Sarita Bhalotra

Setting priorities for the Children's Vaccine Initiative: a cost-effectiveness approach

To help the Childrens Vaccine Initiative (CVI) achieve its goal of new and improved childrens vaccines, we developed and applied a cost-effectiveness model to set priorities for vaccine development. The model measures the health benefits in additional Quality-Adjusted Life Years (QALYs) gained by the combined birth cohorts of all developing countries over an assumed useful life of a proposed vaccine (generally 10 years). It measures costs as the net cost of developing, procuring, and administering the vaccine to the same population and time frame compared to the status quo (the current vaccine, if any). It weights each dollar of in-kind allocation of the existing health infrastructure less heavily than a dollar cash outlay to purchase new vaccine to reflect severe constraints on foreign exchange and non-personnel costs. It expresses cost-effectiveness as the net cost per QALY. The model was applied to 13 candidate vaccines selected by the CVI for initial analysis on the basis of their near-term feasibility. The five most cost-effective improvements, each of which could generate a QALY inexpensively (below

System-level factors and use of cardiac rehabilitation.

25 per QALY), were an early-administration or an early two-dose measles vaccine, slow release tetanus toxoid (for women), improved typhoid vaccine, and hepatitis B combined with diphtheria-tetanus-pertussis vaccine.

Benefits and costs of intensive lifestyle modification programs for symptomatic coronary disease in Medicare beneficiaries

PURPOSE Despite well-established benefits, only 10% to 20% of eligible candidates in the United States currently use formal cardiac rehabilitation (CR) services. Existing studies identify both patient- and provider-level barriers to physician referral and patient uptake. This study, which was driven by new evidence indicating that utilization rates vary enormously from state to state, within states, and from hospital to hospital, explores the relationship between system-level factors and CR use. METHODS Using a qualitative design with semistructured questions, we telephone-interviewed both directors of CR facility programs and presidents of CR state associations operating in states with high and low rates of CR use. We explored the political and cultural environment in which CR facilities operate and the technical capacity to secure referrals and convert referrals to enrollment. RESULTS We identified 4 system-level factors that may help explain regional variation in CR use. These included the degree of automation and assertiveness around securing CR referrals, level of integration of CR within the hospital setting and physician community, relationship to other CR facilities, and capacity constraints. CONCLUSIONS As some of the identified system-level factors can be altered by public and hospital-level policy, study results suggest opportunities for interventions and directions for future research that could increase the use of CR.

Applying Disease Management Strategies to Medicare

BACKGROUND This study reports outcomes of a Medicare-sponsored demonstration of two intensive lifestyle modification programs (LMPs) in patients with symptomatic coronary heart disease: the Cardiac Wellness Program of the Benson-Henry Mind Body Institute (MBMI) and the Dr Dean Ornish Program for Reversing Heart Disease® (Ornish). METHODS This multisite demonstration, conducted between 2000 and 2008, enrolled Medicare beneficiaries who had had an acute myocardial infarction or a cardiac procedure within the preceding 12 months or had stable angina pectoris. Health and economic outcomes are compared with matched controls who had received either traditional or no cardiac rehabilitation following similar cardiac events. Each program included a 1-year active intervention of exercise, diet, small-group support, and stress reduction. Medicare claims were used to examine 3-year outcomes. The analysis includes 461 elderly, fee-for-service, Medicare participants and 1,795 controls. RESULTS Cardiac and non-cardiac hospitalization rates were lower in participants than controls in each program and were statistically significant in MBMI (P < .01). Program costs of

Primary prevention for older adults: no longer a paradox.

3,801 and

Physician profiling in group practices.

4,441 per participant for the MBMI and Ornish Programs, respectively, were offset by reduced health care costs yielding non-significant three-year net savings per participant of about

Relationship Between Cardiorespiratory Fitness, Weight Status, and Academic Performance: Longitudinal Evidence From 1 School District

3,500 in MBMI and

Recruitment into Lifestyle Modification Programmes: A Cross-Atlantic Perspective

1,000 in Ornish. A trend towards lower mortality compared with controls was observed in MBMI participants (P = .07). CONCLUSIONS Intensive, year-long LMPs reduced hospitalization rates and suggest reduced Medicare costs in elderly beneficiaries with symptomatic coronary heart disease.

Disparities in utilization of coronary artery disease treatment by gender, race, and ethnicity: opportunities for prevention.

Medicare coverage begins for many when they have already developed one or more chronic diseases, and it often pays for the latest and costliest phases. Population-based disease modeling, patient screening, and monitoring would be appropriate interventions for chronic renal disease. Patients who have not yet advanced to end-stage renal disease would benefit from management of diabetes and hypertension, avoidance of nephrotoxic substances, and better preparation for dialysis. Administrative support could take the form of clinical guidelines, physician-led multidisciplinary teams, integrated delivery systems, provider and patient education, and new information technologies. Medicare reflects the long-term public perspective, and thus should further this new direction by supporting education, reimbursing for prevention efforts and allied health services, encouraging efficiency, and monitoring cost and quality outcomes.

Bringing Managed Care Incentives to Medicare's Fee-for-Service Sector

Sarita M. Bhalotra is Assistant Professor at the Heller School at Brandeis University. Her work includes studying the management and financing of chronic disease in managed care and fee-for-service settings. Dr. Bhalotra can be contacted at the Heller Graduate School, Brandeis University, Waltham, MA 02454 (E-mail: bhalotra@ brandeis.edu). Phyllis H. Mutschler is Executive Director of the National Center on Women and Aging and Associate Professor and Lecturer at the Heller Graduate School at Brandeis University. Currently, she is conducting studies of midlife and older women’s health insurance coverage, experience with financial planning, and investigating the current and future costs caregivers face in lost wages and retirement benefits. Dr. Mutschler can be contacted at the Heller Graduate School, Brandeis University, Waltham, MA 02454 (E-mail: mutsch1@brandeis.edu).