The Association of Retinal Disease with Vision Impairment and Functional Status in Medicare Patients.

Background: The association of neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO) with functional status in the general Medicare population are not well established. Objectives: This study examined patient-reported survey data linked with Medicare claims to describe the burden of these vision-threatening retinal diseases (VTRDs) among Medicare beneficiaries. Methods: Medicare Current Beneficiary Survey data linked with Medicare Fee-for-Service claims data from 2006 to 2018 were used in a nationally representative retrospective pooled cross-sectional population-based comparison study. Outcomes between community-dwelling beneficiaries with nAMD (n = 1228), DME (n = 101), or RVO (n = 251) were compared with community-dwelling beneficiaries without any VTRDs (n = 104 088), controlling for baseline demographic and clinical differences. Beneficiaries with a diagnosis of nAMD, DME, or RVO during the data year were included; those with other VTRDs were excluded. Outcomes included vision function and loss, overall functioning as assessed by difficulties with activities of daily living (ADLs) and instrumental ADLs (iADLs), anxiety/depression, falls, and fractures. Results: In patient cohorts with nAMD, DME, and RVO, approximately one-third (34.2%-38.3%) reported "a little trouble seeing" (vs 28.3% for controls), and 26%, 17%, and 9%, respectively, reported "a lot of trouble seeing/blindness" (vs 5% of controls). Difficulty walking and doing heavy housework were the most reported ADLs and iADLs, respectively. Compared with those without VTRDs, beneficiaries with nAMD had higher odds of diagnosed vision loss (odds ratio [OR], 5.39; 95% confidence interval, 4.06-7.16; P < .001) and difficulties with iADLs (odds ratio, 1.41; 95% confidence interval, 1.11-1.80; P = .005); no differences were observed for DME or RVO vs control. After adjusting for age, sex, race/ethnicity, poverty status, comorbidities, and other relevant covariates, nAMD, DME, and RVO were not significantly associated with anxiety/depression, falls, or fractures. Discussion: Patients with nAMD or DME were more likely to report severe visual impairment than those without VTRDs, although only those with nAMD were more likely to be diagnosed with vision loss. Conclusions: Patients with nAMD continue to experience more vision impairment and worse functional status compared with a similar population of Medicare beneficiaries despite availability of therapies like antivascular endothelial growth factor to treat retinal disease.

Comparison of prediction models for cardiovascular and mortality risk in people with type 2 diabetes: An external validation in 23 685 adults included in the UK Biobank.

AIMS: To validate cardiovascular risk prediction models for individuals with diabetes using the UK Biobank in order to assess their applicability. METHODS: We externally validated 19 cardiovascular risk scores from seven risk prediction models (Chang et al., Framingham, University of Hong Kong-Singapore [HKU-SG], Li et al, RECODe [risk equations for complications of type 2 diabetes], SCORE [Systematic Coronary Risk Evaluation] and the UK Prospective Diabetes Study Outcomes Model 2 [UKPDS OM2]), identified from systematic reviews, using UK Biobank data from 2006 to 2021 (n = 23 685; participant age 40-71 years, 63.5% male). We evaluated performance by assessing the discrimination and calibration of the models for the endpoints of mortality, cardiovascular mortality, congestive heart failure, myocardial infarction, stroke, and ischaemic heart disease. RESULTS: Over a total of 269 430 person-years of follow-up (median 11.89 years), the models showed low-to-moderate discrimination performance on external validation (concordance indices [c-indices] 0.50-0.71). Most models had low calibration with overprediction of the observed risk. RECODe outperformed other models across four comparable endpoints for discrimination: all-cause mortality (c-index 0.67, 95% confidence interval [CI] 0.65-0.69), congestive heart failure (c-index 0.71, 95% CI 0.69-0.72), myocardial infarction (c-index 0.67, 95% CI 0.65-0.68); and stroke (c-index 0.65, 95% CI 0.62-0.68), and for calibration (except for all-cause mortality). The UKPDS OM2 had comparable performance to RECODe for all-cause mortality (c-index 0.67, 95% CI 0.66-0.69) and cardiovascular mortality (c-index 0.71, 95% CI 0.70-0.73), but worse performance for other outcomes. The models performed better for younger participants and somewhat better for non-White ethnicities. Models developed from non-Western datasets showed worse performance in our UK-based validation set. CONCLUSIONS: The RECODe model led to better risk estimations in this predominantly White European population. Further validation is needed in non-Western populations to assess generalizability to other populations.

Assessment of second primary malignancies among treated and untreated patients with chronic lymphocytic leukemia using real-world data from the USA.

Aim: Improved management of chronic lymphocytic leukemia (CLL) has resulted in a growing population of CLL survivors; these patients have a higher risk of developing second primary malignancies (SPMs) versus the general population. This retrospective cohort study aims to assess the timing, frequency, incidence and types of SPMs in treated and untreated patients with CLL in the USA, using the Surveillance, Epidemiology, and End Results (SEER) Medicare database, which links a nationally representative cancer registry with Medicare claims data. Patients & methods: Patients aged ≥66 years with newly diagnosed CLL between 1 January 2010 and 31 December 2016, who were enrolled in Parts A and B of Medicare for ≥12 months pre-diagnosis of CLL were selected from the database. Patients were assessed for ≥36 months until the end of continuous enrollment in Medicare Parts A, B and D, a switch to a health maintenance organization, death, or end of the study period (December 2019). Results: Of 3053 patients included in the analyses, 620 (20.3%) were treated and 2433 (79.7%) were untreated within 36 months of diagnosis. Overall, 638 (20.9%) patients developed a SPM, 26.8% of patients in the treated cohort and 19.4% of patients in the untreated cohort. The most common SPMs for both cohorts were squamous cell carcinoma and acute myeloid leukemia. Among the 166 treated patients who developed a SPM, a greater proportion developed their first SPM after treatment initiation versus those who developed their first SPM prior to treatment initiation (p < 0.001). A significantly lower percentage of patients who received targeted therapy developed a SPM (p < 0.05) versus patients treated with anti-CD20 + chemotherapy. Conclusion: Findings indicate that treatment type and timing can affect SPM development in patients with CLL. Combined with previous findings, this can help inform best practices in monitoring for SPM in patients with CLL.

Clinical Outcomes in Patients With Refractory Anemia With Excess Blasts (RAEB) Who Receive Hypomethylating Agents (HMAs).

BACKGROUND: We sought to understand the clinical effectiveness associated with use of hypomethylating agents (HMAs) azacitidine (AZA) and decitabine (DEC) for patients with refractory anemia with excess blasts (RAEB; an established proxy for higher-risk myelodysplastic syndromes/neoplasms) in contemporary and representative real-world settings. PATIENTS AND METHODS: We used the Surveillance, Epidemiology and End Results (SEER)-Medicare database, a linkage of cancer registry and Medicare claims data, to identify patients aged ≥ 66 years diagnosed with RAEB, between 2009 and 2017 in the United States, and who received AZA or DEC as first-line therapy. Outcomes measured were overall survival (OS), event-free survival (EFS), and incidence of progression-related acute myeloid leukemia (AML). RESULTS: Of 973 eligible patients, 738 (75.8%) received AZA and 235 (24.2%) received DEC; 6.4% received hematopoietic cell transplantation during follow-up. In the overall population, median OS was 13.9 months (95% confidence interval [CI]: 12.9-15.0), median EFS was 5.2 months (95% CI: 4.9-5.7), and 38.0% of patients progressed to AML. Incidences of AML progression and death were 25.6% and 29.9%, respectively, at Year 1, and 34.3% and 44.8%, respectively, at Year 2. There were no significant differences in clinical benefits between AZA and DEC. CONCLUSION: Median OS with both HMAs remained significantly shorter than in the AZA-001 clinical trial, highlighting how patient outcomes vary between clinical and real-world settings. Further research is required to understand why these disparities exist.

US cost-effectiveness analysis of polatuzumab vedotin in previously untreated diffuse large B-cell lymphoma.

AIMS: We evaluated the pharmacoeconomic value of polatuzumab vedotin plus rituximab, cyclophosphamide, doxorubicin, and prednisone (Pola-R-CHP) in previously untreated diffuse large B-cell lymphoma (DLBCL) versus rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). MATERIALS AND METHODS: A 3-state partitioned survival model was used to estimate life years (LYs), quality-adjusted LYs (QALYs), and cost impacts of Pola-R-CHP versus R-CHOP. Analyses utilized mixture-cure survival modelling, assessed a lifetime horizon, discounted all outcomes at 3% per year, and examined both payer and societal perspectives. Progression-free survival, overall survival (OS), drug utilization, treatment duration, adverse reactions, and subsequent treatment inputs were based on data from the POLARIX study (NCT03274492). Costs included drug acquisition/administration, adverse reaction management, routine care, subsequent treatments, end-of-life care, and work productivity. RESULTS: Incremental cost-effectiveness ratios of Pola-R-CHP versus R-CHOP were $70,719/QALY gained and $88,855/QALY gained from societal and payer perspectives, respectively. The $32,824 higher total cost of Pola-R-CHP versus R-CHOP was largely due to higher drug costs ($122,525 vs $27,694), with cost offsets including subsequent treatment (-$52,765), routine care (-$1,781), end-of-life care (-$383), and work productivity (-$8,418). Pola-R-CHP resulted in an increase of 0.47 LYs and 0.46 QALYs versus R-CHOP. Pola-R-CHP was cost-effective in 60.9% and 58.0% of simulations at a willingness-to-pay threshold of $150,000/QALY gained from societal and payer perspectives, respectively. LIMITATIONS: There was uncertainty around the OS extrapolation in the model, and costs were derived from different sources. Recommended prophylactic medications were not included; prophylactic use of granulocyte colony-stimulating factor for all patients was assumed to be equal across treatment arms in POLARIX. Work productivity loss was estimated from a general population and was not specific to patients with DLBCL. CONCLUSION: Pola-R-CHP was projected to be cost-effective versus R-CHOP in previously untreated DLBCL, suggesting that Pola-R-CHP represents good value relative to R-CHOP in this setting.

Cost of Disease Progression in Diffuse Large B-Cell Lymphoma After Frontline Treatment With Rituximab Plus Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone.

BACKGROUND: In recent years, novel agents have become available to treat relapsed/refractory diffuse large B-cell lymphoma (DLBCL); the impact of such agents on treatment costs has not been formally studied. We present results from 2 independent, retrospective, real-world cohort analyses to determine the cost of disease progression after first-line rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). MATERIALS AND METHODS: Analyses were conducted using the IQVIA PharMetricsⓇ Plus claims database and the Surveillance, Epidemiology, and End Results registry-Medicare-linked database (SEER-Medicare) and included patients ≥18 years and ≥66 years, respectively. "No progression" was defined as no second-line therapy for ≥2 years after the end of first-line R-CHOP and "treated progression" as initiating a second-line therapy within 2 years following the end of first-line R-CHOP. Analyses were adjusted for baseline covariates, and per-patient-per-month (PPPM) costs were compared between progressors and nonprogressors. RESULTS: The IQVIA PharMetrics Plus analysis (January 1, 2010-June 30, 2018) included 871 patients (nonprogressors, n = 725; progressors, n = 146), including 10 patients who received chimeric antigen receptor T-cell therapy (CAR-T). Treated progression was associated with significantly higher adjusted PPPM costs than no progression ($10,554 vs. $1561, P < .001). The SEER-Medicare analysis (January 1, 2010-December 31, 2017) included 4099 patients (nonprogressors, n = 3389; progressors, n = 710), including 12 patients receiving CAR-T. Treated progression was associated with significantly higher adjusted PPPM costs than no progression ($10,928 vs. $2902, P < .001). CONCLUSION: Treated progression of DLBCL increases adjusted PPPM costs by over $8000 compared with no progression.

Estimating the US Baseline Distribution of Health Inequalities Across Race, Ethnicity, and Geography for Equity-Informative Cost-Effectiveness Analysis.

OBJECTIVES: Information on how life expectancy, disability-free life expectancy, and quality-adjusted life expectancy varies across equity-relevant subgroups is required to conduct distributional cost-effectiveness analysis. These summary measures are not comprehensively available in the United States, given limitations in nationally representative data across racial and ethnic groups. METHODS: Through linkage of US national survey data sets and use of Bayesian models to address missing and suppressed mortality data, we estimate health outcomes across 5 racial and ethnic subgroups (non-Hispanic American Indian or Alaska Native, non-Hispanic Asian and Pacific Islander, non-Hispanic black, non-Hispanic white, and Hispanic). Mortality, disability, and social determinant of health data were combined to estimate sex- and age-based outcomes for equity-relevant subgroups based on race and ethnicity, as well as county-level social vulnerability. RESULTS: Life expectancy, disability-free life expectancy, and quality-adjusted life expectancy at birth declined from 79.5, 69.4, and 64.3 years, respectively, among the 20% least socially vulnerable (best-off) counties to 76.8, 63.6, and 61.1 years, respectively, among the 20% most socially vulnerable (worst-off) counties. Considering differences across racial and ethnic subgroups, as well as geography, gaps between the best-off (Asian and Pacific Islander; 20% least socially vulnerable counties) and worst-off (American Indian/Alaska Native; 20% most socially vulnerable counties) subgroups were large (17.6 life-years, 20.9 disability-free life-years, and 18.0 quality-adjusted life-years) and increased with age. CONCLUSIONS: Existing disparities in health across geographies and racial and ethnic subgroups may lead to distributional differences in the impact of health interventions. Data from this study support routine estimation of equity effects in healthcare decision making, including distributional cost-effectiveness analysis.

ALDH2 polymorphism, alcohol intake and the attributable burden of cancer in East Asia: systematic review, meta-analysis, and modeling study.

PURPOSE: To estimate the burden of alcohol-attributable cancer in East Asian populations accounting for aldehyde dehydrogenase-2 (ALDH2) genotype-specific cancer risk and alcohol exposure. METHODS: We conducted a systematic review and meta-analysis of eight databases on cancer risk to derive alcohol dose-response curves by ALDH2 genotype. A simulation-based approach using the Global Burden of Disease (GBD) modeling framework was applied to estimate the population attributable fraction, incidence, and disability-adjusted life-years (DALYs) lost to alcohol-attributable cancer. RESULTS: We included 34 studies (66,655 participants) from China, Japan, and South Korea in the meta-analysis. Alcohol dose-response curves for liver, esophageal, and oral cavity/pharynx cancer showed an increased risk for people with the inactivated ALDH2 genetic polymorphism, resulting in a higher burden of alcohol-attributable cancer compared to GBD estimates. Our methods estimated annual incidence of cancer of 230,177 cases, an underestimate of 69,596 cases compared to GBD estimates. Similarly, total DALYs lost annually were underestimated by 1.20 million. CONCLUSIONS: The burden of liver, esophageal, and oral cavity/pharynx cancer attributable to alcohol is underestimated in populations with the ALDH2 genetic polymorphism when compared to current estimates.

Factors associated with fall risk of community-dwelling older people: A decision tree analysis.

Objective: To examine the predictive attributes for accidental falls in community-dwelling older people in Hong Kong using decision tree analysis. Methods: We recruited 1151 participants with an average age of 74.8 years by convenience sampling from a primary healthcare setting to carry out the cross-sectional study over 6 months. The whole dataset was divided into two sets, namely training set and test set, which respectively occupied 70% and 30% of the whole dataset. The training dataset was used first; decision tree analysis was used to identify possible stratifying variables that could help to generate separate decision models. Results: The number of fallers was 230 with 20% 1-year prevalence. There were significant differences in gender, use of walking aids, presence of chronic diseases, and co-morbidities including osteoporosis, depression, and previous upper limb fractures, and performance in the Timed Up and Go test and the Functional Reach test among the baselines between the faller and non-faller groups. Three decision tree models for the dependent dichotomous variables (fallers, indoor fallers, and outdoor fallers) were generated, with overall accuracy rates of the models of 77.40%, 89.44% and 85.76%, respectively. Timed Up and Go, Functional Reach, body mass index, high blood pressure, osteoporosis, and number of drugs taken were identified as stratifying variables in the decision tree models for fall screening. Conclusion: The use of decision tree analysis for clinical algorithms for accidental falls in community-dwelling older people creates patterns for decision-making in fall screening, which also paves the way for utility-based decision-making using supervised machine learning in fall risk detection.

Potential health and economic impact associated with achieving risk factor control in Chinese adults with diabetes: a microsimulation modelling study.

Background: The prevalence of diabetes has risen sharply in China. Improving modifiable risk factors such as glycaemia and blood pressure could substantially reduce disease burden and treatment costs to achieve a healthier China by 2030. Methods: We used a nationally representative population-based survey of adults with diabetes in 31 provinces in mainland China to assess the prevalence of risk factor control. We adopted a microsimulation approach to estimate the impact of improved control of blood pressure and glycaemia on mortality, quality-adjusted life-years (QALYs), and healthcare cost. We applied the validated CHIME diabetes outcomes model over a 10-year time horizon. Baseline scenario of status quo was evaluated against alternative strategies based on World Health Organization and Chinese Diabetes Society guidelines. Findings: Among 24,319 survey participants with diabetes (age 30-70), 69.1% (95% CI: 67.7-70.5) achieved optimal diabetes control (HbA1c <7% [53 mmol/mol]), 27.7% [26.1-29.3] achieved blood pressure control (<130/80 mmHg) and 20.1% (18.6-21.6) achieved both targets. Achieving 70% control rate for people with diabetes could reduce deaths before age 70 by 7.1% (5.7-8.7), reduce medical costs by 14.9% (12.3-18.0), and gain 50.4 QALYs (44.8-56.0) per 1000 people over 10 years compared to the baseline status quo. The largest health gains were for strategies including strict blood pressure control of 130/80 mmHg, particularly in rural areas. Interpretation: Based on a nationally representative survey, few adults with diabetes in China achieved optimal control of glycaemia and blood pressure. Substantial health gains and economic savings are potentially achievable with better risk factor control especially in rural settings. Funding: Chinese Central Government, Research Grants Council of the Hong Kong Special Administrative Region, China [27112518].

Impact of alcohol taxes on violence in Hong Kong: a population-based interrupted time series analysis.

BACKGROUND: Interpersonal violence is a major public health concern with alcohol use a known risk factor. Despite alcohol taxation being an effective policy to reduce consumption; Hong Kong, contrary to most developed economies, embarked on an alcohol tax reduction and elimination policy. METHODS: To assess the impact of the alcohol tax reductions, we analysed population-based hospitalisation data for assault from the Hong Kong Hospital Authority, and violent and sexual crimes recorded by the Hong Kong Police Force (2004-2018). We conducted an interrupted time series using seasonal autoregressive integrated moving average models on monthly rates. Breakpoints in March 2007 and March 2008 were applied separately. RESULTS: The 2007 tax cut was associated with sustained increases in violence-related hospitalisation rates for 35-49 age group (female: 0.19%, p=0.007; male: 0.22%, p<0.001; overall: 0.16%, p=0.007); and an immediate increase of 51.3% (p=0.005) in the rate of sexual crimes reported. Results for the 35-49 age group after the 2008 tax cut were similar with sustained increases in hospitalisation rates (female: 0.21%, p=0.010; male: 0.23%, p<0.001; overall: 0.17%, p<0.001). The 2008 tax cut was also associated with immediate increases in hospitalisation rates in children (female: 33.1%, p=0.011; male: 49.2%, p<0.001, overall: 31.5%, p=0.007). For both tax cuts, results were insignificant in males and females for other age groups (15-34 and 50+ years). CONCLUSIONS: Both alcohol tax reductions in 2007 and 2008 were in some age groups associated with increases in violence-related hospitalisations and reports of sexual assault even in an environment of low crime.

Study protocol of ConquerFear-HK: a randomised controlled trial of a metacognition-based, manualised intervention for fear of cancer recurrence among Chinese cancer survivors.

INTRODUCTION: Fear of cancer recurrence (FCR) is a prevalent and frequently debilitating response to a cancer diagnosis, affecting a substantial proportion of cancer survivors. Approximately 30% of local Hong Kong Chinese cancer survivors in a recent survey reportedly experienced persistent high FCR over the first-year post-surgery. This was associated with lower levels of psychological well-being and quality of life. A manualised intervention (ConquerFear) developed primarily based on the Self-Regulatory Executive Function Model and the Rational Frame Theory, has been found to reduce FCR effectively among Caucasian cancer survivors. The intervention now has been adapted to a Chinese context; ConquerFear-HK. The primary aim of this study is to evaluate its efficacy vs a standard-survivorship-care control (BasicCancerCare) in FCR improvement in a randomised control trial (RCT). METHODS AND ANALYSIS: In this RCT, using the sealed envelope method, 174 eligible Chinese cancer survivors will be randomised to either the ConquerFear-HK or BasicCancerCare intervention. Both interventions include six sessions over 10 weeks, which will be delivered via face to face or online by trained therapists. The ConquerFear-HK intervention incorporates value classification, metacognitive therapy, attentional training, detached mindfulness and psychoeducation; BasicCancerCare includes relaxation training, dietary and physical activity consultations. Participants will be assessed at prior randomisation (baseline; T0), immediately postintervention (T1), 3 months (T2) and 6 months postintervention (T3) on the measures of FCR (Fear of Cancer Recurrence Inventory) as a primary outcome; metacognition (30-item Metacognitions Quesionnaire) and cognitive attentional syndrome (Cognitive-attentional Syndrome Questionnaire) as process outcomes; psychological distress (Hospital Anxiety and Depression Scale), cancer-related distress (Chinese Impact of Events Scale), quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire) and treatment satisfaction are secondary outcomes. ETHICS AND DISSEMINATION: Ethics approval has been obtained from HKU/HA HKW Institutional Review Board (ref: UW19-183). The patients/participants provide their written informed consent to participate in this study. The study results will be disseminated through international peer-review publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT04568226.

COVID-19 Vaccine Allergy Safety Track (VAS-Track) pathway: real-world outcomes on vaccination rates and antibody protection.

BACKGROUND: Misdiagnosed vaccine-related "allergies" lead to unnecessary vaccine deferrals and incomplete vaccinations, leaving patients unprotected against COVID-19. To overcome limitations and queues for Allergist assessment, the "VAS-Track" pathway was developed to evaluate patients via a multi-disciplinary triage model including nurses, non-specialists, and Allergists. OBJECTIVE: We assessed the effectiveness and safety of VAS-Track and evaluate its real-world impact in terms of vaccination rates and COVID-19 protection. METHODS: Patients referred to VAS-Track between September 2021 and March 2022 were recruited. Subgroup analysis was performed with prospective pre- and post-clinic antibody levels. RESULTS: Nurse-assisted screening identified 10,412 (76%) referrals as inappropriate. 369 patients were assessed by VAS-Track. Overall, 100% of patients were recommended to complete vaccination and 332 (90%) completed their primary series. No patients reported any significant allergic reactions following subsequent vaccination. Vaccination completion rates between patients seen by non-specialists and additional Allergist review were similar (90% vs. 89%, p = 0.617). Vaccination rates were higher among patients with prior history of immediate-type reactions (odds ratio: 2.43, p = 0.025). Subgroup analysis revealed that only 20% (56/284) of patients had seropositive COVID-19 neutralizing antibody levels (≥ 15 AU/mL) prior to VAS-Track, which increased to 92% after vaccine completion (pre-clinic antibody level 6.0 ± 13.5 AU/mL vs. post-clinic antibody level 778.8 ± 337.4 AU/mL, p > 0.001). CONCLUSIONS: A multi-disciplinary allergy team was able to streamline our COVID-19 VAS services, enabling almost all patients to complete their primary series, significantly boosting antibody levels and real-world COVID-19 protection. We propose similar multidisciplinary models to be further utilized, especially in the settings with limited allergy services.

The Impact of Funding Inpatient Treatments for COVID-19 on Health Equity in the United States: A Distributional Cost-Effectiveness Analysis.

OBJECTIVES: We conducted a distributional cost-effectiveness analysis (DCEA) to evaluate how Medicare funding of inpatient COVID-19 treatments affected health equity in the United States. METHODS: A DCEA, based on an existing cost-effectiveness analysis model, was conducted from the perspective of a single US payer, Medicare. The US population was divided based on race and ethnicity (Hispanic, non-Hispanic black, and non-Hispanic white) and county-level social vulnerability index (5 quintile groups) into 15 equity-relevant subgroups. The baseline distribution of quality-adjusted life expectancy was estimated across the equity subgroups. Opportunity costs were estimated by converting total spend on COVID-19 inpatient treatments into health losses, expressed as quality-adjusted life-years (QALYs), using base-case assumptions of an opportunity cost threshold of $150 000 per QALY gained and an equal distribution of opportunity costs across equity-relevant subgroups. RESULTS: More socially vulnerable populations received larger per capita health benefits due to higher COVID-19 incidence and baseline in-hospital mortality. The total direct medical cost of inpatient COVID-19 interventions in the United States in 2020 was estimated at $25.83 billion with an estimated net benefit of 735 569 QALYs after adjusting for opportunity costs. Funding inpatient COVID-19 treatment reduced the population-level burden of health inequality by 0.234%. Conclusions remained robust across scenario and sensitivity analyses. CONCLUSIONS: To the best of our knowledge, this is the first DCEA to quantify the equity implications of funding COVID-19 treatments in the United States. Medicare funding of COVID-19 treatments in the United States could improve overall health while reducing existing health inequalities.

Long-term spill-over impact of COVID-19 on health and healthcare of people with non-communicable diseases: a study protocol for a population-based cohort and health economic study.

INTRODUCTION: The COVID-19 pandemic has a significant spill-over effect on people with non-communicable diseases (NCDs) over the long term, beyond the direct effect of COVID-19 infection. Evaluating changes in health outcomes, health service use and costs can provide evidence to optimise care for people with NCDs during and after the pandemic, and to better prepare outbreak responses in the future. METHODS AND ANALYSIS: This is a population-based cohort study using electronic health records of the Hong Kong Hospital Authority (HA) CMS, economic modelling and serial cross-sectional surveys on health service use. This study includes people aged ≥18 years who have a documented diagnosis of diabetes mellitus, hypertension, cardiovascular disease, cancer, chronic respiratory disease or chronic kidney disease with at least one attendance at the HA hospital or clinic between 1 January 2010 and 31 December 2019, and without COVID-19 infection. Changes in all-cause mortality, disease-specific outcomes, and health services use rates and costs will be assessed between pre-COVID-19 and-post-COVID-19 pandemic or during each wave using an interrupted time series analysis. The long-term health economic impact of healthcare disruptions during the COVID-19 pandemic will be studied using microsimulation modelling. Multivariable Cox proportional hazards regression and Poisson/negative binomial regression will be used to evaluate the effect of different modes of supplementary care on health outcomes. ETHICS AND DISSEMINATION: The study was approved by the institutional review board of the University of Hong Kong, the HA Hong Kong West Cluster (reference number UW 21-297). The study findings will be disseminated through peer-reviewed publications and international conferences.

The impact of alcohol pricing policies on public health in Hong Kong, China: A modelling study.

Background: Contrary to most developed economies, Hong Kong has reduced and eliminated taxes on beer and wine over the last 15 years and observed increasing alcohol consumption. Methods: We applied econometric epidemiological modelling to assess the impact of reverting ad valorem taxation to pre-2008 levels (20% on wine and 40% on beer) on consumption and health outcomes. We used 15 years of industry sales and pricing data (2004-2018) to derive 25 own-price and cross-price elasticity estimates. We applied risk functions from the World Health Organization 2018 Global Status Report to assess the impact on 25 alcohol-attributable conditions. Findings: An estimated 616 deaths (91.3% in men) were attributable to alcohol in 2018. Raising taxes to pre-2008 levels is estimated to reduce consumption of pure alcohol consumption by 8.0%, 15.9%, and 31.1%; and reduce alcohol-attributable deaths by 11.6%, 21.8%, and 40.2% assuming 25%, 50% and 100% pass through rates of taxes to consumers. The largest projected decreases in alcohol-attributable mortality in absolute numbers are alcohol abuse, alcohol dependence, and alcoholic psychoses (wholly alcohol-attributable disorders). The largest absolute number of new alcohol-attributable cases in 2018 were hypertension, alcohol dependence and alcohol abuse; which are estimated to be reduced by 31.3%, 34.2%, and 34.3% respectively by raising taxes to pre-2008 levels. The alcohol-attributable health burden and absolute reductions in health harms are far greater in men. Interpretation: Reversing the 2008 alcohol tax reductions is potentially effective in averting the alcohol-attributable health burden and thus mitigate against the avoidable harms of alcohol-related disease. Funding: Health and Medical Research Fund, Food and Health Bureau of the Hong Kong SAR, China [03170067].

Transmission dynamics of SARS-CoV-2 in British Columbia's largest school district during the second half of the 2020-2021 school year.

OBJECTIVES: To determine the extent and characteristics of in-school transmission of SARS-CoV-2 and determine risk factors for in-school acquisition of COVID-19 in one of Canada's largest school districts. METHODS: We conducted a retrospective chart review of all reportable cases of COVID-19 who attended a kindergarten-Grade 12 (K-12) school within the study area between January and June of the 2020-2021 school year. The acquisition source was inferred based on epidemiological data and, when available, whole genome sequencing results. Mixed effects logistic regression was performed to identify risk factors independently associated with in-school acquisition of COVID-19. RESULTS: Overall, 2877 cases of COVID-19 among staff and students were included in the analysis; of those, 9.1% had evidence of in-school acquisition. The median cluster size was two cases (interquartile range: 1). Risk factors for in-school acquisition included being male (adjusted odds ratio [aOR]: 1.59, 95% confidence interval [CI]: 1.17-2.17), being a staff member (aOR: 2.62, 95% CI: 1.64-4.21) and attending or working in an independent school (aOR: 2.28, 95% CI: 1.13-4.62). CONCLUSION: In-school acquisition of COVID-19 was uncommon during the study period. Risk factors were identified in order to support the implementation of mitigation strategies that can reduce transmission further.

RéSUMé: OBJECTIFS: Déterminer l'étendue et les caractéristiques de la transmission de la SRAS-CoV-2 en milieu scolaire, et déterminer les facteurs de risque de l'acquisition de la COVID-19 dans l'un des plus larges arrondissements scolaires du Canada. MéTHODES: Nous avons mené un examen rétrospectif des dossiers de tous les cas signalés de COVID-19 ayant fréquenté une école de niveau élémentaire, primaire ou secondaire dans la zone à l'étude entre janvier et juin de l'année scolaire 2020-2021. La source d'acquisition était inférée sur la base des données épidémiologiques et, lorsque disponibles, les résultats de séquençage du génome entier. Nous avons eu recours à des régressions logistiques multiniveaux pour identifier les facteurs indépendamment associés avec l'acquisition de la COVID-19 en milieu scolaire. RéSULTATS: Au total, 2 877 cas de COVID-19 parmi les employés et les élèves ont été inclus dans l'analyse; de ceux-ci, 9,1 % avaient acquis l'infection en milieu scolaire. La grosseur médiane des agrégats était de deux cas (écart interquartile : 1). Les risques facteurs de l'acquisition en milieu scolaire incluaient le fait d'être de sexe masculin (rapport de cotes ajusté [RCa] : 1,59, intervalle de confiance [IC] de 95% : 1,17-2,17), être un membre du personnel (RCa : 2,62, IC de 95% : 1,64-4,21) et fréquenter ou travailler dans une école indépendante (RCa : 2,28, IC de 95% : 1,13-4,62). CONCLUSION: Nos résultats suggèrent que l'acquisition de la COVID-19 en milieu scolaire était peu commune pendant la période d'étude. Des facteurs de risque ont été identifiés afin de supporter l'implémentation de mesures de contrôle pouvant réduire davantage la transmission.

Changes in the Incidence of Childhood Obesity.

OBJECTIVES: Examine childhood obesity incidence across recent cohorts. METHODS: We examined obesity incidence and prevalence across 2 cohorts of children in the United States 12 years apart using the Early Childhood Longitudinal Studies, parallel data sets following the kindergarten cohorts of 1998 and 2010 with direct anthropometric measurements at multiple time points through fifth grade in 2004 and 2016, respectively. We investigated annualized incidence rate and cumulative incidence proportion of obesity (BMI z-score ≥95th percentile based on Centers for Disease Control and Prevention weight-for-age z-scores). RESULTS: Among children who did not have obesity at kindergarten entry, there was a 4.5% relative increase in cumulative incidence of new obesity cases by end of fifth grade across cohorts (15.5% [14.1%-16.9%] vs 16.2% [15.0%-17.3%]), though annual incidence did not change substantially. The risk of incident obesity for children who had normal BMI at kindergarten entry stayed the same, but the risk of incident obesity among overweight kindergartners increased slightly. Social disparities in obesity incidence expanded: incidence of new cases during primary school among non-Hispanic Black children increased by 29% (95% confidence interval, 25%-34%), whereas risk for other race-ethnic groups plateaued or decreased. Children from the most socioeconomically disadvantaged households experienced 15% higher cumulative incidence across primary school in 2010 than 1998. CONCLUSIONS: Incidence of childhood obesity was higher, occurred at younger ages, and was more severe than 12 years previous; thus, more youths may now be at risk for health consequences associated with early onset of obesity.

The Role of the Allergist in Coronavirus Disease 2019 Vaccine Allergy Safety: A Pilot Study on a "Hub-and-Spoke" Model for Population-Wide Allergy Service.

BACKGROUND: Hong Kong started its coronavirus disease 2019 (COVID-19) vaccination program in February 2021. A territory-wide Vaccine Allergy Safety (VAS) clinic was set up to assess individuals deemed at "higher risk" of COVID-19 vaccine-associated allergies. A novel "hub-and-spoke" model was piloted to tackle the overwhelming demand of services by allowing nonallergists to conduct assessment. OBJECTIVE: To evaluate the outcomes of the VAS hub-and-spoke model for allergy assessment. METHODS: Records of patients attending the VAS hub-and-spoke Clinics between March and August 2021 were reviewed (n = 2725). We studied the overall results between the Hub (allergist led) and Spoke (nonallergist led) Clinics. The Hub and the Hong Kong West Cluster Spoke Clinic were selected for subgroup analysis as they saw the largest number of patients (n = 1411). RESULTS: A total of 2725 patients were assessed under the VAS hub-and-spoke model. Overall, 2324 patients (85.3%) were recommended to proceed with vaccination. Allergists recommended significantly more patients for vaccination than nonallergists (odds ratio = 21.58; P < .001). Subgroup analysis revealed that 881 of 1055 (83.5%) patients received their first dose of COVID-19 vaccination safely after assessment. Among those recommended vaccination, more patients assessed by allergists received their first dose of vaccination (odds ratio = 4.18; P < .001). CONCLUSION: The hub-and-spoke model has proven to be successful for the vaccination campaign. This study has illustrated the crucial role of allergists in countering vaccine hesitancy. Results from the study revealed considerable differences in outcomes between allergist-led and nonallergist-led clinics. Precise reasons for these differences warrant further evaluation. We are hopeful that the hub-and-spoke model can be similarly adapted for other allergist-integrative services in the future.