharma Broke American Healthcare and How We Can Repair It. The book illustrates how large pharmaceutical companies have become misinformation machines that have corrupted peer-reviewed journals, systematic review authors, and guideline committees. Industry influence includes selective reporting of clinical trial results and selection of control groups likely to enhance benefits and disguise side effects. Other documented forms of influence include clear conflicts of interest for members of guideline committees and even direct intimidation. The book concludes with a series of implementable reforms, such as ensuring the accuracy and completeness of evidence, developing an independent National Health Board, designing clinical research to optimize health outcomes, requiring the posting of research data so that independent scholars can replicate analyses, and ensuring the accuracy of direct consumer advertising. Abramson's book is a must read for students of medicine, public health, and public policy.

Explanations for variations in hospital expenditures among four large California counties.

OBJECTIVE: To investigate competing explanations for why Medicare Fee for Service (FFS) and private sector payments lead to hospital cost variations in Californian counties. DATA SOURCES: Ratios of private to Medicare hospital costs were obtained from state-based all-payer claims databases. Demographics were estimated from the U.S. Census Bureau and the California Health Interview Survey. Medicaid and Medicare spending was obtained from Kaiser Family Foundation. Medicare Advantage enrollment was obtained from the California Department of Health Care Services and market consolidation was estimated using the Herfindahl-Hirschman Index (HHI). STUDY DESIGN: Per capita costs, demographics, Medicaid and Medicare spending, Medicare Advantage enrollment, and HHI scores were compared for San Francisco (SF), Sacramento, Los Angeles (LA), and San Diego (SD). PRINCIPAL FINDINGS: LA hospitals had the lowest per capita private insurer costs, but the highest Medicare FFS costs. The findings might be explained by a lower HHI for LA, indicating a more competitive market, than SD, SF, and Sacramento. CONCLUSIONS: Medicare FFS hospital costs do not provide an accurate representation of health care spending in Californian counties. In more competitive markets, private insurance companies can negotiate lower prices, while oversupply may allow facilities to increase volume in Medicare FFS.

Health-Related Quality of Life Measurement in Public Health.

Patient-reported outcomes are recognized as essential for the evaluation of medical and public health interventions. Over the last 50 years, health-related quality of life (HRQoL) research has grown exponentially from 0 to more than 17,000 papers published annually. We provide an overview of generic HRQoL measures used widely in epidemiological studies, health services research, population studies, and randomized clinical trials [e.g., Medical Outcomes Study SF-36 and the Patient-Reported Outcomes Measurement Information System (PROMIS®)-29]. In addition, we review methods used for economic analysis and calculation of the quality-adjusted life year (QALY). These include the EQ-5D, the Health Utilities Index (HUI), the self-administered Quality of Well-being Scale (QWB-SA), and the Health and Activities Limitation Index (HALex). Furthermore, we consider hybrid measures such as the SF-6D and the PROMIS-Preference (PROPr). The plethora of HRQoL measures has impeded cumulative science because incomparable measures have been used in different studies. Linking among different measures and consensus on standard HRQoL measurement should now be prioritized. In addition, enabling widespread access to common measures is necessary to accelerate future progress.

Design and Implementation of the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT).

The Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) is a prospective cohort study in Puerto Rico (PR) aiming to identify trends and longitudinal associations in risk factors for cardiovascular disease (CVD). In 2019, PROSPECT investigators started recruiting a sample of 2,000 adults aged 30-75 years in PR using multistage probabilistic sampling of households and community approaches. Culturally sensitive trained research assistants assess participants, at baseline and at 2-year follow-up, in private rooms at a network of partner clinics. The study collects comprehensive data on demographic factors, socioeconomic and environmental factors, medical history, health conditions, lifestyle behaviors, psychosocial status, and biomarkers of CVD and stress. PROSPECT will estimate the prevalence and incidence of psychosocial, lifestyle, and biological CVD risk factors, describe variations in risk factors by urbanicity (urban areas vs. rural areas) and exposure (before and after) to natural disasters, and determine predictors of longitudinal changes in CVD risk factors. The study has 4 coordinated operational strategies: 1) research productivity (including synergy with existing epidemiologic cohorts of Hispanics/Latinos for comparison); 2) research infrastructure (biorepository, ancillary studies, and clinical research network); 3) capacity-building, education, and training; and 4) community outreach, dissemination, and policy. PROSPECT will inform public health priorities to help reduce CVD in PR.

Recommendations for cancer screening would be different if we measured endpoints that are valid, reliable, specific, and important to patients.

BACKGROUND: Despite enthusiasm for cancer screening, systematic reviews consistently fail to show that screening reduces all-cause mortality. This narrative review explores conceptual issues, and inconsistencies between evidence and opinion about screening. REVIEW: We examined the interpretation of screening studies in relation to three intellectual traditions: (1) The relationship between prevention and cure; (2) Confirmation bias and the challenge of incorporating new data: less care may produce better outcomes than more care; (3) The answers to three structured questions about efficacy, effectiveness, and value of treatments proposed by Sir Archie Cochrane and Sir Austin Bradford Hill. SYNTHESIS: When considering extensions of life expectancy or all-cause mortality, systematic reviews typically show cancer screening to have only small effects and often non-significant effects on all-cause mortality. Early diagnosis does not assure application of an intervention that alters the pathway toward demise. The interpretation of screening results is also affected by several known biases. Investigators and advocates are encumbered by an over focus on studies designed to determine if a treatment can work under ideal circumstances. To advance the field, we need a greater emphasis on evaluations that ask 'Does the treatment work under real-world conditions?', and 'Is the treatment worth it?' in terms of outcomes that are meaningful to patients.

Association Between HEDIS Performance and Primary Care Physician Age, Group Affiliation, Training, and Participation in ACA Exchanges.

BACKGROUND: There are a limited number of studies investigating the relationship between primary care physician (PCP) characteristics and the quality of care they deliver. OBJECTIVE: To examine the association between PCP performance and physician age, solo versus group affiliation, training, and participation in California's Affordable Care Act (ACA) exchange. DESIGN: Observational study of 2013-2014 data from Healthcare Effectiveness Data and Information Set (HEDIS) measures and select physician characteristics. PARTICIPANTS: PCPs in California HMO and PPO practices (n = 5053) with part of their patient panel covered by a large commercial health insurance company. MAIN MEASURES: Hemoglobin A1c testing; medical attention nephropathy; appropriate treatment hypertension (ACE/ARB); breast cancer screening; proportion days covered by statins; monitoring ACE/ARBs; monitoring diuretics. A composite performance measure also was constructed. KEY RESULTS: For the average 35- versus 75-year-old PCP, regression-adjusted mean composite relative performance scores were at the 60th versus 47th percentile (89% vs. 86% composite absolute HEDIS scores; p < .001). For group versus solo PCPs, scores were at the 55th versus 50th percentiles (88% vs. 87% composite absolute HEDIS scores; p < .001). The effect of age on performance was greater for group versus solo PCPs. There was no association between scores and participation in ACA exchanges. CONCLUSIONS: The associations between population-based care performance measures and PCP age, solo versus group affiliation, training, and participation in ACA exchanges, while statistically significant in some cases, were small. Understanding how to help older PCPs excel equally well in group practice compared with younger PCPs may be a fruitful avenue of future research.

Economic Benefit of "Modern" Nonemergency Medical Transportation That Utilizes Digital Transportation Networks.

OBJECTIVES: To determine the economic benefit of "modern" nonemergency medical transportation (NEMT) that utilizes digital transportation networks compared with traditional NEMT in the United States. METHODS: We used the National Academies' NEMT cost-effectiveness model to perform a baseline cost savings analysis for provision of NEMT for transportation-disadvantaged Medicaid beneficiaries. On the basis of a review of the literature, commercial information, and structured expert interviews, we performed a sensitivity analysis to determine the incremental economic benefit of using modern NEMT. We estimated confidence intervals (CIs) by using Monte Carlo simulation. RESULTS: Total annual net savings for traditional NEMT in Medicaid was approximately $4 billion. For modern NEMT, estimated savings on ride costs varied from 30% to 70%. In comparison with traditional, modern NEMT was estimated to save $268 per expected user (95% CI = $248, $288 per member per year) and $537 million annually (95% CI = $496 million, $577 million) when scaled nationally. CONCLUSIONS: Modern NEMT has the potential to yield greater cost savings than traditional NEMT while also improving patient experience. Public Health Implications: Barriers to NEMT are a health risk affecting high-need, economically disadvantaged patients. Economic arguments supporting modern NEMT are important given decreased support for human services spending.

Systems Delivery Innovation for Alzheimer Disease.

OBJECTIVE: The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support. METHODS: Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs. RESULTS: After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion). CONCLUSION: A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

Contributions of Health Care to Longevity: A Review of 4 Estimation Methods.

PURPOSE: Health care expenditures and biomedical research funding are often justified by the belief that modern health care powerfully improves life expectancy in wealthy countries. We examined 4 different methods of estimating the effect of health care on health outcomes. METHODS: We reviewed the contributions of medical care to health outcomes using 4 methods: (1) analyses by McGinnis and Schroeder, (2) Wennberg and colleagues' studies of small area variation, (3) Park and colleagues' analysis of County Health Rankings and Roadmaps, and (4) the RAND Health Insurance Experiment. RESULTS: The 4 methods, using different data sets, produced estimates ranging from 0% to 17% of premature mortality attributable to deficiencies in health care access or delivery. Estimates of the effect of behavioral factors ranged from 16% to 65%. CONCLUSIONS: The results converge to suggest that restricted access to medical care accounts for about 10% of premature death or other undesirable health outcomes. Health care has modest effects on the extension of US life expectancy, while behavioral and social determinants may have larger effects.

Effect Sizes and Primary Outcomes in Large-Budget, Cardiovascular-Related Behavioral Randomized Controlled Trials Funded by NIH Since 1980.

PURPOSE: We reviewed large-budget, National Institutes of Health (NIH)-supported randomized controlled trials (RCTs) with behavioral interventions to assess (1) publication rates, (2) trial registration, (3) use of objective measures, (4) significant behavior and physiological change, and (5) effect sizes. METHODS: We identified large-budget grants (>$500,000/year) funded by NIH (National Heart Lung and Blood Institute (NHLBI) or National Institute of Diabetes & Digestive and Kidney Diseases (NIDDK)) for cardiovascular disease (dates January 1, 1980 to December 31, 2012). Among 106 grants that potentially met inclusion criteria, 20 studies were not published and 48 publications were excluded, leaving 38 publications for analysis. ClinicalTrials.gov abstracts were used to determine whether outcome measures had been pre-specified. RESULTS: Three fourths of trials were registered in ClinicalTrials.gov and all published pre-specified outcomes. Twenty-six trials reported a behavioral outcome with 81 % reporting significant improvements for the target behavior. Thirty-two trials reported a physiological outcome. All were objectively measured, and 81 % reported significant benefit. Seventeen trials reported morbidity outcomes, and seven reported a significant benefit. Nine trials assessed mortality, and all were null for this outcome. CONCLUSIONS: Behavioral trials complied with trial registration standards. Most reported a physiological benefit, but few documented morbidity or mortality benefits.

Providers' advice concerning smoking cessation: Evidence from the Medical Expenditures Panel Survey.

IMPORTANCE AND OBJECTIVE: We estimate how often adult smokers are advised to quit using a nationally representative sample of adults in the United States. DESIGN AND PARTICIPANTS: Data are from the 2012-2013 household component of the United States (US) Medical Expenditures Panel Survey (MEPS). MAIN OUTCOME MEASURE: Current smoking and advice to quit offered by providers. RESULTS: Smoking was reported by 18.26% (CI 17.13%-19.38%) of 2012 MEPS respondents. Less than half of adult smokers (47.24%, CI 44.30%-50.19%) were advised to quit by their physicians although 17.57% (CI 15.37%-19.76%) had not seen a doctor in the last 12months. Advice to quit was given significantly less often to respondents classified as: aged 18-44 (40.29%), men (40.20%), less educated (42.26%), lower family income (43.51%), Hispanic (33.82%), never married (39.55%), and living outside the northeast. Smoking status at year 2 for patients who had received advice to quit was similar (85.13%: SE 1.62%) to those who had seen a physician but were not advised to quit (81.95%: SE 2.05%). Advice to quit smoking was less common than the use of common medical screening tests. CONCLUSIONS AND RELEVANCE: Smoking cessation advice is given to less than half of current cigarette smokers and it is least likely to be given to the most vulnerable populations. Efforts to reduce smoking are deployed less often than other preventive practices. The rate of advice to quit has not changed over the last decade. Health care providers are missing an important opportunity to affect health behaviors and outcomes.

Update to the Report of Nationally Representative Values for the Noninstitutionalized US Adult Population for Five Health-Related Quality-of-Life Scores.

BACKGROUND: The most recent reports of nationally representative health-related quality-of-life (HRQOL) values for the United States used data that were collected over a decade ago. OBJECTIVES: To update these values using data from 2011, stratified by age and sex. METHODS: This study used data from two sources-the 2011 Medical Expenditures Panel Survey (MEPS) and the 2011 National Health Interview Survey (NHIS). Both are nationally representative surveys of the US noninstitutionalized civilian population. The MEPS was used to calculate four HRQOL scores: categorical self-rated health, mental and physical component summaries from the short form-12 items (SF-12) health survey, and the health state short form-6 dimensions (SF-6D). We also estimated Quality of Well-Being Scale scores from the NHIS. We reported means and quartiles for all continuous scores, stratified by decade of age and sex. RESULTS: There were 23,906 eligible subjects in the 2011 MEPS and 32,242 eligible subjects in the 2011 NHIS. All age and sex categories had instrument completion rates above 84%. Females reported lower mean scores than did males across all ages and instruments. In general, those in older age groups reported lower scores than did those in younger age groups, with the exception of the mental component summary scores from the SF-12 health survey. When compared with previous reports, these new values were generally lower than those in previous reports but rarely reached minimally important difference criteria. CONCLUSIONS: This report updates US nationally representative age- and sex-stratified estimates for five HRQOL scores using data from 2011. These values are important for use in both generalized comparisons of health status and in cost-effectiveness analyses.

A radical psychiatrist and the law: the forensic career of Reg Ellery.

OBJECTIVE: To explore the medico-legal work of Melbourne psychiatrist Reg Ellery. CONCLUSION: Ellery, a radical activist, attacked judges on the grounds that they could not be relied on to produce proper judgements or understand the social and psychiatric basis from which crime arose. Ellery's views were strongly influenced by his support for communism, and he regarded the Soviet Union as a model society that should be emulated. Ellery paid the penalty of losing his hospital position. However, there is no evidence that this affected his medico-legal work, and he continued to assess forensic cases until the end of his career. Some of Ellery's more interesting cases are discussed.