Circulating Nucleated Red Blood Cells: An Updated Reference Interval.

CONTEXT.­: Nucleated red blood cells (nRBCs) are not identified in the peripheral blood in healthy individuals beyond the neonatal period. Their presence in children and adults is traditionally considered pathologic. Contemporary hematology analyzers measure nRBCs at very low levels compared to traditional manual morphometric methods. The original launch of the Sysmex XN analyzer in this study's clinical laboratory verified the previously used nRBC reference interval of 0.00 to 0.01 × 106/µL. However, nRBC results from apparently healthy patients were flagged as abnormal (high), subsequently causing patient anxiety and increased subspecialty referrals. OBJECTIVE.­: To determine whether current reference intervals (RIs) for nRBCs were clinically relevant. DESIGN.­: We performed a prospective analysis of 405 300 specimens from nonhospitalized individuals who received a complete blood count. Applying inclusion/exclusion criteria produced a total specimen pool of 66 498. RESULTS.­: Of the 66 498 samples with otherwise normal complete blood count results from healthy, nonhospitalized individuals, 338 showed results outside the previously established RI; 336 of 66 498 (0.5%) had nRBC results greater than 0.01 × 106/µL. Two samples had nRBC values greater than 0.10 ×106/µL. CONCLUSIONS.­: Based on statistical analysis of our results, we concluded that the upper limit of the RI could be updated from 0.01 × 106/µL to 0.10 × 106/µL. Increasing the upper limit of normal for the nRBC RI should decrease patient consternation from an abnormal laboratory value and significantly decrease costs through reducing unnecessary follow up care, and without causing patient harm.

Cost-effectiveness of herpes zoster vaccines in the U.S.: A systematic review.

The purpose of this study was to conduct a systematic review to evaluate the cost-effectiveness evidence of herpes zoster vaccines in the U.S. A systematic literature review was undertaken for U.S. studies focused on the cost-effectiveness of herpes zoster vaccines. Eligibility criteria included studies that evaluated the cost-effectiveness of the recombinant zoster vaccine (RZV) and zoster vaccine live (ZVL) and were published between 2015 and 2021. Article titles and abstracts were reviewed to identify relevant publications. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) criteria for economic evaluations were used to evaluate the studies. Eleven published studies met inclusion and exclusion criteria. Seven studies compared RZV and ZVL. Four studies compared ZVL dosing regimens with or without a no vaccine option. All studies incorporated health system costs. Ten out of eleven (90.9%) studies conducted their analyses from a societal perspective and included indirect costs. For measurements of effectiveness, ten of eleven (90.9%) studies estimated quality-adjusted life years, four (36.4%) used shingles cases averted, two (18.2%) employed deaths prevented, and one (9.1%) measured life years saved. All studies that compared RZV with no vaccine found RZV to be a cost-effective strategy to prevent both shingles and post-herpetic neuralgia. Additionally, these analyses showed that RZV consistently dominated ZVL. Compliance with the second RZV dose was important for full benefit of the vaccine. The studies identified in this systematic review identified well-constructed cost-effectiveness analyses of herpes zoster vaccines in the U.S. RZV was more cost-effective than no vaccine or ZVL. This systematic review supports removal of ZVL from the U.S. market.

Multistate Health Plans: Agents for Competition or Consolidation?

We discuss and evaluate the Multi-State Plan (MSP) Program, a provision of the Affordable Care Act that has not been the subject of much debate as yet. The MSP Program provides the Office of Personnel Management with new authority to negotiate and implement multistate insurance plans on all health insurance exchanges within the United States. We raise the concern that the MSP Program may lead to further consolidation of the health insurance industry despite the program's stated goal of increasing competition by means of health insurance exchanges. The MSP Program arguably gives a competitive advantage to large insurers, which already dominate health insurance markets. We also contend that the MSP Program's failure to produce increased competition may motivate a new effort for a public health insurance option.

Analysis of the costs and payments of a coordinated stroke center and regional stroke network.

BACKGROUND AND PURPOSE: An earlier study demonstrated significantly improved access, treatment, and outcomes after the implementation of a progressive, comprehensive stroke program at a tertiary care community hospital, Saint Luke's Neuroscience Institute (SLNI). This study evaluated the costs associated with implementing such a program. METHODS: Retrospective analysis of total hospital costs and payments for treating patients with ischemic stroke at SLNI (n=1570) as program enhancement evolved over time (2005, 2007, and 2010) and compared with published national estimates. Analyses were stratified by patient demographic characteristics, patient outcomes, treatments, time, and comorbidities. RESULTS: Controlling for inflation, there was no difference in SLNI total costs between 2005 and either 2007 or 2010, suggesting that while SLNI provided an increased level of services, any additional expenditures were offset by efficiencies. SLNI total costs were slightly lower than published benchmarks. Consistent with previous stroke care cost estimates, the median overall differential between total hospital costs and payments for all ischemic stroke cases was negative. CONCLUSIONS: SLNI total costs remained consistent over time and were slightly lower than previously published estimates, suggesting that a focused, streamlined stroke program can be implemented without a significant economic impact. This finding further demonstrates that providing comprehensive stroke care with improved access and treatment may be financially feasible for other hospitals.