Pneumococcal Vaccination Strategies in 50-Year-Olds to Decrease Racial Disparities: A US Societal Perspective Cost-Effectiveness Analysis.

OBJECTIVES: This study assesses the impact of expanding pneumococcal vaccination to all 50-year-olds to decrease racial disparities by estimating from the societal perspective, the cost-effectiveness of 20-valent pneumococcal conjugate vaccine (PCV20) and 15-valent conjugate vaccine followed by 23-valent polysaccharide vaccine (PCV15/PPSV23) for 50-year-olds. METHODS: A Markov model compared the cost-effectiveness of PCV20 or PCV15/PPSV23 in all general population 50- and 65-years-olds compared with current US recommendations and with no vaccination in US Black and non-Black cohorts. US data informed model parameters. Pneumococcal disease societal costs were estimated using direct and indirect costs of acute illness and of pneumococcal-related long-term disability and mortality. Hypothetical 50-year-old cohorts were followed over their lifetimes with costs and effectiveness discounted 3% per year. Deterministic and probabilistic sensitivity analyses assessed model uncertainty. RESULTS: In Black cohorts, PCV20 for all at ages 50 and 65 was the least costly strategy and had greater effectiveness than no vaccination and current recommendation strategies, whereas PCV15/PPSV23 at 50 and 65 cost more than $1 million per quality-adjusted life year (QALY) gained compared with PCV20 at 50 and 65. In non-Black cohorts, PCV20 at 50 and 65 cost $62 083/QALY and PCV15/PPSV23 at 50 and 65 cost more than $1 million/QALY with current recommendations, again being more costly and less effective. In probabilistic sensitivity analyses, PCV20 at 50 and 65 was favored in 85.7% (Black) and 61.8% (non-Black) of model iterations at a $100 000/QALY gained willingness-to-pay threshold. CONCLUSIONS: When considering the societal costs of pneumococcal disease, PCV20 at ages 50 and 65 years in the general US population is a potentially economically viable strategy, particularly in Black cohorts.

Sex and Psychosocial Differences in Acute Stress Symptoms Prior to Open-Heart Surgery.

BACKGROUND: Acute stress symptoms can occur while cardiac patients await open-heart surgery (OHS). The distress leads to poor outcomes. This study aimed to investigate the association of sex and psychosocial factors (quality-of-life and character strengths). METHOD: Our study cohort included 481 pre-OHS patients (female 42%; mean age 62 years). Medical indices/factors were obtained from the Society of Thoracic Surgeon's national database. Multiple regression analyses were performed following pre-planned steps and adjusting medical factors. RESULTS: Our findings revealed that sex differences in trauma-related symptoms were associated with poor mental well-being, alongside comorbidities. Both mental well-being and comorbidity factors were directly related to acute stress symptoms, while dispositional optimism had an inverse association with this outcome. CONCLUSION: To improve OHS outcomes, our findings suggest healthcare providers be attentive to pre-OHS acute stress symptoms, pay greater attention to the emotional well-being of their female patients, and develop supportive interventions to enhance personality strengths.

Cost-Effectiveness of Pneumococcal Vaccination and Uptake Improvement Programs in Underserved and General Population Adults Aged < 65 Years.

In US adults aged < 65 years, pneumococcal vaccination is recommended when high-risk conditions are present, but vaccine uptake is low. Additionally, there are race-based differences in illness risk and vaccination rates. The cost-effectiveness of programs to improve vaccine uptake or of alternative vaccination policies to increase protection is unclear. A decision analysis compared, in US black and general population cohorts aged 50 years, the public health impact and cost-effectiveness of pneumococcal vaccination recommendations, without and with a vaccine uptake improvement program, and alternative population vaccine policies. Program-based uptake improvement (base case: 12.3% absolute increase, costing $1.78/eligible patient) was based on clinical trial data. US data informed population-specific pneumococcal risk. Vaccine effectiveness was estimated using Delphi panel and trial data. In both black and general population cohorts, an uptake improvement program for current vaccination recommendations was favored, costing $48,621 per QALY gained in black populations ($54,929/QALY in the general population) compared to current recommendations without a program. Alternative vaccination policies largely prevented less illness and were economically unfavorable. In sensitivity analyses, uptake programs were favored, at a $100,000/QALY threshold, unless they improved absolute vaccine uptake < 2.1% in blacks or < 2.6% in the general population. Results were robust in sensitivity analyses. Programs to increase adult pneumococcal vaccination uptake are economically reasonable compared to changes in vaccination recommendations, and more favorable in underserved minorities than in the general population. If addressing race-based health disparities is a priority, evidence-based programs to increase vaccination should be considered.

Cost-effectiveness of increasing vaccination in high-risk adults aged 18-64 Years: a model-based decision analysis.

BACKGROUND: Adults aged 18-64 years with comorbid conditions are at high risk for complications of certain vaccine-preventable diseases, including influenza and pneumococcal disease. The 4 Pillars™ Practice Transformation Program (4 Pillars Program) increases uptake of pneumococcal polysaccharide vaccine, influenza vaccine and tetanus-diphtheria-acellular pertussis vaccine by 5-10% among adults with high-risk medical conditions, but its cost-effectiveness is unknown. METHODS: A decision tree model estimated the cost-effectiveness of implementing the 4 Pillars Program in primary care practices compared to no program for a population of adults 18-64 years of age at high risk of illness complications over a 10 year time horizon. Vaccination rates and intervention costs were derived from a randomized controlled cluster trial in diverse practices in 2 U.S. cities. One-way and probabilistic sensitivity analyses were conducted. RESULTS: From a third-party payer perspective, which considers direct medical costs, the 4 Pillars Program cost $28,301 per quality-adjusted life year gained; from a societal perspective, which adds direct nonmedical and indirect costs, the program was cost saving and more effective than no intervention. Cost effectiveness results favoring the program were robust in sensitivity analyses. From a public health standpoint, the model predicted that the intervention reduced influenza cases by 1.4%, with smaller decreases in pertussis and pneumococcal disease cases. CONCLUSION: The 4 Pillars Practice Transformation Program is an economically reasonable, and perhaps cost saving, strategy for protecting the health of adults aged < 65 years with high-risk medical conditions.

Using the 4 pillars™ practice transformation program to increase adult influenza vaccination and reduce missed opportunities in a randomized cluster trial.

BACKGROUND: An evidence-based, step-by-step guide, the 4 Pillars™ Practice Transformation Program, was the foundation of an intervention to increase adult immunizations in primary care and was tested in a randomized controlled cluster trial. The purpose of this study is to report changes in influenza immunization rates and on factors related to receipt of influenza vaccine. METHODS: Twenty five primary care practices were recruited in 2013, stratified by city (Houston, Pittsburgh), location (rural, urban, suburban) and type (family medicine, internal medicine), and randomized to the intervention (n = 13) or control (n = 12) in Year 1 (2013-14). A follow-up intervention occurred in Year 2 (2014-15). Demographic and vaccination data were derived from de-identified electronic medical record extractions. RESULTS: A cohort of 70,549 adults seen in their respective practices (n = 24 with 1 drop out) at least once each year was followed. Baseline mean age was 55.1 years, 35 % were men, 21 % were non-white and 35 % were Hispanic. After one year, both intervention and control arms significantly (P < 0.001) increased influenza vaccination, with average increases of 2.7 to 6.5 percentage points. In regression analyses, likelihood of influenza vaccination was significantly higher in sites with lower percentages of patients with missed opportunities (P < 0.001) and, after adjusting for missed opportunities, the intervention further improved vaccination rates in Houston (lower baseline rates) but not Pittsburgh (higher baseline rates). In the follow-up intervention, the likelihood of vaccination increased for both intervention sites and those that reduced missed opportunities (P < 0.005). CONCLUSIONS: Reducing missed opportunities across the practice increases likelihood of influenza vaccination of adults. The 4 Pillars™ Practice Transformation Program provides strategies for reducing missed opportunities to vaccinate adults. TRIAL REGISTRATION: This study was registered as a clinical trial on 03/20/2013 at ClinicalTrials.gov, Clinical Trial Registry Number: NCT01868334 , with a date of enrollment of the first participant to the trial of April 1, 2013.

Assessing the quality of a non-randomized pragmatic trial for primary prevention of falls among older adults.

Current approaches to falls prevention mostly rely on secondary and tertiary prevention and target individuals at high risk of falls. An alternative is primary prevention, in which all seniors are screened, referred as appropriate, and educated regarding falls risk. Little information is available on research designs that allow investigation of this approach in the setting of aging services delivery, where randomization may not be possible. Healthy Steps for Older Adults, a statewide program of the Pennsylvania (PA) Department of Aging, involves a combination of education about falls and screening for balance problems, with referral to personal physicians and home safety assessments. We developed a non-randomized statewide trial, Falls Free PA, to assess its effectiveness in reducing falls incidence over 12 months. We recruited 814 seniors who completed the program (503 first-time participants, 311 people repeating the program) and 1,020 who did not participate in the program, from the same sites. We assessed the quality of this non-randomized design by examining recruitment, follow-up across study groups, and comparability at baseline. Of older adults approached in senior centers, 90.5 % (n = 2,219) signed informed consent, and 1,834 (82.4 %) completed baseline assessments and were eligible for follow-up. Attrition in the three groups over 12 months was low and non-differential (<10 % for withdrawal and <2 % for other loss to follow-up). Median follow-up, which involved standardized monthly assessment of falls, was 10 months in all study groups. At baseline, the groups did not differ in measures of health or falls risk factors. Comparable status at baseline, recruitment from common sites, and similar experience with retention suggest that the non-randomized design will be effective for assessment of this approach to primary prevention of falls.

Primary prevention of falls: effectiveness of a statewide program.

OBJECTIVES: We examined a population-wide program, Pennsylvania's Healthy Steps for Older Adults (HSOA), designed to reduce the incidence of falls among older adults. Older adults completing HSOA are screened and educated regarding fall risk, and those identified as being at high risk are referred to primary care providers and home safety resources. METHODS: From 2010 to 2011, older adults who completed HSOA at various senior center sites (n = 814) and a comparison group of older adults from the same sites who did not complete the program (n = 1019) were recruited and followed monthly. Although participants were not randomly allocated to study conditions, the 2 groups did not differ in fall risk at baseline or attrition. We used a telephone interactive voice response system to ascertain the number of falls that occurred each month. RESULTS: In multivariate models, adjusted fall incidence rate ratios (IRRs) were lower in the HSOA group than in the comparison group for both total (IRR = 0.83; 95% confidence interval [CI] = 0.72, 0.96) and activity-adjusted (IRR = 0.81; 95% CI = 0.70, 0.93) months of follow-up. CONCLUSIONS: Use of existing aging services in primary prevention of falls is feasible, resulting in a 17% reduction in our sample in the rate of falls over the follow-up period.

Societal Cost of Racial Pneumococcal Disease Disparities in US Adults Aged 50 Years or Older.

OBJECTIVE: This study aimed to estimate the societal cost of racial disparities in pneumococcal disease among US adults aged ≥  50 years. METHODS: In a model-based analysis, societal costs of invasive pneumococcal disease (IPD) and hospitalized nonbacteremic pneumococcal pneumonia (NBP) were estimated using (1) direct medical costs plus indirect costs of acute illness; (2) indirect costs of pneumococcal mortality; and (3) direct and indirect costs of related disability. Disparities costs were calculated as differences in average per-person pneumococcal disease cost between Black and non-Black adults aged ≥  50 years multiplied by the Black population aged ≥  50 years. Costs were in 2019 US dollars (US$), with future costs discounted at 3% per year. RESULTS: Total direct and indirect costs per IPD case were US$186,791 in Black populations and US$182,689 in non-Black populations; total hospitalized NBP costs per case were US$100,632 (Black) and US$96,781 (non-Black). The difference in population per-person total pneumococcal disease costs between Black and non-Black adults was US$47.85. Combined societal costs of disparities for IPD and hospitalized NBP totaled US$673.2 million for Black adults aged ≥  50 years. Disease and disability risks, life expectancy, and case-fatality rates were influential in one-way sensitivity analyses, but the lowest cost across all analyses was US$194 million. The 95% probability range of racial disparity costs were US$227.2-US$1156.9 million in a probabilistic sensitivity analysis. CONCLUSIONS: US societal cost of racial pneumococcal disease disparities in persons aged ≥ 50 years is substantial. Successful pneumococcal vaccination policy and programmatic interventions to mitigate these disparities could decrease costs and improve health.

Comparing super-utilizers and lower-utilizers among commercial- and Medicare-insured adults with sickle cell disease.

ABSTRACT: Sickle cell disease (SCD) is a rare but costly condition in the United States. Super-utilizers have been defined as a subset of the population with high health care encounters or expenditures. Although super-utilizers have been described in other disease states, little is known about super-utilizers among adults with SCD. This study aimed to characterize the differences in expenditures, overall health care encounters, and pain episode encounters between super-utilizers (top 10% expenditures) and lower-utilizers with SCD (high, top 10%-24.9%; moderate, 25%-49.9%; and low, bottom 50% expenditures). A retrospective longitudinal cohort of adults with SCD were identified using validated algorithms in MarketScan and Medicare claim databases from 2016 to 2020. Encounters and expenditures were analyzed from inpatient, outpatient, and emergency department settings. Differences in encounters and expenditures between lower-utilizers and super-utilizers were compared using logistic regression. Among super-utilizers, differences in encounters and expenditures were compared according to incidences of pain episode encounters. The study population included 5666 patients with commercial insurance and 8600 with Medicare. Adjusted total annual health care expenditure was 43.46 times higher for super-utilizers than for low-utilizers among commercial-insured and 13.37 times higher in Medicare-insured patients. Among super-utilizers, there were patients with few pain episode encounters who had higher outpatient expenditures than patients with a high number of pain episode encounters. Our findings demonstrate the contribution of expensive outpatient care among SCD super-utilizers, in which analyses of high expenditure have largely focused on short-term care. Future studies are needed to better understand super-utilizers in the SCD population to inform the effective use of preventive interventions and/or curative therapies.

Cost-effectiveness of an in-development adult-formulated 21-valent pneumococcal conjugate vaccine in US adults aged 50 years or older.

Indirect effects of childhood pneumococcal conjugate vaccines (PCV) have diminished the cost-effectiveness of current adult vaccine recommendations. An in-development adult-formulated 21-valent pneumococcal conjugate vaccine (PCV21) may play a critical role in reducing pneumococcal illness by targeting a larger number of serotypes responsible for adult pneumococcal infections. This study assesses the cost-effectiveness of PCV21 in US adults aged 50 years or older compared with currently recommended pneumococcal vaccines, from both the societal and healthcare perspectives. A Markov model evaluated the lifetime cost-effectiveness of PCV21 (given at age 50 years only, at ages 50/65 years, and risk-based at ages < 65 years plus age-based at age 65 years) compared to no vaccination and to currently recommended pneumococcal vaccines given either as currently recommended or routinely at ages 50/65 years. The analysis was conducted in hypothetical Black and non-Black cohorts aged 50 years or older, with and without considering childhood pneumococcal vaccination indirect effects. Model parameters were based on US data. Parameter uncertainty was assessed using 1-way and probabilistic sensitivity analyses. From the societal perspective, PCV21 at ages 50/65 years compared to PCV21 at age 50 years cost $7,410 per quality adjusted life year (QALY) gained in Black cohort analyses and $85,696/QALY gained in the non-Black cohort; PCV21 at ages 50/65 years had the most favorable public health outcomes. From the healthcare perspective, compared to no vaccination, PCV21 at age 50 years cost $46,213/QALY gained in the Black cohort and $86,629/QALY in non-Blacks. All other strategies were dominated in both cohorts and from both perspectives. When considering childhood pneumococcal vaccination indirect effects, costs of PCV21 at ages 50/65 years remained less than $140,000/QALY gained from the societal perspective in both populations. PCV21 is potentially cost-effective compared to currently approved pneumococcal vaccines in adults aged 50 years or older from both the societal and healthcare perspectives.

Changes in the cost-effectiveness of pneumococcal vaccination and of programs to increase its uptake in U.S. older adults.

BACKGROUND: Multiple factors, such as less complex U.S. adult pneumococcal recommendations that could increase vaccination rates, childhood pneumococcal vaccination indirect effects that decrease adult vaccination impact, and increased vaccine hesitancy (particularly in underserved minorities), could diminish the cost-effectiveness of programs to increase pneumococcal vaccination in older adults. Prior analyses supported the economic favorability of these programs. METHODS: A Markov model compared no vaccination and current recommendations (either 20-valent pneumococcal conjugate vaccine [PCV20] alone or 15-valent pneumococcal conjugate vaccine plus the 23-valent pneumococcal polysaccharide vaccine [PCV15/PPSV23]) without or with programs to increase vaccine uptake in Black and non-Black 65-year-old cohorts. Pre-pandemic population- and serotype-specific pneumococcal disease risk and illness/vaccine costs came from U.S. DATABASES: Program costs were $2.19 per vaccine-eligible person and increased absolute vaccination likelihood by 7.5%. Delphi panel estimates and trial data informed vaccine effectiveness values. Analyses took a healthcare perspective, discounting at 3%/year over a lifetime time horizon. RESULTS: Uptake programs decreased pneumococcal disease overall. In Black cohorts, PCV20 without program cost $216,805 per quality-adjusted life year (QALY) gained compared with no vaccination; incremental cost-effectiveness was $245,546/QALY for PCV20 with program and $425,264/QALY for PCV15/PPSV23 with program. In non-Black cohorts, all strategies cost >$200,000/QALY gained. When considering the potential indirect effects from childhood vaccination, all strategies became less economically attractive. Increased vaccination with less complex strategies had negligible effects. In probabilistic sensitivity analyses, current recommendations with or without programs were unlikely to be favored at thresholds <$200,000/QALY gained. CONCLUSION: Current U.S. pneumococcal vaccination recommendations for older adults were unlikely to be economically reasonable with or without programs to increase vaccine uptake. Alternatives to current pneumococcal vaccines that include pneumococcal serotypes associated with adult disease should be considered.

Burden of employment loss and absenteeism in adults and caregivers of children with sickle cell disease.

ABSTRACT: Sickle cell disease (SCD) is a genetic disorder affecting 100 000 people with an estimated annual medical cost of $3 billion in the United States; however, the economic impact on patients is not well described. We aimed to examine the indirect economic burden and test the hypothesis that socioeconomic status and greater social vulnerability risks are associated with increased absenteeism and employment loss. We surveyed adults and caregivers of children with SCD at 5 US centers from 2014 to 2021. Logistic regression models were used to examine the associations of employment loss and missed days of work with demographics and social determinants. Indirect costs were estimated by multiplying the self-reported missed days of work and job loss by 2022 average wages by the state of the participating institution. Of the 244 participants, 10.3% reported employment loss in the last 5 years, and 17.5% reported missing 10 or more days of work. Adults had 3 times more employment loss compared with caregivers of children with SCD (OR, 3.18; 95% CI, 1.12-9.01) but fewer missed days of work (OR, 0.24; 95% CI, 0.11-0.0.51). Participants who did not live with a partner reported increased employment loss (OR, 4.70; 95% CI, 1.04-21.17) and more missed days of work (OR, 4.58; 95% CI, 1.04-20.15). The estimated annual indirect economic burden was $2 266 873 ($9290 per participant). Adults with SCD and caregivers of children with SCD commonly report employment loss and missed days of work as important risk factors. The high indirect economic burden suggests that future economic evaluations of SCD should include SCD-related indirect economic burden.

Psychosocial Factors Associated With Physical Activity Among Low-Income Overweight or Obese Mothers with Young Children.

PURPOSE: Investigate the associations between psychosocial factors and physical activity. DESIGN: Secondary data analysis utilizing baseline data of a large-scale community-based randomized controlled lifestyle behavior intervention. SETTING: The Special Supplemental Program for Women, Infants, and Children in Michigan, USA. SUBJECTS: Low-income overweight or obese mothers with young children (N = 740, 65% response rate). MEASURES: Survey data were collected via phone interview. Predictors included self-efficacy, autonomous motivation, emotional coping, and social support. Self-reported leisure physical activity was the outcome variable. Covariates were age, race, smoking, employment, education, body mass index, and postpartum status. ANALYSIS: A multiple linear regression model was applied. RESULTS: Self-efficacy (ß = .32, 95% CI = .11, .52, P = .003) and autonomous motivation (ß = .10, 95% CI = .03, .17, P = .005) were positively associated with physical activity. However, emotional coping and social support were not associated with physical activity. CONCLUSION: Future research should examine the longitudinal association of key psychosocial factors with physical activity.

Cost-effectiveness of an in-development adult-formulated pneumococcal vaccine in older US adults.

INTRODUCTION: CDC pneumococcal vaccination recommendations for older adults now include either 15- or 20-valent pneumococcal conjugate vaccine (PCV15/PCV20). However, an in-development 21-valent vaccine (PCV21), formulated based on adult pneumococcal disease epidemiology, could substantially increase coverage of disease-causing pneumococcal serotypes, particularly in Black older adults, who are at greater risk. The potential public health impact and cost-effectiveness of PCV21 compared to currently recommended vaccines in older adults is unclear. METHODS: A Markov decision model compared current pneumococcal vaccination recommendations to PCV21 use in Black and non-Black 65-year-old cohorts. CDC Active Bacterial Core surveillance data informed population and serotype-specific pneumococcal disease risk. Vaccine effectiveness was estimated using Delphi panel estimates and clinical trial data, with variation in sensitivity analyses. Potential indirect effects on adult disease from PCV15 childhood vaccination were examined. All model parameters were varied individually and collectively in sensitivity analyses. Scenarios with decreased PCV21 effectiveness and potential COVID-19 pandemic effects were also examined. RESULTS: In the Black cohort, the PCV21 strategy cost $88,478 per quality adjusted life-year (QALY) gained without and $97,952/QALY with childhood PCV15 indirect effects. PCV21 in the non-Black cohort cost $127,436/QALY gained without and $141,358/QALY with childhood PCV15 effects. Current recommendation strategies were economically unfavorable, regardless of population or indirect childhood vaccination effects. Results favoring PCV21 use were robust in sensitivity analyses and alternative scenarios. CONCLUSION: An in-development PCV21 vaccine would likely be economically and clinically favorable compared to currently recommended pneumococcal vaccines in older adults. While PCV21 was more favorable in Black cohort analyses, results for both Black and non-Black populations were economically reasonable, highlighting the potential importance of adult-specific pneumococcal vaccine formulations and, pending further investigation, potentially justifying a future general population recommendation for PCV21 use in older adults.

The association between cardiovascular disease and breast and gynecologic cancers among black female patients.

INTRODUCTION: Little is known about whether a breast or gynecologic cancer diagnosis increases long-term cardiovascular disease (CVD) risk among Black females. The purpose of this study was to determine whether a breast or gynecologic cancer diagnosis is associated with CVD risk and identify determinants of subsequent CVD risk among Black females with an incident breast or gynecologic cancer diagnosis. METHODS: Using the Southern Community Cohort Study data from 2002-2016, this study was designed to analyze CVD incidence among Black females without cancer or CVD at enrollment. Cox proportional hazards regression models with or without covariates were used to explore the relationship between a breast or gynecologic cancer diagnosis and CVD risk among women without cancer as well as without CVD at enrollment (N=11,486). In addition, Cox proportional hazards regression models, excluding those who developed CVD before breast and gynecologic cancer diagnosis and those with other types of cancers, were used to assess determinants of CVD risk among breast and gynecologic cancer survivors. RESULTS: Of 11,486 Black females, 531 developed a breast or gynecological cancer (4.6%) over a median follow-up of 140 months (interquartile range: 123-159 months). Compared to women without cancer, women with a breast or gynecological cancers had greater than 20% higher risk of incident CVD during the follow-up period. Without adjusting for covariates, positive association between CVD risk and breast cancer was observed (hazard ratio (HR) = 1.24; 95% confidence interval (CI) = 1.11 - 1.39; p < 0.001); as well as between CVD risk and a gynecological cancer (HR = 1.23; 95% CI = 1.03 - 1.46; p = 0.021). Yet, after adjusting for covariates, CVD risk was only significantly associated with breast cancer (p = 0.001) but not gynecologic cancer. In cancer case-only analyses, CVD risk was significantly increasing with age (p < 0.05). CONCLUSIONS: Like study populations of predominantly White females, our results suggest that, adjusting for covariates, Black females possess a higher risk of CVD following a breast cancer diagnosis compared to women who did not develop breast cancer. Our results suggest a need for active CVD surveillance in the cancer survivorship phase.

Preparedness for pandemics: does variation among states affect the nation as a whole?

OBJECTIVE: Since states' public health systems differ as to pandemic preparedness, this study explored whether such heterogeneity among states could affect the nation's overall influenza rate. DESIGN: The Centers for Disease Control and Prevention produced a uniform set of scores on a 100-point scale from its 2008 national evaluation of state preparedness to distribute materiel from the Strategic National Stockpile (SNS). This study used these SNS scores to represent each state's relative preparedness to distribute influenza vaccine in a timely manner and assumed that "optimal" vaccine distribution would reach at least 35% of the state's population within 4 weeks. The scores were used to determine the timing of vaccine distribution for each state: each 10-point decrement of score below 90 added an additional delay increment to the distribution time. SETTING AND PARTICIPANTS: A large-scale agent-based computational model simulated an influenza pandemic in the US population. In this synthetic population each individual or agent had an assigned household, age, workplace or school destination, daily commute, and domestic intercity air travel patterns. MAIN OUTCOME MEASURES: Simulations compared influenza case rates both nationally and at the state level under 3 scenarios: no vaccine distribution (baseline), optimal vaccine distribution in all states, and vaccine distribution time modified according to state-specific SNS score. RESULTS: Between optimal and SNS-modified scenarios, attack rates rose not only in low-scoring states but also in high-scoring states, demonstrating an interstate spread of infections. Influenza rates were sensitive to variation of the SNS-modified scenario (delay increments of 1 day versus 5 days), but the interstate effect remained. CONCLUSIONS: The effectiveness of a response activity such as vaccine distribution could benefit from national standards and preparedness funding allocated in part to minimize interstate disparities.

Factors Associated with Home Food Environment in Low-Income Overweight or Obese Pregnant Women.

Limited research has examined factors associated with home food availability. This study investigated the associations among demographics, body mass index category, stress, and home food availability among low-income overweight or obese pregnant women. This cross-sectional study enrolled 332 participants who were non-Hispanic black or white. We performed logistic regression modeling for unprocessed food, processed food, overall ultra-processed food, and three subcategories of ultra-processed food (salty snacks, sweet snacks and candies, and soda). Black women were less likely than white women to have large amounts of processed foods (OR = 0.56), salty snacks (OR = 0.61), and soda (OR = 0.49) available at home. Women with at least some college education or at least a college education were more likely to have large amounts of unprocessed food (OR = 2.58, OR = 4.38 respectively) but less likely to have large amounts of soda (OR = 0.44; OR = 0.22 respectively) available at home than their counterparts. Women with higher stress were less likely to have large amounts of unprocessed food available at home (OR = 0.58) than those with lower stress. Home food availability varied by race, education, and levels of stress in low-income overweight or obese pregnant women.

Factors Associated with Beverage Intake in Low-Income, Overweight, or Obese Pregnant Women.

This study examined consumption proportions and factors associated with sugar-sweetened beverages (SSBs), artificially sweetened beverages (ASBs), and 100% fruit juice (FJ) consumption. We recruited Non-Hispanic Black (n = 136) and White (n = 192) low-income overweight or obese pregnant women aged 18 to 46 years (mean = 25.7 years) from the Special Supplemental Nutrition Program for Women, Infants, and Children clinics in Michigan, USA. Independent variables included weight status, trimester, smoking, stress, education, employment, race, and age. Dependent variables were high (consuming ≥ 1 serving/day) versus low consumptions of SSB, ASB, and 100% FJ. Multivariate logistic regression modeling was performed to examine factors associated with beverage consumption. Out of the sample, 48.2%, 6.7%, and 31.3% reported high SSB, ASB, and 100% FJ consumption, respectively. SSB consumption was associated with smoking (OR: 3.77, p < 0.001), education (OR: 0.57, p = 0.03), and race (OR: 1.69, p = 0.03). Artificially sweetened beverage consumption was not associated with any factors examined. One hundred percent FJ consumption was associated with stress (OR: 0.90, p = 0.03) and race (OR: 4.48, p < 0.001). Clinicians may advocate for reductions in SSB and 100% FJ consumption tailored to client consumption characteristics.

Cost-effectiveness of revised US pneumococcal vaccination recommendations in underserved minority adults < 65-years-old.

BACKGROUND: The 15- and 20-valent pneumococcal conjugate vaccines (PCV15/PCV20) were recently recommended for US adults, giving either PCV20 alone or PCV15 followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) to all 65 + -year-olds and to high-risk younger adults. However, general population recommendations to vaccinate all 50-year-olds could reduce racial pneumococcal disease disparities given greater risk in underserved minority populations. METHODS: A Markov model examining hypothetical 50-year-old Black cohorts (serving as a proxy for underserved minorities) and non-Black cohorts estimated the incremental cost effectiveness of US adult pneumococcal vaccination recommendations compared to PCV20 or PCV15/PPSV23 for all 50-year-olds with no vaccination thereafter, or PCV20 or PCV15/PPSV23 for all at ages 50 and 65 years (50/65). Model parameters came from US databases, clinical trials, and Delphi panels. Cohorts were followed over their lifetimes from a healthcare perspective discounted at 3 %/year. RESULTS: PCV15/PPSV23 given at ages 50/65 had greatest public health impact. In Black cohorts, PCV15/PPSV23 at age 50 cost $104,723/quality adjusted life year (QALY) gained compared to PCV20 at age 50, while PCV15/PPSV23 at 50/65 cost $240,952/QALY gained compared to PCV15/PPSV23 at age 50. Both current recommendation options were more expensive and less effective than other strategies in both cohorts. In sensitivity analyses, age-based PCV20 or PCV15/PPSV23 use at ages 50 or 50/65 could be favorable depending on vaccine effectiveness or differential vaccine uptake, while current recommendations remained unfavorable. CONCLUSION: Recent risk-based US adult pneumococcal vaccination recommendations for adults < 65-years-old, were economically and clinically unfavorable compared to general population vaccination of all 50-year-olds in Black and non-Black cohorts. An age-based pneumococcal vaccination recommendation at age 50 years may reduce inequities in pneumococcal disease burden.

Cost-Effectiveness of Newly Recommended Pneumococcal Vaccination Strategies in Older Underserved Minority Adults in the USA.

INTRODUCTION: US pneumococcal vaccination recommendations for adults aged 65 years or older recently changed, with options for either 20-valent pneumococcal conjugate vaccine (PCV20) or the combination of 15-valent conjugate vaccine (PCV15) followed by 23-valent polysaccharide vaccine (PPSV23) 1 year later. Underserved minority adults are at higher risk for pneumococcal disease. METHODS: A Markov decision analysis model estimated the incremental cost-effectiveness of the newly adopted general population pneumococcal vaccination strategies in older underserved minority adults. The model examined hypothetical 65-year-old US Black cohorts (serving as a proxy for underserved minorities) and non-Black cohorts receiving PCV20 or PCV15/PPSV23, or no vaccination. Main outcome measures included incremental cost-effectiveness per quality-adjusted life year (QALY) gained and pneumococcal disease public health outcomes. RESULTS: Black cohorts had a greater risk of pneumococcal disease hospitalization compared to non-Black cohorts. In Black cohorts, total per person PCV20 strategy costs, compared to no vaccination, were $124 higher while gaining 0.00073 QALY, or $169,540/QALY gained. PCV15/PPSV23 cost $535,797/QALY compared to PCV20. In the non-Black cohort, PCV20 cost $210,529/QALY gained compared to no vaccination and PCV15/PPSV23 cost $728,423/QALY. Plausible variation of vaccine effectiveness minimally affected PCV20 strategy results and made PCV15/PPSV23 more unfavorable. In scenarios where the simpler one-vaccine PCV20 strategy increased absolute vaccine uptake by 10%, PCV20 cost-effectiveness changed minimally while PCV15/PPSV23 cost in excess of $6 million/QALY in the Black cohort. In probabilistic sensitivity analyses that varied all parameters simultaneously, PCV15/PPSV23 was unlikely to be favored at thresholds less than $500,000/QALY gained. CONCLUSION: General population recommendations for PCV20 use are substantially more economically reasonable in Black and non-Black older adult populations than PCV15/PPSV23. If using a single vaccine increases uptake, which is potentially more likely in the underserved, then PCV20 use becomes even more favorable.