Trends in Clinical Severity of Hospitalized Patients With Coronavirus Disease 2019-Premier Hospital Dataset, April 2020-April 2021.

BACKGROUND: Clinical severity of coronavirus disease 2019 (COVID-19) may vary over time; trends in clinical severity at admission during the pandemic among hospitalized patients in the United States have been incompletely described, so a historical record of severity over time is lacking. METHODS: We classified 466677 hospital admissions for COVID-19 from April 2020 to April 2021 into 4 mutually exclusive severity grades based on indicators present on admission (from most to least severe): Grade 4 included intensive care unit (ICU) admission and invasive mechanical ventilation (IMV); grade 3 included non-IMV ICU and/or noninvasive positive pressure ventilation; grade 2 included diagnosis of acute respiratory failure; and grade 1 included none of the above indicators. Trends were stratified by sex, age, race/ethnicity, and comorbid conditions. We also examined severity in states with high vs low Alpha (B.1.1.7) variant burden. RESULTS: Severity tended to be lower among women, younger adults, and those with fewer comorbidities compared to their counterparts. The proportion of admissions classified as grade 1 or 2 fluctuated over time, but these less-severe grades comprised a majority (75%-85%) of admissions every month. Grades 3 and 4 consistently made up a minority of admissions (15%-25%), and grade 4 showed consistent decreases in all subgroups, including states with high Alpha variant burden. CONCLUSIONS: Clinical severity among hospitalized patients with COVID-19 has varied over time but has not consistently or markedly worsened over time. The proportion of admissions classified as grade 4 decreased in all subgroups. There was no consistent evidence of worsening severity in states with higher vs lower Alpha prevalence.

Public Health Emergency Preparedness System Evaluation Criteria and Performance Metrics: A Review of Contributions of the CDC-Funded Preparedness and Emergency Response Research Centers.

OBJECTIVES: The US Centers for Disease Control and Prevention (CDC)-funded Preparedness and Emergency Response Research Centers (PERRCs) conducted research from 2008 to 2015 aimed to improve the complex public health emergency preparedness and response (PHEPR) system. This paper summarizes PERRC studies that addressed the development and assessment of criteria for evaluating PHEPR and metrics for measuring their efficiency and effectiveness. METHODS: We reviewed 171 PERRC publications indexed in PubMed between 2009 and 2016. These publications derived from 34 PERRC research projects. We identified publications that addressed the development or assessment of criteria and metrics pertaining to PHEPR systems and describe the evaluation methods used and tools developed, the system domains evaluated, and the metrics developed or assessed. RESULTS: We identified 29 publications from 12 of the 34 PERRC projects that addressed PHEPR system evaluation criteria and metrics. We grouped each study into 1 of 3 system domains, based on the metrics developed or assessed: (1) organizational characteristics (n = 9), (2) emergency response performance (n = 12), and (3) workforce capacity or capability (n = 8). These studies addressed PHEPR system activities including responses to the 2009 H1N1 pandemic and the 2011 tsunami, as well as emergency exercise performance, situational awareness, and workforce willingness to respond. Both PHEPR system process and outcome metrics were developed or assessed by PERRC studies. CONCLUSIONS: PERRC researchers developed and evaluated a range of PHEPR system evaluation criteria and metrics that should be considered by system partners interested in assessing the efficiency and effectiveness of their activities. Nonetheless, the monitoring and measurement problem in PHEPR is far from solved. Lack of standard measures that are readily obtained or computed at local levels remains a challenge for the public health preparedness field. (Disaster Med Public Health Preparedness. 2019;13:626-638).

Determinants of venous thromboembolism among hospitalizations of US adults: a multilevel analysis.

BACKGROUND: Venous thromboembolism (VTE) is a significant clinical and public health concern. We evaluated a variety of multilevel factors--demographics, clinical and insurance status, preexisting comorbid conditions, and hospital characteristics--for VTE diagnosis among hospitalizations of US adults. METHODS: We generated adjusted odds ratios with 95% confidence intervals (CIs) and determined sources of outcome variation by conducting multilevel logistic regression analysis of data from the 2011 Nationwide Inpatient Sample that included 6,710,066 hospitalizations of US adults nested within 1,039 hospitals. RESULTS: Among hospitalizations of adults, age, sex, race or ethnicity, total days of hospital stay, status of health insurance, and operating room procedure were important determinants of VTE diagnosis; each of the following preexisting comorbid conditions--acquired immune deficiency syndrome, anemia, arthritis, congestive heart failure, coagulopathy, hypertension, lymphoma, metastatic cancer, other neurological disorders, obesity, paralysis, pulmonary circulation disorders, renal failure, solid tumor without metastasis, and weight loss--was associated independently with 1.04 (95% CI: 1.02-1.06) to 2.91 (95% CI: 2.81-3.00) times increased likelihood of VTE diagnosis than among hospitalizations of adults without any of these corresponding conditions. The presence of 2 or more of such conditions was associated a 180%-450% increased likelihood of a VTE diagnosis. Hospitalizations of adults who were treated in urban hospitals were associated with a 14%-15% increased likelihood of having a VTE diagnosis than those treated in rural hospitals. Approximately 7.4% of the total variation in VTE diagnosis occurred between hospitals. CONCLUSION: The presence of certain comorbidities and hospital contextual factors is associated with significantly elevated likelihood of VTE diagnosis among hospitalizations of adults. The findings of this study underscore the importance of clinical risk assessment and adherence to evidence-based clinical practice guidelines in preventing VTE, as well as the need to evaluate potential contextual factors that might modify the risk of VTE among hospitalized patients.

Risk of venous thromboembolism occurrence among adults with selected autoimmune diseases: a study among a U.S. cohort of commercial insurance enrollees.

OBJECTIVE: This study assessed the risk of venous thromboembolism (VTE) among privately insured adults in the U.S. with one or more of the following autoimmune diseases: autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE). MATERIALS AND METHODS: Using the Truven Health MarketScan® Databases, patients 18-64 years of age with a diagnosis of AIHA, ITP, RA, or SLE in 2007 and a sex and age-group matched comparison group of enrollees were followed up through 2010 to identify VTE events. Survival curve and Cox proportional hazards analyses were conducted to assess differences between groups. RESULTS: Among patients with AIHA, ITP, RA, or SLE, or >1 of these diseases, the risk of at least one VTE event was 19.74, 7.72, 4.90, 9.89, and 13.35 per 1,000 person-years, respectively; among the comparison group, the risk was 1.91 per 1,000 person-years. The adjusted hazard ratios (aHRs) for VTE among patients with AIHA, ITP, RA, or SLE, or >1 of these diseases (when compared with the comparison group) tended to decline over follow-up time; at 1year, the aHRs were 6.30 (95% confidence interval [CI]: 4.44-8.94), 2.95 (95% CI: 2.18-4.00), 2.13 (95% CI: 1.89-2.40), 4.68 (95% CI: 4.10-5.33), and 5.11 (95% CI: 4.26-6.14), respectively. CONCLUSION: Having AIHA, ITP, RA, or SLE, or >1 of these diseases was associated with an increased likelihood of a VTE event. More research is necessary to develop better understanding of VTE occurrence among people with autoimmune diseases.

Risk of venous thromboembolism among hospitalizations of adults with selected autoimmune diseases.

Previous research has suggested autoimmune diseases are risk factors for developing venous thromboembolism (VTE). We assessed whether having diagnoses of selected autoimmune diseases associated with antiphospholipid antibodies--autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE)--were associated with having a VTE diagnosis among US adult hospitalizations. A cross-sectional study was conducted using the 2010 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. VTE and autoimmune diseases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification coded diagnoses information. The percentages of hospitalizations with a VTE diagnosis among all non-maternal adult hospitalizations without any of the four autoimmune diseases of interest and among those with AIHA, ITP, RA, and SLE diagnoses were 2.28, 4.46, 3.35, 2.65 and 2.77%, respectively. The adjusted odds ratios (OR) for having a diagnosis of VTE among non-maternal adult hospitalizations with diagnoses of AIHA, ITP, RA, and SLE were 1.25 [95% confidence interval (CI) 1.05-1.49], 1.20 (95% CI 1.07-1.34), 1.17 (95% CI 1.13-1.21), and 1.23 (95% CI 1.15-1.32), respectively, when compared to those without the corresponding conditions. The adjusted OR for a diagnosis of VTE associated with a diagnosis of any of the four autoimmune diseases was 1.20 (95% CI 1.16-1.24). The presence of a diagnosis of AIHA, ITP, RA, and SLE was associated with an increased likelihood of having a VTE diagnosis among the group of all non-maternal adult hospitalizations.

Hospitalizations of adults ≥60 years of age with venous thromboembolism.

We assessed the rates, trends, and factors associated with venous thromboembolism (VTE) diagnosis among hospitalizations of adults ≥60 years of age during the period 2001 to 2010. Data from the National Hospital Discharge Survey were used for this study. During the period 2001 to 2010, the estimated annual number of hospitalizations in which a VTE diagnosis was recorded, among adults ≥ 60 years of age, ranged from approximately 2 70 000 in 2001 to 4 23 000 in 2010. The rate of such hospitalizations per 1 00 000 US population ≥60 years of age ranged from 581 in 2001 to 739 in 2010. During the period 2001 to 2004, there was a significant increasing trend in the rate of hospitalizations with VTE among women ≥60 years of age. The factors positively associated with an increased risk of VTE diagnosis were female sex, summer and autumn seasons (compared with spring), venous catheterization, cancer, and greater length of hospital stay.

U.S. trends in computed tomography use and diagnoses in emergency department visits by patients with symptoms suggestive of pulmonary embolism, 2001-2009.

OBJECTIVES: Using computed tomography (CT) to evaluate patients with chest symptoms is common in emergency departments (EDs). This article describes recent trends of CT use in U.S. EDs for patients presenting with symptoms common to acute pulmonary embolism (PE). METHODS: The 2001-2009 National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative survey of U.S. ED encounters, was used for data collection. Patients with at least one of three complaints (chest pain, dyspnea, or hemoptysis) were categorized into the chest symptom study (CSS) group. The yearly increases in CT use for the complaints were tabulated first, then linear regression analysis was used to calculate average rates of increases in CT use between 2001 and 2007, the years where CT use increased, for the overall population and among specific subgroups. The ratios of the number of visits when CT was ordered and there was a target diagnosis relative to the total number of visits with CT in the CSS group (diagnosis/CT ratio) were calculated for PE and pneumonia. RESULTS: Annual CT rates for the CSS group increased from 2.6% in 2001 to 13.2% in 2007, subsequently leveling off at approximately 12.5% in 2008 and 2009. The average growth rate of CT use for the CSS group was 28.1% (95% confidence interval [CI] = 20.9% to 35.7%) per year between 2001 and 2007. Testing rates for all subgroups increased. The lowest growth rate was among Hispanic patients, whose CT rates grew 14.2% (95% CI = 5.7% to 23.5%) per year. The highest growth rate was in nonurban hospitals, at 43.1% (95% CI = 15.2% to 77.8%) per year. Patients triaged as nonurgent received the fewest CTs, compared to those who should be seen in 2 hours or less. With regard to sources of payment, the self-pay subgroup experienced the highest rate of increase at 35.1% (95% CI = 18.6% to 53.9%). The PE diagnosis/CT ratio from 2002 to 2009 was 2.7% for the CSS group. The pneumonia diagnosis/CT ratio grew from 5.8% in 2002 to 2005 to 7.8% in 2006 to 2009. CONCLUSIONS: Computed tomography use in ED visits by patients with chest symptoms increased dramatically from 2001 to 2007 and seems to have leveled off in subsequent years. The low PE diagnosis-to-CT ratio suggests that EDs may need to promote evidence-based use of CT.

Clustering patterns of comorbidities associated with in-hospital death in hospitalizations of US adults with venous thromboembolism.

BACKGROUND: Venous thromboembolism (VTE) is a significant source of mortality, morbidity, disability, and impaired health-related quality of life in the world. OBJECTIVE: We aimed to evaluate the clustering patterns and associations of 29 comorbidities with in-hospital death among adult hospitalizations with a diagnosis of VTE in the United States by analyzing data from the 2009 Nationwide Inpatient Sample. METHODS: This cross-sectional study included 153,124 adult hospitalizations with a diagnosis of VTE. Adjusted rate ratios and 95% confidence intervals (CI) for in-hospital death were generated by using multivariable log-linear regression models to measure independent associations between comorbidities and in-hospital death. RESULTS: We estimated that 44,200 in-hospital deaths occurred in 2009 among 773,273 US adult hospitalizations with a diagnosis of VTE. Subgroups of hospitalizations with comorbidities of "congestive heart failure," "chronic pulmonary disease," "coagulopathy," "liver disease," "lymphoma," "fluid and electrolyte disorders," "metastatic cancer," "peripheral vascular disorders," "pulmonary circulation disorders," "renal failure," "solid tumor without metastasis," or "weight loss" were positively and independently associated with 1.07 (95% CI: 1.02-1.12 ) to 2.06 (95% CI: 1.97-2.16) times increased likelihoods of in-hospital death, when compared to those without the corresponding comorbidities. The clustering patterns of these comorbidities by 4 disease categories (i.e., "cancer," "cardiovascular/respiratory/blood," "gastrointestinal/urologic," and "nutritional/bodyweight") were associated with 2.74 to 10.28 times increased likelihoods of in-hospital death, as compared to hospitalizations without any of these comorbidities. The overall increase in the cumulative number of comorbidities corresponded to significantly elevated risks (P-trend<0.01) for in-hospital death among hospitalizations with a diagnosis of VTE. CONCLUSION: The presence of multiple comorbidities is ubiquitous among hospitalizations of adults with VTE and among in-hospital deaths with VTE in the United States. The findings of our study further suggest that, among hospitalizations of adults with VTE, the presence of certain comorbidities or clustering of these comorbidities significantly elevates the risk of in-hospital death.

Is polycystic ovary syndrome another risk factor for venous thromboembolism? United States, 2003-2008.

OBJECTIVE: We sought to determine prevalence and likelihood of venous thromboembolism (VTE) among women with and without polycystic ovary syndrome (PCOS). STUDY DESIGN: We performed a cross-sectional analysis using Thomson Reuters MarketScan Commercial databases for the years 2003 through 2008. The association between VTE and PCOS among women aged 18-45 years was assessed using age-stratified multivariable logistic regression models. RESULTS: Prevalence of VTE per 100,000 was 374.2 for PCOS women and 193.8 for women without PCOS. Compared with women without PCOS, those with PCOS were more likely to have VTE (adjusted odds ratio [aOR] 18-24 years, 3.26; 95% confidence interval [CI], 2.61-4.08; aOR 25-34 years, 2.39; 95% CI, 2.12-2.70; aOR 35-45 years, 2.05; 95% CI, 1.84-2.38). A protective association (odds ratio, 0.8; 95% CI, 0.73-0.98) with oral contraceptive use was noted for PCOS women. CONCLUSION: PCOS might be a predisposing condition for VTE, particularly among women aged 18-24 years. Oral contraceptive use might be protective.

Prevalence of polycystic ovary syndrome among the privately insured, United States, 2003-2008.

OBJECTIVE: The purpose of this study was to estimate the prevalence of polycystic ovary syndrome (PCOS) and its phenotypes as defined by the National Institutes of Health, Rotterdam criteria, and Androgen Society. STUDY DESIGN: Thomson Reuters MarketScan Commercial databases (Thomson Reuters Healthcare Inc, New York, NY) for 2003-2008 were used to calculate the prevalence of PCOS and to assess differences in demographic characteristics and comorbid conditions among women who were 18-45 years old with and without PCOS. RESULTS: The prevalence of PCOS was 1585.1 per 100,000; women with phenotype A or classic PCOS were most prevalent at 1031.5 per 100,000. Women with PCOS were more likely than those without PCOS to be 25-34 years old, be from the South, be infertile, have metabolic syndrome, have been seen by an endocrinologist, and have taken oral contraceptives. CONCLUSION: This is the first study to use all available criteria to estimate the prevalence of PCOS. Providers should evaluate women with menstrual dysfunction for the presence of PCOS.

Sickle cell disease: the need for a public health agenda.

Sickle cell disease (SCD) is a collection of inherited blood disorders that affect a substantial number of people in the U.S., particularly African Americans. People with SCD have an abnormal type of hemoglobin, Hb S, which polymerizes when deoxygenated, causing the red blood cells to become misshapen and rigid. Individuals with SCD are at higher risk of morbidity and mortality from infections, vaso-occlusive pain crises, acute chest syndrome, and other complications. Addressing the public health needs related to SCD is an important step toward improving outcomes and maintaining health for those affected by the disorder. The objective of this study was to review public health activities focusing on SCD and define the need to address it more comprehensively from a public health perspective. We found that there has been some progress in the development of SCD-related public health activities. Such activities include establishing newborn screening (NBS) for SCD with all states currently having universal NBS programs. However, additional areas needing focus include strengthening surveillance and monitoring of disease occurrence and health outcomes, enhancing adherence to health maintenance guidelines, increasing knowledge and awareness among those affected, and improving healthcare access and utilization. These and other activities discussed in this paper can help strengthen public health efforts to address SCD.

Emergency department visits made by patients with sickle cell disease: a descriptive study, 1999-2007.

BACKGROUND: Patients with sickle cell disease (SCD) often use emergency department services to obtain medical care. Limited information is available about emergency department use among patients with SCD. PURPOSE: This study assessed characteristics of emergency department visits made nationally by patients with SCD. METHODS: Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 1999-2007 were analyzed. The NHAMCS is a survey of hospital emergency department and outpatient visits. Emergency department visits by patients with SCD were identified using ICD-9-CM codes, and nationally weighted estimates were calculated. RESULTS: On average, approximately 197,333 emergency department visits were estimated to have occurred each year between 1999 and 2007 with SCD as one of the diagnoses listed. The expected source of payment was private insurance for 14%, Medicaid/State Children's Health Insurance Program for 58%, Medicare for 14%, and other/unknown for 15%. Approximately 29% of visits resulted in hospital admission; this was 37% among patients aged 0-19 years, and 26% among patients aged >/=20 years. The episode of care was indicated as a follow-up visit for 23% of the visits. Patient-cited reasons for the emergency department visit included chest pain (11%); other pain or unspecified pain (67%); fever/infection (6%); and shortness of breath/breathing problem/cough (5%), among other reasons. CONCLUSIONS: Substantial numbers of emergency department visits occur among people with SCD. The most common reason for the emergency department visits is pain symptoms. The findings of this study can help to improve health services delivery and utilization among patients with SCD.

Causes of death among women aged 10-50 years in Bangladesh, 1996-1997.

Limited information is available at the national and district levels on causes of death among women of reproductive age in Bangladesh. During 1996-1997, health-service functionaries in facilities providing obstetric and maternal and child-heath services were interviewed on their knowledge of deaths of women aged 10-50 years in the past 12 months. In addition, case reports were abstracted from medical records in facilities with in-patient services. The study covered 4,751 health facilities in Bangladesh. Of 28,998 deaths reported, 13,502 (46.6%) occurred due to medical causes, 8,562 (29.5%) due to pregnancy-related causes, 6,168 (21.3%) due to injuries, and 425 (1.5%) and 259 (0.9%) due to injuries and medical causes during pregnancy respectively. Cardiac problems (11.7%), infectious diseases (11.3%), and system disorders (9.1%) were the major medical causes of deaths. Pregnancy-associated causes included direct maternal deaths (20.1%), abortion (5.1%), and indirect maternal deaths (4.3%). The highest proportion of deaths among women aged 10-19 years was due to injuries (39.3%) with suicides accounting for 21.7%. The largest proportion of direct obstetric deaths occurred among women aged 20-29 years (30.5%). At least one quarter (24.3%) of women (n = 28,998) did not receive any treatment prior to death, and 47.8% received treatment either from a registered physician or in a facility. More focus is needed on all causes of deaths among women of reproductive age in Bangladesh.

Economic evaluation of the 7-vaccine routine childhood immunization schedule in the United States, 2001.

OBJECTIVE: To evaluate the economic impact of the routine US childhood immunization schedule: diphtheria and tetanus toxoids and acellular pertussis; tetanus and diphtheria toxoids; Haemophilus influenzae type b conjugate; inactivated poliovirus; measles, mumps, and rubella; hepatitis B; and varicella vaccines. DESIGN: Decision tree-based analysis was conducted using population-based vaccination coverage, published vaccine efficacies, historical data on disease incidence before vaccination, and disease incidence reported for 1995-2001. Costs were estimated using the direct cost and societal (direct and indirect costs) perspectives. Program costs included vaccine, administration, vaccine-associated adverse events, and parent travel and time lost. All costs were inflated to 2001 US dollars, and all costs and benefits in the future were discounted at a 3% annual rate. PARTICIPANTS: A hypothetical 2001 US birth cohort of 3,803,295 infants was followed up from birth through death. MAIN OUTCOME MEASURES: Net present value (net savings) and benefit-cost ratios of routine immunization. RESULTS: Routine childhood immunization with the 7 vaccines was cost saving from the direct cost and societal perspectives, with net savings of 9.9 billion dollars and 43.3 billion dollars, respectively. Without routine vaccination, direct and societal costs of diphtheria, tetanus, pertussis, H influenzae type b, poliomyelitis, measles, mumps, rubella, congenital rubella syndrome, hepatitis B, and varicella would be 12.3 billion dollars and 46.6 billion dollars, respectively. Direct and societal costs for the vaccination program were an estimated 2.3 billion dollars and 2.8 billion dollars, respectively. Direct and societal benefit-cost ratios for routine childhood vaccination were 5.3 and 16.5, respectively. CONCLUSION: Regardless of the perspective, the current routine childhood immunization schedule results in substantial cost savings.

Factors associated with underimmunization at 3 months of age in four medically underserved areas.

OBJECTIVE: Risk factors for underimmunization at 3 months of age are not well described. This study examines coverage rates and factors associated with under-immunization at 3 months of age in four medically underserved areas. METHODS: During 1997-1998, cross-sectional household surveys using a two-stage cluster sample design were conducted in four federally designated Health Professional Shortage Areas. Respondents were parents or caregivers of children ages 12-35 months: 847 from northern Manhattan, 843 from Detroit, 771 from San Diego, and 1,091 from rural Colorado. A child was considered up-to-date (UTD) with vaccinations at 3 months of age if documentation of receipt of diphtheria-tetanus-pertussis, polio, haemophilus influenzae type B, and hepatitis B vaccines was obtained from a provider or a hand-held vaccination card, or both. RESULTS: Household response rates ranged from 79% to 88% across sites. Vaccination coverage levels at 3 months of age varied across sites: 82.4% in northern Manhattan, 70.5% in Detroit, 82.3% in San Diego, and 75.8% in rural Colorado. Among children who were not UTD, the majority (65.7% to 71.5% per site) had missed vaccines due to missed opportunities. Factors associated with not being UTD varied by site and included having public or no insurance, >/=2 children living in the household, and the adult respondent being unmarried. At all sites, vaccination coverage among WIC enrollees was higher than coverage among children eligible for but not enrolled in WIC, but the association between UTD status and WIC enrollment was statistically significant for only one site and marginally significant for two other sites. CONCLUSIONS: Missed opportunities were a significant barrier to vaccinations, even at this early age. Practice-based strategies to reduce missed opportunities and prenatal WIC enrollment should be focused especially toward those at highest risk of underimmunization.

An economic analysis of the current universal 2-dose measles-mumps-rubella vaccination program in the United States.

To evaluate the economic impact of the current 2-dose measles-mumps-rubella (MMR) vaccination program in the United States, a decision tree-based analysis was conducted with population-based vaccination coverage and disease incidence data. All costs were estimated for a hypothetical US birth cohort of 3803295 infants born in 2001. The 2-dose MMR vaccination program was cost-saving from both the direct cost and societal perspectives compared with the absence of MMR vaccination, with net savings (net present value) from the direct cost and societal perspectives of US dollars 3.5 billion and US dollars 7.6 billion, respectively. The direct and societal benefit-cost ratios for the MMR vaccination program were 14.2 and 26.0. Analysis of the incremental benefit-cost of the second dose showed that direct and societal benefit-cost ratios were 0.31 and 0.49, respectively. Varying the proportion of vaccines purchased and administered in the public versus the private sector had little effect on the results. From both perspectives under even the most conservative assumptions, the national 2-dose MMR vaccination program is highly cost-beneficial and results in substantial cost savings.

A survey of pediatricians on the reintroduction of a rotavirus vaccine.

OBJECTIVE: Rhesus-based rotavirus tetravalent vaccine (RRV-TV; RotaShield) was withdrawn voluntarily from the market in October 1999, and recommendations for use were suspended. Rotavirus infection continues to be a significant health problem affecting children worldwide. The objective of this study was to investigate whether pediatricians would either reconsider using RRV-TV or consider other, newer, and presumably safer rotavirus vaccines if they were recommended routinely and to determine factors that influence their opinion. METHODS: A questionnaire was sent to a random sample of 250 members of the Wisconsin Chapter of the American Academy of Pediatrics (AAP) and to 437 randomly selected members of the Georgia Chapter of the AAP. Nonresponders received reminder questionnaires. RESULTS: Of the 687 pediatricians surveyed, 384 (56%) responded. Responses from 319 eligible immunization providers were included in the final analysis. Although only 15% of respondents reported that they would give RRV-TV if it were available today, 94% reported that they would use a new rotavirus vaccine if proved to be safer than RRV-TV and if recommended by the AAP and Advisory Committee on Immunization Practices for routine use among infants. Barriers to reintroducing a rotavirus vaccine were fear of adverse reactions among 95% of pediatricians, followed by potential high vaccine cost (63%) and amount of time required to educate parents (57%). CONCLUSIONS: Pediatricians reported that they would use a rotavirus vaccine if it was safer than RRV-TV and routinely recommended by the AAP and the Advisory Committee on Immunization Practices.

Comparison of e-mail, fax, and postal surveys of pediatricians.

OBJECTIVES: To compare 3 communication modes (postal, fax, and e-mail) in a rotavirus vaccine physician survey. METHODS: We used 3 communication modes to distribute a survey to physicians listed in the membership directory of the Georgia Chapter of the American Academy of Pediatrics. The directory listed 1391 members; however, 404 were deemed ineligible on the basis of their listing as a specialist, retiree, resident in training, or government public health employee. Of the 987 members expected to administer vaccines, 150 were selected randomly to receive the postal survey (postal group). Of the remaining listings, 488 (58%) of 837 listed a fax number; 150 members were selected randomly and faxed a survey (fax group). Of the remaining members, 266 (39%) of 687 had e-mail addresses listed; 150 members were selected randomly for the e-mail survey (e-mail group). A follow-up survey was sent by the same mode at 2 weeks. A final survey was sent via another mode (mixed mode) at 1 month: by fax to e-mail and postal nonresponders and by post to fax nonresponders and those without fax. RESULTS: Eligible respondents in the 3 survey groups were similar in their practice setting and location. Although the e-mail group had fewer median years (8 years) since medical school graduation than the fax group (19 years) and postal group (17 years), a similar percentage of responders in all groups had computers (>85%) and Internet access (> or =70%) at work. However, only 39% of members listed an e-mail address in the directory. In the 2 weeks after the first mailing, 39 surveys were completed via postal mail, 50 via fax, and 16 via e-mail. In the 2 weeks after the second contact (sent at 2 weeks), 20 surveys were completed via postal mail, 15 via fax, and 17 via e-mail. The response rate after the first 2 mailings was 41% (59 of 143) for postal, 47% (65 of 137) for fax, and 26% (33 of 125) for e-mail surveys. The third and final survey (sent 1 month after the first mailing) was sent by a different (ie, mixed) mode and elicited an additional 73 responses: 19 responses (15 postal, 4 fax) from the postal group, 19 responses (18 postal, 1 fax) from the fax group, and 35 responses (15 postal, 13 fax, 7 e-mail) from the e-mail group. Twenty-three percent (9 of 40) of the e-mail and 18% (15 of 83) of the fax surveys completed were returned on the same or subsequent day they were sent, compared with none of the postal surveys. There were significant differences among the 3 groups for invalid addresses/numbers (4% postal, 8% fax, and 16% e-mail) listed in the directory. Using mixed modes as the third contact, the overall response rate increased from 39% before mixed mode to a final of 53%. On the basis of the 3 initial groups, responses to 1 of 12 rotavirus questions differed significantly. CONCLUSIONS: Future use of e-mail surveys in selected circumstances is promising, because the majority of providers have Internet access and acknowledged interest in participating in e-mail surveys. E-mail surveys could be especially useful if rapid response time is necessary. There were fewer incomplete questions by participants who completed the e-mail survey compared with postal or fax participants. Updating membership e-mail addresses and routinely using e-mail as a communication tool should improve the ability to use e-mail surveys. There may need to be ongoing evaluations that critically evaluate providers' responses to e-mail surveys compared with other survey modes before e-mail surveys can become a standard survey tool. In the meantime, mixed-mode surveys may be an option.

Impact of universal Haemophilus influenzae type b vaccination starting at 2 months of age in the United States: an economic analysis.

OBJECTIVE: To evaluate the economic impact of universal Haemophilus influenzae type b (Hib) vaccination starting at 2 months of age. METHODS: Decision-tree-based analysis was conducted of a hypothetical US birth cohort of 3 815 469 infants using population-based vaccination coverage and disease incidence data. All costs were estimated from both the direct cost (medical and nonmedical) and societal perspectives. Net present value, cost-effectiveness ratios, and benefit-cost ratios of the US Hib vaccination program were evaluated. RESULTS: The results of these analyses showed that the universal vaccination program using the Hib conjugate vaccines in the United States in 2000 was cost-saving from both the direct and societal perspectives, with the benefit of the Hib vaccination program (net present value) from the direct cost and societal perspectives of $0.95 billion and $2.09 billion, respectively. Without a Hib vaccination program, the direct and societal costs of Hib invasive cases would be $1.35 billion and $2.58 billion, respectively. The direct and societal costs of the Hib vaccination program were estimated at $0.39 billion and $0.48 billion, respectively. The direct and societal benefit-cost ratios for the Hib vaccination program were 3.4 and 5.4, respectively. Varying the proportion of vaccines purchased and administered in the public versus the private sector and the proportion of combination vaccine versus monovalent vaccine administered did not have much effect on the results. CONCLUSIONS: Regardless of the perspective (direct cost or societal) and the assumptions used, the benefit-cost ratios of the US vaccination program are >1.0. Potential changes in the program, including use of more or less Hib combination vaccines, would not significantly alter the benefit-cost ratio. The national Hib vaccination program is highly cost beneficial and results in substantial cost savings.