Assessment of the Costs of Implementing COVID-19 Vaccination Clinics in 34 Sites, United States, March 2021.

OBJECTIVES: To estimate the costs to implement public health department (PHD)-run COVID-19 vaccination clinics. DESIGN: Retrospectively reported data on COVID-19 vaccination clinic characteristics and resources used during a high-demand day in March 2021. These resources were combined with national average wages, supply costs, and facility costs to estimate the operational cost and start-up cost of clinics. SETTING: Thirty-four PHD-run COVID-19 vaccination clinics across 8 states and 1 metropolitan statistical area. PARTICIPANTS: Clinic managers at 34 PHD-run COVID-19 vaccination clinics. INTERVENTION: Large-scale COVID-19 vaccination clinics were implemented by public health agencies as part of the pandemic response. MAIN OUTCOMES MEASURED: Operational cost per day, operational cost per vaccination, start-up cost per clinic. RESULTS: Median operational cost per day for a clinic was $10 314 (range, $637-$95 163) and median cost per vaccination was $38 (range, $9-$206). There was a large range of operational costs across clinics. Clinics used an average of 99 total staff hours per 100 patients vaccinated. Median start-up cost per clinic was $15 348 (range, $1 409-$165 190). CONCLUSIONS: Results show that clinics require a large range of resources to meet the high throughput needs of the COVID-19 pandemic response. Estimating the costs of PHD-run vaccination clinics for the pandemic response is essential for ensuring that resources are available for clinic success. If clinics are not adequately supported, they may stop functioning, which would slow the pandemic response if no other setting or approach is possible.

The cost-effectiveness of using chronic kidney disease risk scores to screen for early-stage chronic kidney disease.

BACKGROUND: Better treatment during early stages of chronic kidney disease (CKD) may slow progression to end-stage renal disease and decrease associated complications and medical costs. Achieving early treatment of CKD is challenging, however, because a large fraction of persons with CKD are unaware of having this disease. Screening for CKD is one important method for increasing awareness. We examined the cost-effectiveness of identifying persons for early-stage CKD screening (i.e., screening for moderate albuminuria) using published CKD risk scores. METHODS: We used the CKD Health Policy Model, a micro-simulation model, to simulate the cost-effectiveness of using CKD two published risk scores by Bang et al. and Kshirsagar et al. to identify persons in the US for CKD screening with testing for albuminuria. Alternative risk score thresholds were tested (0.20, 0.15, 0.10, 0.05, and 0.02) above which persons were assigned to receive screening at alternative intervals (1-, 2-, and 5-year) for follow-up screening if the first screening was negative. We examined incremental cost-effectiveness ratios (ICERs), incremental lifetime costs divided by incremental lifetime QALYs, relative to the next higher screening threshold to assess cost-effectiveness. Cost-effective scenarios were determined as those with ICERs less than $50,000 per QALY. Among the cost-effective scenarios, the optimal scenario was determined as the one that resulted in the highest lifetime QALYs. RESULTS: ICERs ranged from $8,823 per QALY to $124,626 per QALY for the Bang et al. risk score and $6,342 per QALY to $405,861 per QALY for the Kshirsagar et al. risk score. The Bang et al. risk score with a threshold of 0.02 and 2-year follow-up screening was found to be optimal because it had an ICER less than $50,000 per QALY and resulted in the highest lifetime QALYs. CONCLUSIONS: This study indicates that using these CKD risk scores may allow clinicians to cost-effectively identify a broader population for CKD screening with testing for albuminuria and potentially detect people with CKD at earlier stages of the disease than current approaches of screening only persons with diabetes or hypertension.

The future burden of CKD in the United States: a simulation model for the CDC CKD Initiative.

BACKGROUND: Awareness of chronic kidney disease (CKD), defined by kidney damage or reduced glomerular filtration rate, remains low in the United States, and few estimates of its future burden exist. STUDY DESIGN: We used the CKD Health Policy Model to simulate the residual lifetime incidence of CKD and project the prevalence of CKD in 2020 and 2030. The simulation sample was based on nationally representative data from the 1999 to 2010 National Health and Nutrition Examination Surveys. SETTING & POPULATION: Current US population. MODEL, PERSPECTIVE, & TIMELINE: Simulation model following up individuals from current age through death or age 90 years. OUTCOMES: Residual lifetime incidence represents the projected percentage of persons who will develop new CKD during their lifetimes. Future prevalence is projected for 2020 and 2030. MEASUREMENTS: Development and progression of CKD are based on annual decrements in estimated glomerular filtration rates that depend on age and risk factors. RESULTS: For US adults aged 30 to 49, 50 to 64, and 65 years or older with no CKD at baseline, the residual lifetime incidences of CKD are 54%, 52%, and 42%, respectively. The prevalence of CKD in adults 30 years or older is projected to increase from 13.2% currently to 14.4% in 2020 and 16.7% in 2030. LIMITATIONS: Due to limited data, our simulation model estimates are based on assumptions about annual decrements in estimated glomerular filtration rates. CONCLUSIONS: For an individual, lifetime risk of CKD is high, with more than half the US adults aged 30 to 64 years likely to develop CKD. Knowing the lifetime incidence of CKD may raise individuals' awareness and encourage them to take steps to prevent CKD. From a national burden perspective, we estimate that the population prevalence of CKD will increase in coming decades, suggesting that development of interventions to slow CKD onset and progression should be considered.

Patient flow time data of COVID-19 vaccination clinics in 23 sites, United States, April and May 2021.

INTRODUCTION: Public health department (PHD) led COVID-19 vaccination clinics can be a critical component of pandemic response as they facilitate high volume of vaccination. However, few patient-time analyses examining patient throughput at mass vaccination clinics with unique COVID-19 vaccination challenges have been published. METHODS: During April and May of 2021, 521 patients in 23 COVID-19 vaccination sites counties of 6 states were followed to measure the time spent from entry to vaccination. The total time was summarized and tabulated by clinic characteristics. A multivariate linear regression analysis was conducted to evaluate the association between vaccination clinic settings and patient waiting times in the clinic. RESULTS: The average time a patient spent in the clinic from entry to vaccination was 9 min 5 s (range: 02:00-23:39). Longer patient flow times were observed in clinics with higher numbers of doses administered, 6 or fewer vaccinators, walk-in patients accepted, dedicated services for people with disabilities, and drive-through clinics. The multivariate linear regression showed that longer patient waiting times were significantly associated with the number of vaccine doses administered, dedicated services for people with disabilities, the availability of more than one brand of vaccine, and rurality. CONCLUSIONS: Given the standardized procedures outlined by immunization guidelines, reducing the wait time is critical in lowering the patient flow time by relieving the bottleneck effect in the clinic. Our study suggests enhancing the efficiency of PHD-led vaccination clinics by preparing vaccinators to provide vaccines with proper and timely support such as training or delivering necessary supplies and paperwork to the vaccinators. In addition, patient wait time can be spent answering questions about vaccination or reviewing educational materials on other public health services.

Evaluation of a Pharmacists' Patient Care Process Approach for Hypertension.

INTRODUCTION: An estimated 116 million American adults (47.3%) have hypertension. Most adults with hypertension do not have it controlled-3 in 4 (92.1 million) U.S. adults with hypertension have a blood pressure ≥130/80 mmHg. The Pharmacists' Patient Care Process is a standardized patient-centered approach to the provision of pharmacist care that is done in collaboration with other healthcare providers. Through the Michigan Medicine Hypertension Pharmacists' Program, pharmacists use the Pharmacists' Patient Care Process to provide hypertension management services in collaboration with physicians in primary care and community pharmacy settings. In 2019, the impact of Michigan Medicine Hypertension Pharmacists' Program patient participation on blood pressure control was evaluated. METHODS: Propensity scoring was used to match patients in the intervention group with patients in the comparison group and regression analyses were then conducted to compare the 2 groups on key patient outcomes. Negative binomial regression was used to examine the number of days with blood pressure under control. The findings presented in this brief are part of a larger multimethod evaluation. RESULTS: More patients in the intervention group than in the comparison group achieved blood pressure control at 3 months (66.3% vs 42.4%) and 6 months (69.1% vs 56.5%). The intervention group experienced more days with blood pressure under control within a 3-month (18.6 vs 9.5 days) and 6-month period (57.0 vs 37.4 days) than the comparison group did. CONCLUSIONS: Findings support the effectiveness of the Michigan Medicine Hypertension Pharmacists' Program approach to implementing the Pharmacists' Patient Care Process to improve blood pressure control.

Modeling the impact of obesity on the lifetime risk of chronic kidney disease in the United States using updated estimates of GFR progression from the CRIC study.

RATIONALE & OBJECTIVE: As the prevalence of obesity continues to rise in the United States, it is important to understand its impact on the lifetime risk of chronic kidney disease (CKD). STUDY DESIGN: The CKD Health Policy Model was used to simulate the lifetime risk of CKD for those with and without obesity at baseline. Model structure was updated for glomerular filtration rate (GFR) decline to incorporate new longitudinal data from the Chronic Renal Insufficiency Cohort (CRIC) study. SETTING AND POPULATION: The updated model was populated with a nationally representative cohort from National Health and Nutrition Examination Survey (NHANES). OUTCOMES: Lifetime risk of CKD, highest stage and any stage. MODEL, PERSPECTIVE, & TIMEFRAME: Simulation model following up individuals from current age through death or age 90 years. RESULTS: Lifetime risk of any CKD stage was 32.5% (95% CI 28.6%-36.3%) for persons with normal weight, 37.6% (95% CI 33.5%-41.7%) for persons who were overweight, and 41.0% (95% CI 36.7%-45.3%) for persons with obesity at baseline. The difference between persons with normal weight and persons with obesity at baseline was statistically significant (p<0.01). Lifetime risk of CKD stages 4 and 5 was higher for persons with obesity at baseline (Stage 4: 2.1%, 95% CI 0.9%-3.3%; stage 5: 0.6%, 95% CI 0.0%-1.1%), but the differences were not statistically significant (stage 4: p = 0.08; stage 5: p = 0.23). LIMITATIONS: Due to limited data, our simulation model estimates are based on assumptions about the causal pathways from obesity to CKD, diabetes, and hypertension. CONCLUSIONS: The results of this study indicate that obesity may have a large impact on the lifetime risk of CKD. This is important information for policymakers seeking to set priorities and targets for CKD prevention and treatment.

The Cost-Effectiveness of Anemia Treatment for Persons with Chronic Kidney Disease.

BACKGROUND: Although major guidelines uniformly recommend iron supplementation and erythropoietin stimulating agents (ESAs) for managing chronic anemia in persons with chronic kidney disease (CKD), there are differences in the recommended hemoglobin (Hb) treatment target and no guidelines consider the costs or cost-effectiveness of treatment. In this study, we explored the most cost-effective Hb target for anemia treatment in persons with CKD stages 3-4. METHODS AND FINDINGS: The CKD Health Policy Model was populated with a synthetic cohort of persons over age 30 with prevalent CKD stages 3-4 (i.e., not on dialysis) and anemia created from the 1999-2010 National Health and Nutrition Examination Survey. Incremental cost-effectiveness ratios (ICERs), computed as incremental cost divided by incremental quality adjusted life years (QALYs), were assessed for Hb targets of 10 g/dl to 13 g/dl at 0.5 g/dl increments. Targeting a Hb of 10 g/dl resulted in an ICER of $32,111 compared with no treatment and targeting a Hb of 10.5 g/dl resulted in an ICER of $32,475 compared with a Hb target of 10 g/dl. QALYs increased to 4.63 for a Hb target of 10 g/dl and to 4.75 for a target of 10.5 g/dl or 11 g/dl. Any treatment target above 11 g/dl increased medical costs and decreased QALYs. CONCLUSIONS: In persons over age 30 with CKD stages 3-4, anemia treatment is most cost-effective when targeting a Hb level of 10.5 g/dl. This study provides important information for framing guidelines related to treatment of anemia in persons with CKD.

Predicting the health effects of switching infant feeding practices for use in decision-making.

Research has been plentiful to show pediatricians and public health practitioners the importance of exclusive breastfeeding for infant health. However, this past research is lacking in a few ways that are important for pediatricians and public health practitioners: it rarely examines broad geographies, and so cannot be generalized for different countries, it does not quantify the predicted effects of infant feeding, and it does not examine the effects of a range of feeding practices on infant health, instead focusing solely on exclusive breastfeeding. The present research simulates the effect on infant health of switching between a range of feeding practices using data from many countries. The results provide quantified estimates of the effect of switching between specific feeding practices such as exclusive breastfeeding, breastfeeding supplemented with milk liquids, or breastfeeding supplemented with solid foods and nonmilk liquids, as well as others. These quantified estimates of the effect of switching infant feeding practices can be used by pediatricians to motivate individual decisions about infant feeding and by public health practitioners and policymakers to motivate infant feeding programs and policy. Through these channels, they can hopefully play a role in improving infant health.

Associations between Infant Feeding Practices and Length, Weight, and Disease in Developing Countries.

The health benefits of exclusive breastfeeding are well-known, but the relative detrimental impacts of other foods on infant health are unknown. Because infants in developing countries are fed a wide range of food, quantifying the burden of these diverse feeding practices on infant health is essential for public health policy. We used data from the Demographic Health Survey from 20 developing countries over multiple years to examine the independent association of six different types of food (exclusive breastfeeding, non-exclusive breastfeeding, infant formula, milk liquids, non-milk liquids, and solid foods) with five measures of infant health (length, weight, diarrhea, fever, and cough). We estimated associations with regression analysis, controlling for confounding factors with infant, mother, and household factors and community-year fixed effects. We used these estimates in a simulation model to quantify the burden of different combinations of food on infant health. We show that for an infant younger than 6 months old, following current guidelines and exclusively breastfeeding instead of giving the infant solid foods may increase length by 0.75 cm and weight by 0.25 kg and decrease diarrhea, fever, and cough prevalence by 8, 12, and 11%, respectively. We found that the burden on infant health of some feeding practices is less than others. Although all other feeding practices are associated with worse health outcomes than exclusive breastfeeding, breastfeeding supplemented with liquids has a lower burden on infant health than solid foods and infant formula has a lower burden than milk or non-milk liquids as measured by four of five health metrics. Providing specific quantified burden estimates of these practices can help inform public health policy related to infant feeding practices.