Julia Driessen

Reassessing the value of vaccines

In May, 1974, WHO launched the Expanded Programme on Immunization—the global programme to immunise children worldwide with a set of (at the time) six core vaccines. 40 years on, the GAVI Alliance has brought us together, a group of 29 leading technical experts in health and development economics, cognitive development, epidemiology, disease burden, and economic modelling to review and understand the broader outcomes of vaccines beyond morbidity and mortality, to identify research opportunities, and to create a research agenda that will help to further quantify the value of this eff ect. What is the value of immunising every child with all 11 vaccines that WHO now recommends, 1 beyond the prevention of illness and death? The full benefi ts of childhood vaccination could reach well into a childs life, through adulthood, into the wider community, and, ultimately, the national economy. 2 Some evidence of these benefi ts has already been generated, but gaps in knowledge remain. For example, preliminary research suggests that a 5-year improvement in life expectancy can translate into 0·3–0·5% more annual growth added to income per head. 3 Similarly, results of research done in Bangladesh show that the benefi ts of antibodies from maternal tetanus vaccinations passing from a mother to her unborn child can lead to gains of about 0·25 years of schooling for children whose parents did not attend school. 4 And fi ndings from the Philippines showed that vaccinations induced improvements in test scores in children, 5 which had a return on investment as high as 21% when translated into the earning gains of adults. 6 Meanwhile in South Africa, researchers have shown a signifi cant association between coverage of measles vaccination and the level of school-grade attainment in sibling-pairs, after controlling for intrinsic factors such as birth order, education levels of parents, and household wealth. 7 This research suggests that, on average, 1 year of schooling is gained for every six children vaccinated against measles. But evidence to link health inputs and wealth outcomes needs to be further assessed and investigated. Vaccines are usually given when the rate of brain development is at its peak, which can benefi t cognitive development through prevention of illness and its neurological complications (eg, encephalitis). But so far, the only evidence for this model is based on observational studies; such studies are an important fi rst step, but more work is needed. Similarly, evidence for the positive …

Effect of Multiple Pharmacy Use on Medication Adherence and Drug–Drug Interactions in Older Adults with Medicare Part D

To assess the association between multiple pharmacy use and medication adherence and potential drug–drug interactions (DDIs) in older adults.

Modeling return on investment for an electronic medical record system in Lilongwe, Malawi

Objective To model the financial effects of implementing a hospital-wide electronic medical record (EMR) system in a tertiary facility in Malawi. Materials and Methods We evaluated three areas of impact: length of stay, transcription time, and laboratory use. We collected data on expenditures in these categories under the paper-based (pre-EMR) system, and then estimated reductions in each category based on findings from EMR systems in the USA and backed by ambulatory data from low-income settings. We compared these potential savings accrued over a period of 5 years with the costs of implementing the touchscreen point-of-care EMR system at that site. Results Estimated cost savings in length of stay, transcription time, and laboratory use totaled US

Nursing Home Provider Perceptions of Telemedicine for Reducing Potentially Avoidable Hospitalizations

284 395 annually. When compared with the costs of installing and sustaining the EMR system, there is a net financial gain by the third year of operation. Over 5 years the estimated net benefit was US

Health inequalities and development plans in Iran; an analysis of the past three decades (1984–2010)

613 681. Discussion Despite considering only three categories of savings, this analysis demonstrates the potential financial benefits of EMR systems in low-income settings. The results are robust to higher discount rates, and a net benefit is realized even under more conservative assumptions. Conclusions This model demonstrates that financial benefits could be realized with an EMR system in a low-income setting. Further studies will examine these and other categories in greater detail, study the financial effects at different levels of organization, and benefit from post-implementation data. This model will be further improved by substituting its assumptions for evidence as we conduct more detailed studies.

Trends in Off-Label Use of Second-Generation Antipsychotics in the Medicare Population From 2006 to 2012

OBJECTIVE Potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents are common, costly, and can have significant economic consequences. Telemedicine has been shown to reduce emergency department and hospitalization of NH residents, yet adoption has been limited and little is known about providers perceptions and desired functionality for a telemedicine program. The goal of this study was to survey a nationally representative sample of NH physicians and advanced practice providers to quantify provider perceptions and desired functionality of telemedicine in NHs to reduce PAHs. DESIGN/SETTING/PARTICIPANTS/MEASUREMENT We surveyed physicians and advanced practice providers who attended the 2015 AMDA-The Society for Post-Acute and Long-Term Care Medicine Annual Conference about their perceptions of telemedicine and desired attributes of a telemedicine program for managing acute changes of condition associated with PAHs. RESULTS We received surveys from 435 of the 947 conference attendees for a 45.9% response rate. Providers indicated strong agreement with the potential for telemedicine to improve timeliness of care and fill existing service gaps, while disagreeing most with the ideas that telemedicine would reduce care effectiveness and jeopardize resident privacy. Responses indicated clear preferences for the technical requirements of such a program, such as high-quality audio and video and inclusion of an electronic stethoscope, but with varying opinions about who should be performing the consults. CONCLUSION Among NH providers, there is a high degree of confidence in the potential for a telemedicine solution to PAHs in NHs, as well as concrete views about features of such a solution. Such consensus could be used to drive an approach to telemedicine for PAHs in NHs that retains the theoretical strengths of telemedicine and reflects the needs of facilities, providers, and patients. Further research is needed to objectively study the impact of successful telemedicine implementations on patient, provider, and economic outcomes.

Understanding and valuing the broader health system benefits of Uganda’s national Human Resources for Health Information System investment

IntroductionReducing inequalities in health care is one of the main challenges in all countries. In Iran as in other oil-exporting upper middle income countries, we expected to witness fewer inequalities especially in the health sector with the increase in governmental revenues.MethodsThis study presents an inequalities assessment of health care expenditures in Iran. We used data from the Household Income and Expenditure Survey (HIES) in Iran from 1984–2010. The analysis included 308,735 urban and 342,532 rural households.ResultsThe results suggest heightened inequality in health care expenditures in Iran over the past three decades, including an increase in the gap between urban and rural areas. Furthermore, inflation has affected the poor more than the rich. The Kakwani progressivity index in all years is positive, averaging 0.436 in rural and 0.470 in urban areas during the time period of analysis. Compared to inequality in income distribution over the last 30 years, health expenditures continuously show more inequality and progressivity over the same period of time.ConclusionsAccording to the result of our study, during this period Iran introduced four National Development Plans (NDPs); however, the NDPs failed to provide sustainable strategies for reducing inequalities in health care expenditures. Policies that protect vulnerable groups should be prioritized.

The effect of childhood measles vaccination on school enrolment in Matlab, Bangladesh

OBJECTIVE The study evaluated trends in the off-label use of second-generation antipsychotics in the Medicare population, a practice that has been identified as lacking adequate supporting evidence for many indications. METHODS Medicare claims data from 2006 to 2012 were used to identify beneficiaries who filled at least one prescription for any second-generation antipsychotic. Any use that was not associated with a medical claim for an approved indication in a given year was classified as off-label use. Rates of off-label use and of diagnoses associated with off-label use were compared over time. Fill counts standardized for 30-day supply and costs were compared by type of use. RESULTS On the basis of a sample of 490,314 patient-years, the rate of off-label use among beneficiaries prescribed a second-generation antipsychotic declined from 51% to 45%. Fill counts were 16% lower for off-label users compared with on-label users. Off-label users had higher out-of-pocket costs but lower total costs for second-generation antipsychotics. Off-label users most commonly had claims related to dementia, minor depression, anxiety disorders, and other psychosis. The proportion of off-label users without any claims for the most common off-label uses of second-generation antipsychotics declined from 45% in 2006 to 30% in 2012. CONCLUSIONS Off-label use of second-generation antipsychotics has declined, especially among persons without any of the common off-label conditions. The diagnoses accompanying off-label use did not systematically reflect changes in the evidence base for the use of these drugs, suggesting a mismatch between evidence supporting the use of off-label second-generation antipsychotics and prescribing practices.

Perceived Benefits, Barriers, and Drivers of Telemedicine From the Perspective of Skilled Nursing Facility Administrative Staff Stakeholders

BackgroundTo address the need for timely and comprehensive human resources for health (HRH) information, governments and organizations have been actively investing in electronic health information interventions, including in low-resource settings. The economics of human resources information systems (HRISs) in low-resource settings are not well understood, however, and warrant investigation and validation.Case descriptionThis case study describes Uganda’s Human Resources for Health Information System (HRHIS), implemented with support from the US Agency for International Development, and documents perceptions of its impact on the health labour market against the backdrop of the costs of implementation. Through interviews with end users and implementers in six different settings, we document pre-implementation data challenges and consider how the HRHIS has been perceived to affect human resources decision-making and the healthcare employment environment.Discussion and evaluationThis multisite case study documented a range of perceived benefits of Uganda’s HRHIS through interviews with end users that sought to capture the baseline (or pre-implementation) state of affairs, the perceived impact of the HRHIS and the monetary value associated with each benefit. In general, the system appears to be strengthening both demand for health workers (through improved awareness of staffing patterns) and supply (by improving licensing, recruitment and competency of the health workforce). This heightened ability to identify high-value employees makes the health sector more competitive for high-quality workers, and this elevation of the health workforce also has broader implications for health system performance and population health.ConclusionsOverall, it is clear that HRHIS end users in Uganda perceived the system to have significantly improved day-to-day operations as well as longer term institutional mandates. A more efficient and responsive approach to HRH allows the health sector to recruit the best candidates, train employees in needed skills and deploy trained personnel to facilities where there is real demand. This cascade of benefits can extend the impact and rewards of working in the health sector, which elevates the health system as a whole.

Comparing the health and social protection effects of measles vaccination strategies in Ethiopia: An extended cost-effectiveness analysis

There is increasing evidence that early childhood health interventions have long-term effects on cognitive development, educational achievement and adult productivity. We examine the effect of measles vaccination on the school enrolment of children in Matlab, Bangladesh. An intensive measles vaccination programme was introduced in one area in 1982, and extended to another in 1985, while a third area acted as a control. Using this staggered roll-out as an instrument, we find that age-appropriate vaccination raises the probability that a boy has enrolled in school by 7.4 percentage points but appears to have no effect on girls’ enrolment.