Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known. (JAMA1988;260:1743-1748)

https://jamanetwork.com/journals/JAMA/articlepdf/374139/jama_260_12_033.pdf

The Quality of Care: How Can It Be Assessed?

Background Although the protective efficacy of pneumococcal polysaccharide vaccine has been demonstrated in randomized trials in young African gold miners, there has been controversy about its efficacy in older Americans at risk for serious pneumococcal infections. To assess the vaccine's protective efficacy against invasive pneumococcal infections, we conducted a hospital-based case-control study of the efficacy of pneumococcal vaccine in adults with a condition recognized to be an indication for receiving the vaccine. Methods From 1984 to 1990, adults in whom Streptococcus pneumoniae was isolated from any normally sterile site were identified by prospective surveillance in the microbiology laboratories of 11 large hospitals; those with an indication for pneumococcal vaccine were enrolled as case patients. For each case patient, one control was matched according to age, underlying illness, and site of hospitalization. We contacted all providers of medical care to ascertain each subject's history of immunization with pneumococcal vaccine. Isolates of S. pneumoniae were serotyped by an investigator unaware of the subject's vaccination history. Results Thirteen percent of the 1,054 case patients and 20 percent of the 1,054 matched controls had received pneumococcal vaccine (P less than 0.001). When vaccine was given in either its 14-valent or its 23-valent form, its aggregate protective efficacy (calculated as a percentage: 1 minus the odds ratio of having been vaccinated times 100) against infections caused by the serotypes represented in the vaccine was 56 percent (95 percent confidence interval, 42 percent to 67 percent; P less than 0.00001) for all 983 patients infected with a serotype represented in the vaccine, 61 percent for a subgroup of 808 immunocompetent patients (95 percent confidence interval, 47 percent to 72 percent; P less than 0.00001), and 21 percent for a subgroup of 175 immunocompromised patients (95 percent confidence interval, -55 percent to 60 percent; P = 0.48). The vaccine was not efficacious against infections caused by serotypes not represented in the vaccine (protective efficacy, -73 percent; 95 percent confidence interval, -263 percent to 18 percent; P = 0.15). Conclusions Polyvalent pneumococcal vaccine is efficacious in preventing invasive pneumococcal infections in immunocompetent patients with indications for its administration. This vaccine should be used more widely.

https://www.nejm.org/doi/pdf/10.1056/NEJM199111213252101

The protective efficacy of polyvalent pneumococcal polysaccharide vaccine.

OBJECTIVE To determine whether published cost-effectiveness and cost-benefit analyses have adhered to basic analytic principles. DESIGN Structured methodologic review of published articles. STUDY SAMPLE Seventy-seven articles published either from 1978 to 1980 or from 1985 to 1987 in general medical, general surgical, and medical subspecialty journals. MAIN OUTCOME MEASUREMENTS Articles were reviewed to assess the use and reporting of six fundamental principles of analysis. These principles were derived by reviewing widely cited textbooks and articles describing the methods for performing economic analyses and by selecting the methods universally recommended. MAIN RESULTS Overall performance was only fair. Three articles adhered to all six principles, and the median number of principles to which articles adhered was three. Among the problems noted were failure to make underlying assumptions explicit and, therefore, verifiable, and failure to test assumptions with sensitivity analyses. No improvement in performance was observed between 1978 and 1987. Articles in general medical journals, however, were more likely to use analytic methods appropriately than articles in the general surgical or medical subspecialty literature. CONCLUSIONS Greater attention should be devoted to ensuring the appropriate use of analytic methods for economic analyses, and readers should make note of the methods used when interpreting the results of economic analyses.

Cost-effectiveness and cost-benefit analyses in the medical literature. Are the methods being used correctly?

https://www.nber.org/system/files/working_papers/w5946/w5946.pdf

Accounting for future costs in medical cost-effectiveness analysis.

Context. —Clinical, epidemiologic, and policy considerations support updating the cost-effectiveness of pneumococcal vaccination for elderly people and targeting the evaluation only to prevention of pneumococcal bacteremia. Objective. —To assess the implications for medical costs and health effects of vaccination against pneumococcal bacteremia in elderly people. Design. —Cost-effectiveness analysis of pneumococcal vaccination compared with no vaccination, from a societal perspective. Setting and Participants. —The elderly population aged 65 years and older in the United States in 3 geographic areas: metropolitan Atlanta, Ga; Franklin County, Ohio; and Monroe County, New York. Main Outcome Measures. —Incremental medical costs and health effects, expressed in quality-adjusted life-years per person vaccinated. Results. —Vaccination was cost saving, ie, it both reduced medical expenses and improved health, for all age groups and geographic areas analyzed in the base case. For people aged 65 years and older, vaccination saved $8.27 and gained 1.21 quality-adjusted days of life per person vaccinated. Vaccination of the 23 million elderly people unvaccinated in 1993 would have gained about 78 000 years of healthy life and saved $194 million. In univariate sensitivity analysis, the results remained cost saving except for doubling vaccination costs, including future medical costs of survivors, and lowering vaccination effectiveness. With assumptions most unfavorable to vaccination, cost per quality-adjusted life-year ranged from $35822 for ages 65 to 74 years to $598487 for ages 85 years and older. In probabilistic sensitivity analysis, probability intervals were more narrow, with less than 5% probability that the ratio for ages 85 years and older would exceed $100000. Conclusions. —Pneumococcal vaccination saves costs in the prevention of bacteremia alone and is greatly underused among the elderly population, on both health and economic grounds. These results support recent recommendations of the Advisory Committee on Immunization Practices and public and private efforts under way to improve vaccination rates.

Cost-effectiveness of Vaccination Against Pneumococcal Bacteremia Among Elderly People

We used cost-effectiveness analysis to examine the medical-care costs of vaccination against pneumococcal pneumonia in relation to its effects on health. Vaccination could add a year of healthy life among all age groups for about $4,800 in net medical-care costs. Cost-effectiveness ratios vary according to the age of the person vaccinated--from $1,000 per year of healthy life for an adult 65 years old or older to $77,000 per year of healthy life for a child between the ages of two and four. These ratios may change substantially with variations in such factors as the cost of vaccination, the duration of immunity, the efficacy and composition of the vaccine, and the percentage of pneumonia that is pneumococcal. This analysis has particular relevance for the Medicare program, since present legislation excludes coverage of most immunizations and other preventive services. Provision of pneumococcal vaccine to the elderly and inclusion of the vaccine as a Medicare benefit merit serious consideration.

Cost Effectiveness of Vaccination against Pneumococcal Pneumonia

https://www.jstor.org/stable/pdfplus/30109469.pdf

Claudia R. Sanders

Papers

Cost Effectiveness of Vaccination against Pneumococcal Pneumonia

Cost-Effectiveness and Cost-Benefit Analyses of Vaccines