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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.

To assess the public health impact and economic value of booster vaccination with the Pfizer-BioNTech COVID-19 Vaccine, Bivalent in the United States. A combined cohort Markov decision tree model estimated the cost-effectiveness and budget impact of booster vaccination compared to no booster vaccination in individuals aged ≥5 years. Analyses prospectively assessed three scenarios (base case, low, high) defined based upon the emergence (or not) of subvariants, using list prices. Age-stratified parameters were informed by literature. The cost-effectiveness analysis estimated cases, hospitalizations and deaths averted, Life Years (LYs) and Quality Adjusted Life Years (QALYs) gained, the incremental cost-effectiveness ratio (ICER), the net monetary benefit (NMB), and the Return on Investment (ROI). The budget impact analyses used the perspective of a hypothetical 1-million-member plan. Sensitivity analyses explored parameter uncertainty. Conservatively, indirect effects and broad societal benefits were not considered. The base case predicted that, compared to no booster vaccination, the Pfizer-BioNTech COVID-19 Vaccine, Bivalent could result in ∼3.7 million fewer symptomatic cases, 162 thousand fewer hospitalizations, 45 thousand fewer deaths, 373 thousand fewer discounted QALYs lost, and was cost-saving. Using a conservative value of $50,000 for 1 LY, every $1 invested yielded estimated $4.67 benefits. Unit costs, health outcomes and effectiveness had the greatest impact on results. At $50,000 per QALY gained, the booster generated a 34.2 billion NMB and probabilistic sensitivity analyses indicated a 92% chance of being cost-saving and 98% of being cost-effective. The bivalent was cost-saving or highly cost-effective in high and low scenarios. In a hypothetical 1-million-member health plan population, the vaccine was predicted to be a budget-efficient solution for payers. Booster vaccination with the Pfizer-BioNTech COVID-19 Vaccine, Bivalent for the US population aged ≥5 years could generate notable public health impact and be cost-saving based on the findings of our base case analyses.

Introduction Demonstrating the validity of a public health simulation model helps to establish confidence in the accuracy and usefulness of a model’s results. In this study we evaluated the validity of the Prevention Impacts Simulation Model (PRISM), a system dynamics model that simulates health, mortality, and economic outcomes for the US population. PRISM primarily simulates outcomes related to cardiovascular disease but also includes outcomes related to other chronic diseases that share risk factors. PRISM is openly available through a web application. Methods We applied the model validation framework developed independently by the International Society of Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making modeling task force to validate PRISM. This framework included model review by external experts and quantitative data comparison by the study team. Results External expert review determined that PRISM is based on up-to-date science. One-way sensitivity analysis showed that no parameter affected results by more than 5%. Comparison with other published models, such as ModelHealth, showed that PRISM produces lower estimates of effects and cost savings. Comparison with surveillance data showed that projected model trends in risk factors and outcomes align closely with secular trends. Four measures did not align with surveillance data, and those were recalibrated. Conclusion PRISM is a useful tool to simulate the potential effects and costs of public health interventions. Results of this validation should help assure health policy leaders that PRISM can help support community health program planning and evaluation efforts.

High sodium intake can lead to hypertension and increase the risk for heart disease and stroke; however, research is lacking on the effectiveness of community-based sodium reduction programs. From 2013 through 2016, the Centers for Disease Control and Prevention (CDC) funded 10 state and local health departments to implement sodium reduction strategies across diverse institutional food settings. Strategies of the Sodium Reduction in Communities Program (SRCP) are implementing food service guidelines, making menu modifications, enabling purchase of reduced-sodium foods, and providing consumer information. CDC aggregated awardee-reported performance measures to evaluate progress in increasing the access, availability, and purchase of reduced sodium foods. Evaluation results of the SRCP show the potential differential effects of sodium reduction strategies in a community setting and support the need for additional community-level efforts in this emerging area of public health.

Limited data are available on the costs of evidence-based community-wide prevention programs. The objective of this study was to estimate the per-person costs of strategies that support policy, systems, and environmental changes implemented under the Community Transformation Grants (CTG) program. We collected cost data from 29 CTG awardees and estimated program costs as spending on labor; consultants; materials, travel, and services; overhead activities; partners; and the value of in-kind contributions. We estimated costs per person reached for 20 strategies. We assessed how per-person costs varied with the number of people reached. Data were collected in 2012-2015, and the analysis was conducted in 2015-2016. Two of the tobacco-free living strategies cost less than $1.20 per person and reached over 6 million people each. Four of the healthy eating strategies cost less than $1.00 per person, and one of them reached over 6.5 million people. One of the active living strategies cost $2.20 per person and reached over 7 million people. Three of the clinical and community preventive services strategies cost less than $2.30 per person, and one of them reached almost 2 million people. Across all 20 strategies combined, an increase of 10,000 people in the number of people reached was associated with a $0.22 reduction in the per-person cost. Results demonstrate that interventions, such as tobacco-free indoor policies, which have been shown to improve health outcomes have relatively low per-person costs and are able to reach a large number of people.

Purpose and objectives We evaluated the costs of implementing coordinated systems of stroke care by state health departments from 2012 through 2015 to help policy makers and planners gain a sense of the potential return on investments in establishing a stroke care quality improvement (QI) program. Intervention approach State health departments funded by the Paul Coverdell National Acute Stroke Program (PCNASP) implemented activities to support the start and proficient use of hospital stroke registries statewide and coordinate data-driven QI efforts. These efforts were aimed at improving the treatment and transition of stroke patients from prehospital emergency medical services (EMS) to in-hospital care and postacute care facilities. Health departments provided technical assistance and data to support hospitals, EMS agencies, and posthospital care agencies to carry out small, rapid, incremental QI efforts to produce more effective and efficient stroke care practices. Evaluation methods Six of the 11 PCNASP-funded state health departments in the United States volunteered to collect and report programmatic costs associated with implementing the components of stroke systems of care. Six health departments reported costs paid directly by Centers for Disease Control and Prevention-provided funds, 5 also reported their own in-kind contributions, and 4 compiled data from a sample of their partners' estimated costs of resources, such as staff time, involved in program implementation. Costs were analyzed separately for PCNASP-funded expenditures and in-kind contributions by the health department by resource category and program activity. In-kind contributions by partners were also analyzed separately. Results PCNASP-funded expenditures ranged from $790,123 to $1,298,160 across the 6 health departments for the 3-year funding period. In-kind contributions ranged from $5,805 to $1,394,097. Partner contributions (n = 22) ranged from $3,912 to $362,868. Implications for public health Our evaluation reports costs for multiple state health departments and their partners for implementing components of stroke systems of care in the United States. Although there are limitations, our findings represent key estimates that can guide future program planning and efforts to achieve sustainability.

Introduction Public health focuses on a range of evidence-based approaches for addressing chronic conditions, from individual-level clinical interventions to broader changes in policies and environments that protect people's health and make healthy living easier. This study examined the potential long-term impact of clinical and community interventions as they were implemented by Community Transformation Grant (CTG) program awardees. Methods We used the Prevention Impacts Simulation Model, a system dynamics model of cardiovascular disease prevention, to simulate the potential 10-year and 25-year impact of clinical and community interventions implemented by 32 communities receiving a CTG program award, assuming that program interventions were sustained during these periods. Results Sustained clinical interventions implemented by CTG awardees could potentially avert more than 36,000 premature deaths and $3.2 billion in discounted direct medical costs (2017 US dollars) over 10 years and 109,000 premature deaths and $8.1 billion in discounted medical costs over 25 years. Sustained community interventions could avert more than 24,000 premature deaths and $3.4 billion in discounted direct medical costs over 10 years and 88,000 premature deaths and $9.1 billion in discounted direct medical costs over 25 years. CTG clinical activities had cost-effectiveness of $302,000 per death averted at the 10-year mark and $188,000 per death averted at the 25-year mark. Community interventions had cost-effectiveness of $169,000 and $57,000 per death averted at the 10- and 25-year marks, respectively. Conclusion Clinical interventions have the potential to avert more premature deaths than community interventions. However, community interventions, if sustained over the long term, have better cost-effectiveness.

Vaccinations are recommended to prevent serious morbidity and mortality. However, providers' concerns regarding costs and payments for providing vaccination services are commonly reported barriers to adult vaccination. Information on the costs of providing vaccination is limited, especially for adults.We recruited 4 internal medicine, 4 family medicine, 2 pediatric, 2 obstetrics and gynecology (OBGYN) practices, and 2 community health clinics in North Carolina to participate in a study to assess the economic costs and benefits of providing vaccination services for adults and children. We conducted a time-motion assessment of vaccination-related activities in the provider office and a survey to providers on vaccine management costs. We estimated mean cost per vaccination, minimum and maximum payments received, and income.Across all provider settings, mean cost per vaccine administration was $14 with substantial variation by practice setting (pediatric: $10; community health clinics: $15; family medicine: $17; OBGYN: $23; internal medicine: $23). When receiving the maximum payment, all provider settings had positive income for vaccination services. When receiving the minimum reported payments for vaccination services, pediatric and family medicine practices had positive income, internal medicine, and OBGYN practices had approximately equal costs and payments, and community health clinics had losses or negative income.Overall, vaccination service providers appeared to have small positive income from vaccination services. In some cases, providers experienced negative income, which underscores the need for providers and policymakers to design interventions and system improvements to make vaccination services financially sustainable for all provider types.

INTRODUCTION: Vaccination coverage among adults remains low in the United States. Understanding the barriers to provision of adult vaccination is an important step to increasing vaccination coverage and improving public health. To better understand financial factors that may affect practice decisions about adult vaccination, this study sought to understand how costs compared with payments for adult vaccinations in a sample of U.S. physician practices. METHODS: We recruited a convenience sample of 19 practices in nine states. We collected data on the time and material costs of the vaccination work flow using a management survey and a time-motion study. We collected data on payments received for vaccine doses and vaccine administration for different payer types using a finance survey. We received complete cost and payment data from 13 of the 19 practices. We compared payments for vaccines to prices paid for vaccines. We calculated annual net revenue from vaccination services by combining payments received for vaccine doses and vaccine administration with estimated costs. RESULTS: The extent to which vaccine payments exceeded vaccine prices varied by payer type, with per-dose payments from Medicare exceeding prices paid for 5 out of 5 vaccines , from Medicaid for 9 out of 14 vaccines, and from private health plans for 16 out of 21 vaccines. The median annual total net revenue from vaccination services was $90,343 at family medicine practices (range: $3,968 to $249,628), $28,267 at internal medicine practices (−$32,659 to $141,034) and $2,886 at obstetrics and gynecology practices (−$73,451 to $23,820). CONCLUSIONS: Payments received generally exceeded prices paid for most vaccines. Adult vaccination was profitable at the median of our sample, but there is wide variation in profitability due to differences in costs and payment rates across practices. This study provides evidence on the economic viability of adult vaccination that can help inform practices’ decisions whether to provide adult vaccines and contribute to keeping adults up-to-date with the recommended vaccination schedule.

Purpose Using a standardized approach and metrics to estimate home visiting costs across multiple evidence-based models and regions could improve the consistency and accuracy of cost estimates, allow stakeholders to observe trends in cost allocation, analyze how home visiting costs vary, and develop future program budgets. Between October 2015 and December 2018, we developed and pilot-tested the Home Visiting Budget Assistance Tool (HV-BAT) to standardize the collection of home visiting program costs and analyze costs for local implementing agencies (LIAs). Methods We recruited LIAs that implemented at least one of nine evidence-based home visiting models in 15 states implementing the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program. LIAs reported their costs to implement a home visiting model using the HV-BAT and provided feedback on the tool. We estimated annual total cost and cost per family served for each LIA, examined cost summary statistics for the sample, and analyzed whether and how LIA characteristics affected home visiting costs using regression analyses. Results Of the 168 LIAs invited to participate in the HV-BAT pilot study, 75 agreed to participate, and 45 across 14 states completed the HV-BAT. We estimated home visiting costs of approximately $8500 per family per year, but costs varied across LIAs (range $1970–$39,770; standard deviation = $5794). The marginal cost of adding a family declined as the number of families served by an LIA increased. Feedback from LIAs indicated that users had difficulty providing some details on costs (e.g., mileage for specific services), needed more detailed instructions, and desired a summary of subtotals and total costs reported in the HV-BAT. Conclusions The HV-BAT provides an approach to standardize cost data collection for home visiting programs. Pilot study results indicate that there may be significant economies of scale for home visiting services. This study provides preliminary estimates of costs that can help in program planning and budgeting.

Amid provider reports of financial barriers as an impediment to adult immunization, this study explores the time and costs of vaccination in adult provider practices. Both a Vaccination Time-Motion Study and Vaccine Practice Management Survey were conducted (March – October 2017) in a convenience sample of 19 family medicine (FM), internal medicine (IM), and obstetrician-gynecology (OBGYN) practices, in nine states. Practices were directly observed during a one week period; estimates were collected of time spent on activities that could not be directly observed. Cost estimates were calculated by converting staff time for performed activities. In the time-motion study, FM and IM practices spent similar time conducting vaccination activities (median = 5 min per vaccination), while OBGYN practices spent more time (median = 29 min per vaccination). Combining results from the time-motion study and the practice management survey, the median costs of vaccination remained similar for FM practices and IM practices at $7 and $8 per vaccination, respectively, but was substantially higher for OBGYN practices at $43 per vaccination. Factors that contributed to higher costs among OBGYN practices were the increased time to counsel patients, administer vaccines, and to plan and manage vaccine supplies. In addition, 68% of OBGYN patients who were offered and counseled to receive vaccines declined to receive them. Counseling patients who ultimately do not go on to receive a vaccine may be an important cost factor. Lower costs of vaccination services may be achieved by increasing efficiencies in workflow or the volume of vaccinations.

In 2010, the Centers for Disease Control and Prevention (CDC) funded communities to implement policy, systems, and environmental (PSE) changes under the Communities Putting Prevention to Work (CPPW) program to make it easier for people to make healthier choices to prevent chronic disease. Twenty-one of 50 funded communities implemented interventions intended to reduce tobacco use. To examine the potential cost-effectiveness of tobacco control changes implemented under CPPW from a healthcare system perspective, we compared program cost estimates with estimates of potential impacts. We used an existing simulation model, the Prevention Impacts Simulation Model (PRISM), to estimate the potential cumulative impact of CPPW tobacco interventions on deaths and medical costs averted through 2020. We collected data on the costs to implement CPPW tobacco interventions from 2010 to 2013. We adjusted all costs to 2010 dollars. CPPW tobacco interventions cost $130.5 million across all communities, with an average community cost of $6.2 million. We found $735 million in potentially averted medical costs cumulatively from 2010 through 2020 because of the CPPW-supported interventions. If the CPPW tobacco control PSE changes are sustained through 2020 without additional funding after 2013, we find that medical costs averted will likely exceed program costs by $604 million. Our results suggest that the medical costs averted through 2020 may more than offset the initial investment in CPPW tobacco control interventions, implying that such interventions may be cost saving, especially over the long term.

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.

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.

A significant portion of teens work while in school and the consequences of that work are of potential concern to society. While there is widespread support for combining work and school, and some evidence that employment has positive effects on youth development, previous research has revealed some potentially harmful consequences of employment among teens. In this paper, we investigate the relationship between teen employment and substance use. We extended this literature by studying two different cohorts of youth, and by exploiting arguably exogenous variation in youth employment and earnings caused by changes in minimum wages and the business cycle (unemployment). Estimates suggest that hours of work are positively associated with alcohol and cigarette use. However, if selection on unobserved variables were equal to selection on observed variables, these associations would be close to zero. With respect to the association between earnings and substance use, the evidence is less clear.

Low-birth-weight infants, in particular those with birth weights

Objective: During 2012-2015, the Centers for Disease Control and Prevention’s (CDC) Paul Coverdell National Acute Stroke Program (PCNASP) funded state health departments to improve the quality of stroke care in key clinical settings. The objective of this study was to assess costs for health departments and partners implementing PCNASP newly established programs. Methods: We developed Excel-based data collection instruments to collect costs associated with implementing stroke systems of care from volunteer PCNASP-funded health departments. Nine PCNASP-funded health departments were eligible based on program characteristics, six of which agreed to participate; five focused on pre- and in-hospital stroke care, and one also included transitions to post-hospital settings. These health departments partnered with a total of 467 organizations in their six states (37 to 125 partners per state). We used an activity-based costing approach to allocate costs across primary program activities: data collection, linkage, and management; clinical guidance and expertise; quality improvement (QI); building and maintaining partnerships; program evaluation; and administration. We collected costs to the health departments paid directly by PCNASP funds, in-kind contributions from the health department, and in-kind contributions from partners. Four of the six health departments received in-kind contributions from select partners. We analyzed costs by resource category (labor; materials, travel, services, equipment; contracts, consultants; overhead) and program activities across three settings: pre-hospital, in-hospital, and post-hospital. Results: Six health departments reported grant expenditures averaging $991,549 (ranging from $790,123 to $1,298,160) per health department over 36 months. Three of those health departments reported health department in-kind contributions averaging $374,439 (ranging from $5,805 to $1,394,097) for the same 36 months. Health departments reported greatest expenditures on labor (46%, ranging from 15% to 79%) and contracts and consultants (37%, ranging from 5% to 76%). Across program activities, health departments incurred costs for QI (37%, ranging from 17% to 60%); administration (19%, ranging from 7% to 39%); data (17%, ranging from 15% to 79%); partnerships (10%, ranging from 2% to 23%); clinical guidance (9%, ranging from 4% to 16%); and evaluation (8%, ranging from 4% to 15%). Four health departments collected in-kind contributions for 22 partners. Partners had average in-kind contributions of $373,211 (ranging from $1,040 to $1,421,729). Conclusion: Results from this study highlight key cost drivers of implementing components of stroke systems of care. This study was the first to comprehensively document actual costs of implementing QI for stroke systems of care across multiple programs and can inform future planning efforts.

We examine whether adults’ alcohol consumption and traffic fatalities are associated with the legal drinking environment those adults experienced between the ages of 18 and 20. We find that the difference between an environment in which a person was never allowed to drink legally at those ages and one in which a person could always drink legally is associated with a 20–33 percent increase in alcohol consumption and a 10 percent increase in fatal accidents for adult males. There are no statistically significant or practically important associations between the youths’ legal drinking environment and adult females’ alcohol consumption and driving fatalities.

Biological research predicts that giving children vitamin A supplements will significantly reduce mortality from diarrheal and respiratory infections, but evaluations of supplementation programs in the field have produced a wide range of estimated mortality effects. In this paper, I explain these differences by differential household behavioral responses to programs. I find evidence that the mortality effect varies by observable determinants of household allocation to children. Additionally, I find that households improve malaria prevention for children that receive vitamin A supplements and that this effect varies by the same household allocation determinants.

Introduction Computer simulation offers the ability to compare diverse interventions for reducing cardiovascular disease risks in a controlled and systematic way that cannot be done in the real world. Methods We used the Prevention Impacts Simulation Model (PRISM) to analyze the effect of 50 intervention levers, grouped into 6 (2 x 3) clusters on the basis of whether they were established or emerging and whether they acted in the policy domains of care (clinical, mental health, and behavioral services), air (smoking, secondhand smoke, and air pollution), or lifestyle (nutrition and physical activity). Uncertainty ranges were established through probabilistic sensitivity analysis. Results Results indicate that by 2040, all 6 intervention clusters combined could result in cumulative reductions of 49% to 54% in the cardiovascular risk-related death rate and of 13% to 21% in risk factor-attributable costs. A majority of the death reduction would come from Established interventions, but Emerging interventions would also contribute strongly. A slim majority of the cost reduction would come from Emerging interventions. Conclusion PRISM allows public health officials to examine the potential influence of different types of interventions - both established and emerging - for reducing cardiovascular risks. Our modeling suggests that established interventions could still contribute much to reducing deaths and costs, especially through greater use of well-known approaches to preventive and acute clinical care, whereas emerging interventions have the potential to contribute significantly, especially through certain types of preventive care and improved nutrition.

Objectives: We explore the complex factors associated with infant feeding by analyzing what mother, infant, and household factors are associated with the types of food given to infants. We seek to quantify associations in order to inform public health policy about the importance of target populations for infant feeding programs. Methods: We used data from the Demographic Health Survey in 20 developing countries for multiple years to examine mother, infant, and household factors associated with six types of food given to infants (exclusive breastfeeding, non-exclusive breastfeeding, infant formula, milk liquids, non-milk liquids, and solid foods). We performed a seemingly unrelated regressions analysis with community-year fixed effects to account for correlation between food types and control for confounding factors associated with community resources, culture, time period, and geography in the pooled analysis.Results: We found that several mother, infant, and household characteristics were associated with each of the feeding types. Most notably, mother’s education, working status, and weight are significantly associated with the type of food given to infants. We provide quantified estimates of the association of each of these variables with six types of food given to infants. Conclusions: By identifying maternal characteristics associated with infant feeding and quantifying those associations, we help public health policymakers generate priorities for targeting infant feeding programs to specific populations that are at greatest risk. Higher educated, working mothers are best to target with exclusive breastfeeding programs for young infants. Mothers with lower education are best to target with complementary feeding programs in infants older than 1 year. Finally, while maternal weight is associated with higher levels of exclusive breastfeeding the association is too weak to merit targeting of breastfeeding programs to low-weight mothers.

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.

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, nonexclusive 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 centimeters and weight by 0.25 kilograms 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 nonmilk 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.

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.

We examine whether adult alcohol consumption and traffic fatalities are associated with the legal drinking environment when a person was between the ages of 18 and 20. We find that moving from an environment in which a person was never allowed to drink legally to one in which a person could always drink legally was associated with a 20 to 30 percent increase in alcohol consumption and a ten percent increase in fatal accidents for adult males. There were no statistically significant or practically important associations between the legal drinking environment when young and adult female alcohol consumption and driving fatalities.

In this paper, we investigate the association between weight and adolescent's educational attainment, as measured by highest grade attended, highest grade completed, and drop out status. Data for the study came from the 1997 cohort of the National Longitudinal Survey of Youth (NLSY), which contains a large, national sample of teens between the ages of 14 and 18. We obtained estimates of the association between weight and educational attainment using several regression model specifications that controlled for a variety of observed characteristics. Our results suggest that, in general, teens that are overweight or obese have levels of attainment that are about the same as teens with average weight.

In this paper, we investigate the association between weight and adolescent's educational attainment, as measured by highest grade attended, highest grade completed, and drop out status. Data for the study came from the 1997 cohort of the National Longitudinal Survey of Youth (NLSY), which contains a large, national sample of teens between the ages of 14 and 18. We obtained estimates of the association between weight and educational attainment using several regression model specifications that controlled for a variety of observed characteristics. Our results suggest that, in general, teens that are overweight or obese have levels of attainment that are about the same as teens with average weight.