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Results There were 33,269 apixaban-warfarin, 9,345 dabigatran-warfarin, and 42,156 rivaroxaban-warfarin matched pairs, with a median follow-up of 4-5 months. Compared with warfarin, apixaban was associated with lower rates of stroke/systemic embolism (hazard ratio [HR] 0.52; 95% confidence interval [95% CI], 0.43-0.62), major bleeding (HR 0.60; 95% CI, 0.55-0.66) and stroke/myocardial infarction/all-cause mortality (HR 0.70; 95%CI, 0.66-0.74); dabigatran was associated with lower rates of major bleeding (HR: 0.73; 95% CI, 0.62-0.85); dabigatran and rivaroxaban were associated with lower rates of stroke/myocardial infarction/all-cause mortality (HR 0.77; 95% CI, 0.69-0.86 and HR 0.81; 95% CI, 0.77-0.85, respectively). Rivaroxaban was associated with a lower rate of stroke/systemic embolism (HR 0.61; 95% CI, 0.53-0.71) and a higher rate of major bleeding (HR 1.10; 95%CI, 1.03-1.18) versus warfarin.

To address literature gaps on treatment with real-world evidence, this study compared effectiveness, safety, and cost outcomes in NVAF patients with coronary or peripheral artery disease (CAD, PAD) prescribed apixaban versus other oral anticoagulants. NVAF patients aged ≥65 years co-diagnosed with CAD/PAD initiating warfarin, apixaban, dabigatran, or rivaroxaban were selected from the US Medicare population (January 1, 2013 to September 30, 2015). Propensity score matching was used to match apixaban versus warfarin, dabigatran, and rivaroxaban cohorts. Cox models were used to evaluate the risk of stroke/systemic embolism (SE), major bleeding (MB), all-cause mortality, and a composite of stroke/myocardial infarction/all-cause mortality. Generalized linear and two-part models were used to compare stroke/SE, MB, and all-cause costs between cohorts. A total of 33,269 warfarin-apixaban, 9,335 dabigatran-apixaban, and 33,633 rivaroxaban-apixaban pairs were identified after matching. Compared with apixaban, stroke/SE risk was higher in warfarin (hazard ratio [HR]: 1.93; 95% confidence interval [CI]: 1.61 to 2.31), dabigatran (HR: 1.69; 95% CI: 1.18 to 2.43), and rivaroxaban (HR: 1.24; 95% CI: 1.01 to 1.51) patients. MB risk was higher in warfarin (HR: 1.67; 95% CI: 1.52 to 1.83), dabigatran (HR: 1.37; 95% CI: 1.13 to 1.68), and rivaroxaban (HR: 1.87; 95% CI: 1.71 to 2.05) patients vs apixaban. Stroke/SE- and MB-related medical costs per-patient per-month were higher in warfarin, dabigatran, and rivaroxaban patients versus apixaban. Total all-cause health care costs were higher in warfarin and rivaroxaban patients compared with apixaban patients. In conclusion, compared with apixaban, patients on dabigatran, rivaroxaban, or warfarin had a higher risk of stroke/SE, MB, and event-related costs.

Supplemental Digital Content is available in the text., Background: Infant-specific pertussis data, especially among neonates, are limited and variable. This study (NCT01890850) provides overall and age-specific pertussis incidence and associated health care utilization and costs among commercially insured infants in the US. Methods: Nearly 1.2 million infants born from 2005 to 2010 with commercial health plan coverage were followed during their first 12 months of life. Pertussis cases were identified from medical claims (International Classification of Diseases, 9th revision, Clinical Modification code: 033.0, 033.9, 484.3), and incidence rates were calculated. Each pertussis case was then matched to 10 comparators, so pertussis-related health care utilization and costs before and after the index date could be assessed. Results: The overall pertussis incidence rate among infants

BACKGROUND Pertussis infection remains an important public health problem, particularly in infants. Despite high coverage, pertussis vaccination delays can leave infants at a vulnerable age with less protection than anticipated. METHODS Current diphtheria-tetanus-pertussis (DTaP) vaccination timeliness for the first 3 doses in the US was estimated using National Immunization Survey data. A Markov model estimated the potential impact on outcomes and costs of a hypothetical situation of vaccination at exactly 60, 120 and 180 days, compared with current timeliness. Incidence and unit cost data came from published sources. Age-specific incidence (for month of life) of pertussis and the associated probabilities of hospitalization and death for the US, during 2000-2007, were taken from a recently published US DTaP vaccination cost-effectiveness study. The cost analysis was conducted from the healthcare system's perspective over a 1-year time horizon. A regression analysis was conducted to explore the factors associated with vaccination delay. RESULTS Current DTaP vaccination was estimated to be delayed by 16, 27 and 44 days, for the first, second and third doses, respectively, relative to vaccination at exactly 60, 120 and 180 days. The model estimated that vaccination at exactly age 60, 120 and 180 days could prevent approximately 278 pertussis cases, 103 hospitalizations and 1 death in infants aged

Background Direct oral anticoagulants (DOAC) are at least non-inferior to warfarin in efficacy and safety among patients with nonvalvular atrial fibrillation. Limited evidence is available regarding outcomes for nonvalvular atrial fibrillation patients with coronary/peripheral artery disease. Methods Non-valvular atrial fibrillation patients aged ≥65 years diagnosed with coronary/peripheral artery disease in the US Medicare population, newly initiating DOACs (apixaban, rivaroxaban, dabigatran) or warfarin were selected from January 1, 2013 to September 30, 2015. Propensity score matching was used to compare DOACs vs warfarin. Cox proportional hazards models were used to estimate the risk of stroke/systemic embolism, major bleeding, and composite of stroke/myocardial infarction/all-cause mortality. Results There were 15,527 apixaban-warfarin, 6,962 dabigatran-warfarin, and 25,903 rivaroxaban-warfarin–matched pairs, with a mean follow-up of 5-6 months. Compared with warfarin, apixaban was associated with lower rates of stroke/systemic embolism (hazard ratio [HR] 0.48; 95% confidence interval [CI], 0.37-0.62), major bleeding (HR 0.66; 95% CI, 0.58-0.75), and stroke/myocardial infarction/all-cause mortality (HR 0.63; 95% CI, 0.58-0.69); dabigatran and rivaroxaban were associated with lower rates of stroke/myocardial infarction/all-cause mortality (HR 0.79; 95% CI, 0.70-0.90 and HR 0.87; 95% CI, 0.81-0.92, respectively). Rivaroxaban was associated with a lower rate of stroke/systemic embolism (HR 0.72; 95% CI, 0.60-0.89) and a higher rate of major bleeding (HR 1.14; 95% CI, 1.05-1.23) vs warfarin. Conclusions All DOACs were associated with lower stroke/myocardial infarction/all-cause mortality rates compared with warfarin; differences were observed in rates of stroke/systemic embolism and major bleeding. Findings from this observational analysis provide important insights about oral anticoagulation therapy among non-valvular atrial fibrillation patients with coronary/peripheral artery disease and may help physicians in the decision-making process when treating this high-risk group of patients.

Limited real-world data are available regarding the comparative safety of non-vitamin K antagonist oral anticoagulants (NOACs). The objective of this retrospective claims observational cohort study was to compare the risk of bleeding among non-valvular atrial fibrillation (NVAF) patients prescribed apixaban, dabigatran, or rivaroxaban. NVAF patients aged ≥18 years with a 1-year baseline period were included if they were new initiators of NOACs or switched from warfarin to a NOAC. Cox proportional hazards modelling was used to estimate the adjusted hazard ratios of any bleeding, clinically relevant non-major (CRNM) bleeding, and major inpatient bleeding within 6 months of treatment initiation for rivaroxaban and dabigatran compared to apixaban. Among 60,227 eligible patients, 8,785 were prescribed apixaban, 20,963 dabigatran, and 30,529 rivaroxaban. Compared to dabigatran or rivaroxaban patients, apixaban patients were more likely to have greater proportions of baseline comorbidities and higher CHA2DS2-VASc and HAS-BLED scores. After adjusting for baseline clinical and demographic characteristics, patients prescribed rivaroxaban were more likely to experience any bleeding (HR: 1.35, 95% confidence interval [CI]: 1.26–1.45), CRNM bleeding (HR: 1.38, 95% CI: 1.27–1.49), and major inpatient bleeding (HR: 1.43, 95% CI: 1.17–1.74), compared to patients prescribed apixaban. Dabigatran patients had similar bleeding risks as apixaban patients. In conclusion, NVAF patients treated with rivaroxaban appeared to have an increased risk of any bleeding, CRNM bleeding, and major inpatient bleeding, compared to apixaban patients. There was no significant difference in any bleeding, CRNM bleeding, or inpatient major bleeding risks between patients treated with dabigatran and apixaban.

This article uses panel data to investigate the extent of income-related inequity in the likelihood of visiting a General Practitioner (GP), specialist, dentist and hospital among individuals aged 65 years and over in the UK. The probability of accessing health care is predicted with separate random effects probit panel models using data from the British Household Panel Survey (BHPS) for the period 1998 to 2006. We use well-established methods based on the concept of the concentration curve to compare the cumulative distribution of health care utilization with the cumulative distribution of the population ranked by income. The results find evidence for inequity in specialist and dental care, but only slight inequity for GP care and not significant inequity in hospital admissions. Levels of inequity are highest for specialist and dental care, even when users of the private sector are excluded from analyses. The Mobility Index (MI) is also used to compare short- and long-run estimates of inequities and show...

Purpose This subgroup analysis of ARISTOPHANES study used multiple datasources to compare S/SE, MB, and their respective components among NVAF patients (pts) prescribed NOACs stratified by index dosage. Methods A retrospective observational study of NVAF pts initiating api, dabi, riva or warfarin from 01/01/2013–09/30/2015 was conducted using CMS Medicare data and four other US commercial claims databases, covering > 180 million beneficiaries. After propensity score matching (PSM) in each database between standard-dose NOACs (5 mg BID api–150 mg BID dabi, 5 mg BID api–20 mg QD riva, and 150 mg BID dabi–20 mg QD riva) and lower-dose NOACs (2.5 mg BID api-75 mg BID dabi, 2.5 mg BID api–10 or 15 mg QD riva, and 75 mg BID dabi–10 or 15 mg QD riva), the resulting patient records were pooled. Cox models were used to estimate hazard ratios of S/SE and MB. S/SE included ischemic stroke, hemorrhagic stroke, and SE; MB included gastrointestinal (GI) bleeding, intracranial hemorrhage (ICH), and other MB. Results Standard-dose api pts had a similar rate of S/SE but a lower rate of MB vs. standard-dose dabi; lower-dose api pts had a lower rate of S/SE and MB versus lower-dose dabi. In both standard and lower dose analyses, api was associated with a lower rate of S/SE and MB compared to riva. Compared to standard-dose riva, standard-dose dabi was associated with a similar rate of S/SE and lower rate of MB. Lower-dose dabi was associated with a higher rate of S/SE and similar rate of MB compared to lower-dose riva. Conclusions Among NVAF pts, both standard- and lower-dose api pts had lower rates of MB compared to corresponding doses of dabi and riva, respectively; both doses of api demonstrated lower rates of S/SE vs. corresponding doses of riva. The comparisons between dabi and riva showed varying results for S/SE and MB across dosage levels. Dose selection criteria cannot be ascertained from the current data sources. Future studies of pts who were appropriately dosed are warranted.

Background Limited real-world evidence exists on comparative effectiveness and safety of NOACs vs warf by NOAC dosage. Methods A retrospective observational study of NVAF patients (pts) newly initiating apixaban, dabigatran, rivaroxaban, or warfarin from 01 January 2013–30 September 2015 was conducted using CMS Medicare data and four other US commercial claims databases, covering > 180 million beneficiaries annually (∼56% of US population). After propensity score matching in each database between each standard NOAC dose and warfarin (5 mg BID api-warf, 150 mg BID dabi-warf, 20 mg QD riva-warf), as well as each lower NOAC dose and warf (2.5 mg BID api-warf, 75 mg BID dabi-warf, and 10 or 15 mg QD riva-warf), the resulting pts records were pooled. Cox models were used to estimate S/SE and MB hazard ratios. S/SE included ischemic stroke, hemorrhagic stroke, and SE; MB included gastrointestinal (GI) bleeding, intracranial hemorrhage (ICH), and other MB. Results Pts initiating lower and standard NOAC doses had different baseline characteristics, such as age and renal disease. Pts data were assessed for a mean of 7–8 months. Standard- and lower-dose api pts were each associated with lower rates of S/SE and MB vs warf. Standard and lower-dose dabi pts each had similar rates of S/SE compared to warf. Standard-dose dabi pts had a lower rate of MB and lower-dose dabi pts had a similar rate of MB vs warf. Standard-dose riva pts were associated with a lower S/SE rate, and lower-dose riva pts had a similar rate of S/SE compared to warf. Standard- and lower-dose riva pts were each associated with higher MB rates compared to warf. All doses of NOACs were associated with lower rates of ICH compared to warf. Conclusions In this large observational study, api was the only NOAC associated with lower rates of S/SE and MB for both doses compared to warf. Dose selection criteria cannot be ascertained from current data sources. Future studies of pts who were appropriately dosed should be warranted.

Most observational studies on direct oral anticoagulants (DOACs) used single data sources with limited generalizability. This ARISTOPHANES (Anticoagulants for Reduction In STroke: Observational Pooled analysis on Health outcomes ANd Experience of patientS) study aimed to use multiple data sources to

BACKGROUND: Limited data are available about the real-world safety of non-vitamin K antagonist oral anticoagulants (NOACs).OBJECTIVES: To compare the major bleeding risk among newly anticoagulated non-valvular atrial fibrillation (NVAF) patients initiating apixaban, warfarin, dabigatran or rivaroxaban in the United States.METHODS AND RESULTS: A retrospective cohort study was conducted to compare the major bleeding risk among newly anticoagulated NVAF patients initiating warfarin, apixaban, dabigatran or rivaroxaban. The study used the Truven MarketScan(®) Commercial & Medicare supplemental US database from 1 January 2013 through 31 December 2013. Major bleeding was defined as bleeding requiring hospitalisation. Cox model estimated hazard ratios (HRs) of major bleeding were adjusted for age, gender, baseline comorbidities and co-medications. Among 29 338 newly anticoagulated NVAF patients, 2402 (8.19%) were on apixaban; 4173 (14.22%) on dabigatran; 10 050 (34.26%) on rivaroxaban; and 12 713 (43.33%) on warfarin. After adjusting for baseline characteristics, initiation on warfarin [adjusted HR (aHR): 1.93, 95% confidence interval (CI): 1.12-3.33, P=.018] or rivaroxaban (aHR: 2.19, 95% CI: 1.26-3.79, P=.005) had significantly greater risk of major bleeding vs apixaban. Dabigatran initiation (aHR: 1.71, 95% CI: 0.94-3.10, P=.079) had a non-significant major bleeding risk vs apixaban. When compared with warfarin, apixaban (aHR: 0.52, 95% CI: 0.30-0.89, P=.018) had significantly lower major bleeding risk. Patients initiating rivaroxaban (aHR: 1.13, 95% CI: 0.91-1.41, P=.262) or dabigatran (aHR: 0.88, 95% CI: 0.64-1.21, P=.446) had a non-significant major bleeding risk vs warfarin.CONCLUSION: Among newly anticoagulated NVAF patients in the real-world setting, initiation with rivaroxaban or warfarin was associated with a significantly greater risk of major bleeding compared with initiation on apixaban. When compared with warfarin, initiation with apixaban was associated with significantly lower risk of major bleeding. Additional observational studies are required to confirm these findings.

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia [1-3] with increasing prevalence in the aging [4]. With the advent of the three NOACs including apixaban, dabigatran and rivaroxaban, it is important to characterize patients prescribed with the different dosage of treatment in the real-world setting. Purpose: To describe the baseline clinical and demographic characteristics of NVAF patients on apixaban (5 mg vs 2.5 mg -reduced), rivaroxaban (20mg vs reduced dose: 15 mg or 10 mg), and dabigatran (150 mg vs reduced 75 mg). Methods: A retrospective cohort study was conducted using MarketScan Earlyview ® data. NVAF patients ≥18 years with a minimum of 1 year baseline period were included if they either received a NOAC or were switched from warfarin to NOAC during the study period of Jan 1, 2013 to October 31, 2014. Results: For NVAF patients , the majority of the patients were on the standard dosage (Table 1). Similarly for each NOAC, patients using low dosage versus standard dosage were older, had a greater stroke risk, had a prior history of bleeding and were sicker in terms of presence of congestive heart disease, renal disease and Charleson comorbidity index. Patients switching from warfarin had on average a large number of missing dosage data, and if switching to apixaban were more likely to be prescribed the reduced dose than the 5 mg dose. No clear trend was observed for patients switching to dabigatran or rivaroxaban. More than 15% Apixaban and rivaroxaban patients switched from warfarin while only Conclusion: AF patient initiated with standard dosages of NOACs had better clinical and demographic characteristics than patients initiated with reduced dosages of NOAC. Table 1.

Background: Non-valvular atrial fibrillation (NVAF) was commonly treated with warfarin. With the introduction of Non-Vitamin K Oral Anticoagulants (NOACs) in the United States, some patients are switching from standard of care to NOACs Purpose: To investigate demographic and clinical characteristics associated with switching among NVAF patients treated with warfarin to a NOAC (apixaban, dabigatran and rivaroxaban). Methods: A retrospective cohort study was conducted using Truven MarketScan EarlyView data. The patient recruitment period was from 01/12/2012 to 01/31/2015. Study enrolled adult NVAF patients ≥18 years with 2 or more warfarin prescriptions at least 90 days apart, with 6 months continuous enrollment prior to their last warfarin prescription. Warfarin switch to NOAC will be defined for patients who had a pharmacy claim of NOACs within 60 days from the last day of supply of the last filled prescription of warfarin. Stepwise logistic regression was used to identify patient characteristics associated with switching status (yes or no). Results: A total of 141,198 eligible patients were identified, apixaban n=2177, dabigatran n=771, rivaroxaban n=4317 and non-switchers n=133,933.Cardioversion was identified as the variable most significantly associated with switching followed in order by health plan type, hypertension, age, Charlson Comorbidity Index (CCI), stroke, days on warfarin, and bleeding history. On average people who undergo cardioversion, with hypertension at baseline, with prior stroke, with a history of bleeding, and with a longer exposure to warfarin treatment were more likely to switch to a NOAC than to continue warfarin treatment. NVAF elderly patients and those with multiple comorbidities were more likely to continue warfarin treatment. Conclusion: In the real world setting, by using a stepwise logistic regression, cardioversion, health plan type, hypertension, age, CCI, stroke, days on warfarin and bleeding history were the main demographic and clinical characteristics associated with switching from warfarin to a NOAC.

Background Pertussis is believed to be widely underreported and under-recognized, particularly among adults. The aim of this study was to estimate the incidence of private practitioner-attended cough illness that could be attributed to Bordetella pertussis in adults aged ≥50 years in the US. Methods Multiple linear regressions were employed to estimate the overall incidence of pertussis. Data were extracted from IMS’ private practice database of longitudinal, patient-level claims and IMS’ commercial laboratory database during 4/1/2006–12/31/2010. Patients were ≥50 years old and had ≥1 ICD-9-CM claim for cough illness relating to pertussis, cough, or acute bronchitis. Pertussis positive laboratory tests, seasonal and secular variables were used for estimating the B. pertussis attributable fraction of cough illness. Results During the study period, there were 20.7 million cases of cough illness among people aged 50–64 and 27.5 million cases among those ≥65; of which the model attributed 2.5 and 1.7 %, respectively, to B. pertussis. The estimated incidences of cough illness attributed to B. pertussis during the study period were on average 202 and 257/100,000 among people aged 50–64 and ≥65 years, respectively, and increased over the years in both age groups. Depending on the year, estimated pertussis incidences were 42 to 105 times higher than medically attended ones in the same database. Conclusions These findings indicate that the B. pertussis disease incidence in adults aged ≥50 years is significantly higher than generally estimated. Additional research regarding pertussis reporting and diagnosis in the adult populations is needed to validate these findings.

The objective of this study was to determine the association between warfarin discontinuation and stroke among patients with nonvalvular atrial fibrillation (NVAF).This was a retrospective, observational study of adult NVAF patients (≥ 18 years) who were on warfarin in the Truven MarketScan commercial claims and encounters and Medicare supplemental and coordination of benefits databases (1 January 2008 to 30 June 2012). Warfarin discontinuation was defined as a gap of ≥ 45 days in warfarin prescription within 1 year after initiation. Patients who did and did not discontinue warfarin were matched at a 1:1 ratio using a propensity score method. Matched patients were followed for up to 1 year to determine risks of ischemic stroke, transient ischemic attack (TIA), and hemorrhagic stroke. A multivariate Cox proportional hazards model was used to further adjust for the effects of potential confounders.A total of 27,000 patients were included. Patients who discontinued warfarin had higher rates of ischemic stroke compared to persistent patients (1.0 vs. 0.5 per 100 patient years, P0.01), but similar rates of TIA (1.2 vs. 0.9 per 100 patient years, respectively; P = 0.07) and hemorrhagic stroke (0.3 vs. 0.2 per 100 patient years, P = 0.31). After adjustment for potential confounders, warfarin discontinuation was significantly associated with increased risk of ischemic stroke (hazard ratio [HR]: 2.04; 95% confidence interval [CI]: 1.47-2.84), TIA (HR: 1.36; 95% CI: 1.04-1.78), and ischemic stroke or TIA (HR: 1.50; 95% CI: 1.20-1.87).Warfarin discontinuation is associated with increased risk of ischemic stroke and TIA. Health care providers may need to take a more active role in the management of warfarin discontinuation and clinical outcomes, e.g., by considering newer anticoagulants with favorable risk-benefit profiles. Key limitations of the study include unavailability of important clinical factors and measures in claims data.

A systematic review and network meta-analysis (NMA) were conducted to compare oral anticoagulants and aspirin for the secondary prevention of venous thromboembolism (VTE). Databases were searched (July 2014) to identify phase III randomized controlled trials (RCTs) evaluating the novel oral anti

To assess the predictive validity of apixaban cost-effectiveness model by comparing key event rates from model to those seen in AMPLIFY and AMPLIFY-EXT trials in patients with venous thromboembolism (VTE). Markov model was developed to extrapolate the observed clinical impact of apixaban versus

Background: Most of the member countries of the Organization for Economic Cooperation and Development (OECD) aim to ensure equitable access to health care. This is often interpreted as requiring that care be available on the basis of need and not willingness or ability to pay. We sought to examine equity in physician utilization in 21 OECD countries for the year 2000. Methods: Using data from national surveys or from the European Community Household Panel, we extracted the number of visits to a general practitioner or medical specialist over the previous 12 months. Visits were standardized for need differences using age, sex and reported health levels as proxies. We measured inequity in doctor utilization by income using concentration indices of the need-standardized use. Results: We found inequity in physician utilization favouring patients who are better off in about half of the OECD countries studied. The degree of pro-rich inequity in doctor use is highest in the United States and Mexico, followed by Finland, Portugal and Sweden. In most countries, we found no evidence of inequity in the distribution of general practitioner visits across income groups, and where it does occur, it often indicates a pro-poor distribution. However, in all countries for which data are available, after controlling for need differences, people with higher incomes are significantly more likely to see a specialist than people with lower incomes and, in most countries, also more frequently. Pro-rich inequity is especially large in Portugal, Finland and Ireland. Interpretation: Although in most OECD countries general practitioner care is distributed fairly equally and is often even pro-poor, the very pro-rich distribution of specialist care tends to make total doctor utilization somewhat pro-rich. This phenomenon appears to be universal, but it is reinforced when private insurance or private care options are offered.

The Advisory Committee on Immunization Practices recommends administering diphtheria, tetanus and acellular pertussis (DTaP) vaccines to children at 2, 4, 6, 15–18 months, and 4–6 y of age; preferably with the same-brand vaccine for the whole series. We estimated age-appropriate DTaP dose completion and the proportion of children receiving a “mixed” DTaP vaccination series (ie, including DTaP vaccines from ≥2 brands) across the 3 milestones. Commercially-insured children born between 01/01/2003 and 04/30/2011 were identified from United States health insurance claims data and assigned to ≥1 of 3 study cohorts based on the duration of continuous health plan enrollment: 1) birth to

The Advisory Committee on Immunization Practices (ACIP) recommends the use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine for routine wound management in adolescents and adults who require a tetanus toxoid-containing vaccine who were vaccinated ≥ 5 years earlier with tetanus toxoid, reduced diphtheria toxoid (Td) vaccine, and who have not previously received Tdap.To estimate the overall budget and health impact of vaccinating individuals presenting for wound management with Tdap instead of Td vaccine, the current standard of care in practices that do not use Tdap for purposes of wound management.A decision-analytic economic model was developed to estimate the expected increase in direct medical costs and the expected number of cases of pertussis avoided associated with the use of Tdap instead of Td vaccine in the wound management setting. Patients eligible for Tdap were aged 10+ years and required a tetanus-containing vaccine. Age-specific wound incidence data and Td and Tdap vaccination rates were taken from the National Health Interview Survey and the National Immunization Survey for the most recent available year. Age-specific pertussis incidence used in this analysis (151 per 100,000 for adolescents, 366 per 100,000 for those aged 20-64 years, and 176 per 100,000 for those aged 65+ years) used reported incidence rates adjusted by a factor of 10 for adolescents and by a factor of 100 for adults, based on assumptions previously made by ACIP to account for underreporting. Vaccine wholesale acquisition costs without federal excise tax were assumed in the base case. Efficacy of vaccination with Tdap in preventing pertussis was based on clinical trial data. Possible herd immunity effects of vaccination were not included in the model. Costs associated with vaccination and treatment of pertussis cases were reported as total annual costs and per-member-per-month (PMPM) costs for hypothetical health plans and for the U.S. population. Aggregate and incremental costs and pertussis cases avoided were presented undiscounted (as recommended for budget-impact analyses) annually and cumulatively over a 3-year time horizon in 2012 U.S. dollars. Scenario analyses were conducted on key parameters, including wound incidence, pertussis incidence, vaccine efficacy and waning protection against pertussis, uptake rates for Tdap, and vaccine prices using alternative data sources or alternative clinically relevant assumptions.For a health plan with 1 million covered lives aged65 years, vaccination with Tdap instead of Td was estimated to cost an additional $132,364 ($0.01 PMPM) in the first year and an additional $368,640 ($0.01 PMPM) cumulatively over 3 years. For a health plan with 1 million covered lives aged 65+ years, vaccination with Tdap instead of Td was estimated to cost an additional $201,165 ($0.02 PMPM) in the first year and an additional $549,568 ($0.02 PMPM) cumulatively over 3 years. For the U.S. population aged 10+ years, vaccination with Tdap instead of Td was estimated to result in protection against pertussis for an additional 2.7 million patients with wounds annually and was estimated to cost an additional $121,101,671 to avoid 42,104 cases of pertussis over the 3-year time horizon. Results were sensitive to input parameter values, particularly parameters associated with the number of patients with wounds vaccinated with Tdap (range 2.7 to 5.1 million patients). However, for all of the alternative scenarios tested, the expected increase in PMPM costs ranged from$0.01 to $0.03.Vaccination of adolescents and adults with Tdap for wound management may result in an increase in PMPM costs for health plans of$0.01 to $0.03. Given the potential reduction in pertussis cases at the population level, vaccination with Tdap for routine wound management could be considered as another strategy to help address the pertussis public health concern in the United States.

Information about the risk of bleeding and bleeding-related resource use and costs among non-Vitamin K antagonist oral anticoagulants (NOACs) in the real-world setting is scarce. This study aim was to compare inpatient bleeding risks, bleeding-related hospitalization rates and costs among non

Limited information is available about safety and resource utilization among non-valvular atrial fibrillation (NVAF) patients treated with oral anticoagulants in the real-world setting. This study assessed incidence of all-cause and major bleeding (MB)-related hospitalization and length of stay (LOS

Given limited data on real world safety of non-vitamin K antagonist oral anticoagulants (NOACs), this study compared the risk of a first major bleeding event among non-valvular atrial fibrillation (NVAF) patients newly initiated on apixaban versus dabigatran, rivaroxaban, or warfarin. Retrospective

Background: Equitable access to health care is a core objective of the Italian health care system. Despite having achieved universal coverage for a fairly comprehensive set of health services for decades, there is still evidence of inequities systematically associated with income. Method: Income-related inequity indices were estimated for the probability of general practitioner (GP), specialist, inpatient care and also emergency care using a variety of need indicators. The data used were the Multiscopo survey, 2000 matched with the European Community Household Panel survey for Italy. The contribution of regional inequality was also estimated. Horizontal inequity indices for health care utilization measures were computed separately for people reporting hypertension, arthritis, tumour and heart disease. Results: Significant pro-rich income related inequity was found for GP, specialist and emergency care, no inequity was found for inpatient care. The disease approach showed statistically significant inequity in the probability of specialist care in three of the four chronic conditions analysed, and pro-poor inequity in GP care for all conditions. Inequity was mainly caused by income and regional variations. Conclusions: By reducing regional variation it would be possible to significantly reduce the pro-rich inequity in GP, specialist and emergency care. For specialist care inequity was found for the overall adult population and also among people with serious chronic conditions, and was caused not only by income and regional variation, but also by educational attainment and insurance.

Objectives. We compared the extent of socioeconomic differences in use of health care services based on wealth (i.e., accumulated assets) as the socioeconomic ranking variable with the extent of differences based on income to explore the sensitivity of the estimates of equity to the choice of the socioeconomic indicator. Methods. We used data from the Health and Retirement Study in the United States and the Survey of Health, Ageing, and Retirement in Europe to estimate levels of income- and wealth-related disparity in use of physician and dental services among adults 50 or older in 12 countries. Results. We found socioeconomic differences in use of physician services after standardizing for need in about half of the countries studied. No consistent pattern in levels of disparity measured by wealth versus those measured by income was found. However, the rich were significantly more likely to use dental services in all countries. Wealth-related differences in dental service use were consistently higher than were income-related differences. Conclusions. We found some support for wealth as a more sensitive indicator of socioeconomic status among older adults than was income. Wealth may thus allow more accurate measurements of socioeconomic differences in use of health care services for this population.

OBJECTIVES: To describe the context for implementing the national programme for information technology (NPfIT) in England, actual and perceived barriers, and opportunities to facilitate implementation. DESIGN: Case studies and in depth interviews, with themes identified using a framework developed from grounded theory. SETTING: Four acute NHS trusts in England. PARTICIPANTS: Senior trust managers and clinicians, including chief executives, directors of information technology, medical directors, and directors of nursing. RESULTS: The trusts varied in their circumstances, which may affect their ability to implement the NPfIT. The process of implementation has been suboptimal, leading to reports of low morale by the NHS staff responsible for implementation. The overall timetable is unrealistic, and trusts are uncertain about their implementation schedules. Short term benefits alone are unlikely to persuade NHS staff to adopt the national programme enthusiastically, and some may experience a loss of electronic functionality in the short term. CONCLUSIONS: The sociocultural challenges to implementing the NPfIT are as daunting as the technical and logistical ones. Senior NHS staff feel these have been neglected. We recommend that national programme managers prioritise strategies to improve communication with, and to gain the cooperation of, front line staff.

Objectives In February 2012, the Advisory Committee on Immunization Practices (ACIP) advised that all adults aged ≥65 years receive a single dose of reduced-antigen-content tetanus, diphtheria, and acellular pertussis (Tdap), expanding on a 2010 recommendation for adults >65 that was limited to those with close contact with infants. We evaluated clinical and economic outcomes of adding Tdap booster of adults aged ≥65 to “baseline” practice [full-strength DTaP administered from 2 months to 4–6 years, and one dose of Tdap at 11–64 years replacing decennial Td booster], using a dynamic model. Methods We constructed a population-level disease transmission model to evaluate the cost-effectiveness of supplementing baseline practice by vaccinating 10% of eligible adults aged ≥65 with Tdap replacing the decennial Td booster. US population effects, including indirect benefits accrued by unvaccinated persons, were estimated during a 1-year period after disease incidence reached a new steady state, with consequences of deaths and long-term pertussis sequelae projected over remaining lifetimes. Model outputs include: cases by severity, encephalopathy, deaths, costs (of vaccination and pertussis care) and quality-adjusted life-years (QALYs) associated with each strategy. Results in terms of incremental cost/QALY gained are presented from payer and societal perspectives. Sensitivity analyses vary key parameters within plausible ranges. Results For the US population, the intervention is expected to prevent >97,000 cases (>4,000 severe and >5,000 among infants) of pertussis annually at steady state. Additional vaccination costs are $4.7 million. Net cost savings, including vaccination costs, are $47.7 million (societal perspective) and $44.8 million (payer perspective). From both perspectives, the intervention strategy is dominant (less costly, and more effective by >3,000 QALYs) versus baseline. Results are robust to sensitivity analyses and alternative scenarios. Conclusions Immunization of eligible adults aged ≥65, consistent with the current ACIP recommendation, is cost saving from both payer and societal perspectives.

Objectives Health benefits and costs of combined reduced-antigen-content tetanus, diphtheria, and pertussis (Tdap) immunization among adults ≥65 years have not been evaluated. In February 2012, the Advisory Committee on Immunization Practices (ACIP) recommended expanding Tdap vaccination (one single dose) to include adults ≥65 years not previously vaccinated with Tdap. Our study estimated the health and economic outcomes of one-time replacement of the decennial tetanus and diphtheria (Td) booster with Tdap in the 10% of individuals aged 65 years assumed eligible each year compared with a baseline scenario of continued Td vaccination. Methods We constructed a model evaluating the cost-effectiveness of vaccinating a cohort of adults aged 65 with Tdap, by calculating pertussis cases averted due to direct vaccine effects only. Results are presented from societal and payer perspectives for a range of pertussis incidences (25-200 cases per 100,000), due to the uncertainty in estimating true annual incidence. Cases averted were accrued throughout the patient 's lifetime, and a probability tree used to estimate the clinical outcomes and costs (US$ 2010) for each case. Quality-adjusted life-years (QALYs) lost to acute disease were calculated by multiplying cases of mild/moderate/severe pertussis by the associated health-state disutility; QALY losses due to death and long-term sequelae were also considered. Incremental costs and QALYs were summed over the cohort to derive incremental cost-effectiveness ratios. Scenario analyses evaluated the effect of alternative plausible parameter estimates on results. Results At incidence levels of 25, 100, 200 cases/100,000, vaccinating adults aged 65 years costs an additional $336,000, $63,000 and $17,000/QALY gained, respectively. Vaccination has a cost-effectiveness ratio less than $50,000/QALY if pertussis incidence is >116 cases/100,000 from societal and payer perspectives. Results were robust to scenario analyses. Conclusions Tdap immunization of adults aged 65 years according to current ACIP recommendations is a cost-effective health-care intervention at plausible incidence assumptions.