Journal of Medical Economics

Purpose: Neurogenic dysphagia is prevalent in neurological inpatients and associated with adverse outcomes, yet its independent economic impact after adjustment for frailty and functional status remains poorly quantified. We aimed to estimate the independent effect of dysphagia on hospital length of stay (LOS) and costs, to test whether this effect differs between geriatric and non-geriatric patients, and to quantify the probability and magnitude of cost savings from improvements in swallowing function. Methods: We analysed 10,375 neurological inpatient cases (2021-2024) at a German university hospital. Dysphagia was defined by fiberoptic endoscopic evaluation of swallowing (FEES) or ICD-10 R13 coding (n = 1,382; 13.3%). Bayesian Gamma-log regression with informative priors from historical data and published literature was used to model LOS and total case costs (German DRG), adjusted for age, sex, Hospital Frailty Risk Score (HFRS, R13-adjusted), self-care index ("Selbstpflege-Index", SPI), stroke status, and emergency admission. A geriatric cohort was defined as age >=70 and adjusted HFRS >=5 (n = 2,053; 19.8%). Posterior predictive simulation estimated cost savings for hypothetical improvements of 1-3 points on the Functional Oral Intake Scale (FOIS). Results: After comprehensive adjustment, dysphagia was independently associated with 46.5% longer LOS (posterior ratio 1.465; 95% credible interval [CrI] 1.397-1.537) and 28.2% higher total case costs (ratio 1.282; CrI 1.213-1.354). The dysphagia x geriatric interaction was small but credible and ran in opposite directions: slightly attenuated for LOS (interaction ratio 0.908, CrI 0.837-0.986) but slightly amplified for costs (1.096, CrI 1.012-1.185), consistent with complexity-driven DRG grouping in geriatric patients. The absolute economic burden remained larger in the geriatric cohort due to higher baseline costs. In the geriatric cohort, a one-point FOIS improvement yielded a 74.3% posterior probability of LOS-based savings (mean EUR 555/case); at three points, this rose to 84.2% (mean EUR 1,115/case). The direct cost model confirmed high benefit probabilities from the payer's perspective (82.6% at dFOIS = 3). Conclusions: Neurogenic dysphagia is an independent and substantial driver of hospital LOS and costs in neurological inpatients, even after adjustment for frailty and functional status. The proportional effect on costs is slightly larger in geriatric patients, while the LOS effect is slightly smaller, consistent with the mechanics of the G-DRG system. Bayesian simulation indicates that improvements in swallowing function carry a high probability of generating cost savings, supporting the characterisation of dysphagia as a modifiable economic target with particular relevance to geriatric neurology.

Introduction The link between Human Papillomavirus (HPV) and cancer is well-established. In Singapore, bivalent HPV vaccines are subsidised for females, but not males. Economic analysis of HPV vaccination has generally assessed the costs to the health system, but this may not be as relevant to individual decision-making as potential lost income. We estimated the impact of bivalent HPV 16/18 vaccination on sick leave, unemployment, and premature mortality as a function of age and sex to understand the broader impact of HPV-related cancers. Methods We developed a population-level economic model to estimate lifetime income losses by diagnosis age, sex and cancer type. We applied sex- and cancer-specific Cox regressions to the Singapore Cancer Registry for annual predicted survival from 1992 to 2022. These were combined with census and employment data to estimate HPV-associated income losses in Singapore. Attributable fractions and vaccine effectiveness data for HPV 16/18 from the literature were used to estimate the effectiveness of bivalent HPV vaccination. Structural sensitivity analysis examined the role of 80% population coverage conferring herd immunity. Results The registry contained 17,294 individuals with an HPV-associated cancer diagnosis. Lost income was greatest for cervical cancer due to its high prevalence, however the losses per diagnosis were highest for oropharyngeal cancer. Bivalent HPV vaccination led to income benefits of $SGD1,397 [$895 to $1,838] in girls and -$62 [-$76 to -$48] in boys. A gender-neutral HPV vaccination of 80% of 15-year-old Singaporeans, conferring herd immunity, would have lifetime income protective benefits of $24.4m [$14.2m, $33.7m] per cohort, a five-fold return on investment. Conclusions In addition to avoiding healthcare costs and lost quality of life, parents should consider vaccination as a means of avoiding potential income losses. A national policy of gender-neutral HPV vaccination could deliver substantial income protection due to both individual vaccine protection and herd immunity.

Objective: To externally validate a risk stratified delivery timing model for nulliparous, term, singleton, vertex (NTSV) cesarean reduction using national data. Design: Population based cohort study of NTSV births in US National Vital Statistics System (NVSS) natality files, 2020 to2024, using logistic regression for cesarean predictors and risk stratified Monte Carlo simulation (10,000 iterations per strategy and risk group) to evaluate delivery timing policies. Setting: All live births in the US recorded in the NVSS natality files. Participants: NTSV patients with term (37+ weeks) pregnancies and complete gestational age and delivery mode data (N=5 776 412). A sensitivity cohort excluded pre 39 week deliveries and pregnancies with preexisting diabetes or hypertension. Exposures: Delivery timing strategies defined by gestational age and labor onset (elective induction at 39, 40, or 41 weeks, or expectant management to 42 weeks), evaluated within maternal age and body mass index (BMI) risk strata (low: age <35 and BMI <30; moderate: age > 35 or BMI > 30; high: age > 35 and BMI > 35). Main Outcomes and Measures: Primary outcome was cesarean delivery, measured as the proportion of deliveries completed by cesarean across gestational ages, labor onset types, and age BMI strata. Secondary outcomes included gestational age specific cesarean rates, area under the receiver operating characteristic curve (AUC) for cesarean prediction, and simulated mean cesarean rates with 95% simulation intervals under four delivery timing strategies within each risk group. Results: The overall NTSV cesarean rate was 26.4%. Cesarean Rates were U shaped across gestational ages, with the lowest rate at 38 weeks (24.9%) and higher rates at 37 weeks (29.8%) and 41 to 42 weeks (28.1 to 28.5%). Risk group distribution was 64.9% low, 33.7% moderate, and 1.4% high. Model AUC was 0.65. Induction had higher cesarean rates than spontaneous labor (29.3% vs 24.2%; odds ratio 1.30, 95% confidence interval 1.29 to 1.30). Monte Carlo simulation favored induction at 39 weeks for high risk patients (59.3%) and expectant management to 41 to 42 weeks for low risk patients (19.1%). Conclusions and Relevance: A risk stratified NTSV labor management model showed external validity in 5.8 million US births and consistently identified risk-specific timing strategies that lowered cesarean rates, supporting individualized delivery timing policies.

Objective: To externally validate, at the national level, a cumulative risk score for vaginal birth after cesarean (VBAC) success and neonatal morbidity derived from single center data. Methods: We conducted a population based cohort study of all trial of labor after cesarean (TOLAC) attempts among term, singleton deliveries recorded in the Centers for Disease Control and Prevention natality files, 2020 to 2024 (N=477,693). The cumulative risk score (range - 1 to 7 points) incorporated body mass index (BMI) 30 or greater (+1), BMI 40 or greater (+1), induction of labor (IOL; +1), diabetes mellitus (+1), hypertensive disorder (+1), maternal age 40 years or older (+1), gestational age 41 weeks or greater (+1), and prior vaginal delivery (-1). VBAC success rates and neonatal intensive care unit (NICU) admission rates were evaluated across risk strata. Results: The overall VBAC rate was 73.3% (350,340/477,693). The cumulative risk score demonstrated a monotonic relationship with VBAC success: score -1, 90.5%; score 0, 76.4%; score 1, 69.4%; score 2, 62.2%; score 3, 55%; and score 4 or higher, 44.8%. NICU admission rates increased concordantly from 43.8 to 111.1 per 1,000 across strata. Prior vaginal delivery was the strongest individual predictor (VBAC 86.4% vs 62.5%). VBAC rates and TOLAC volume were stable across 2020 to 2024. Conclusion: The cumulative risk score derived from single center data was externally validated in a national cohort of 477,693 TOLAC attempts. The monotonic dose-response relationship between risk score and both VBAC success and NICU admission was confirmed, supporting the use of this score for individualized TOLAC counseling.

Background: In Burkina Faso, typhoid fever remains a major public health concern, with a high incidence among children younger than 15 years of age. To address this burden, the country introduced typhoid conjugate vaccine in January 2025 through a national vaccination campaign reaching children aged 9 months to 14 years. This study aimed to estimate the cost of typhoid conjugate vaccine delivery during the national campaign and to identify the main cost drivers across different administrative levels. Methods: We conducted a cross-sectional, retrospective costing study using a microcosting approach from the government perspective. We collected data from fifty health facilities, eight health districts, five health regions, and the national level. Financial and economic costs were estimated for each level, excluding vaccine and syringe costs. All costs were converted to 2024 USD using the official exchange rate. Findings: Vaccinators administered a total of 10.5 million typhoid conjugate vaccine doses. The average financial cost per dose was $0.47 (95% CI: $0.39-$0.51), and the economic cost was $2.16 (95% CI: $1.71-$2.56). Human resources and per diem payments were the main contributors to costs. Costs varied by geography, delivery strategy, and security context, with higher costs observed in rural and conflict-affected areas. The mobile-temporary posts strategy had the highest economic cost per dose ($2.02; 95% CI: $1.64-$2.40), while the fixed strategy had the highest financial cost per dose ($0.41; 95% CI: ($0.32-$0.49). Conclusion: The financial cost per dose remained within Gavi, the Vaccine Alliance's operational support range. The observed cost variations highlight the need for targeted funding and enhanced logistical support to ensure equitable access, particularly in rural and insecure areas. This study provides evidence to inform future vaccination campaigns and supports decision-making for typhoid conjugate vaccine introduction in other countries in the region.

Background: COVID vaccination with periodically updated compositions remains important as SARS-CoV-2 continues to circulate, cause disease, and evolve. Available COVID-19 vaccines in the 2024-2025 season differed by platform, including mRNA-1273, an mRNA-based vaccine, and NVX-CoV2705, a recombinant protein-based vaccine and antigen composition (KP.2-targeted and JN.1-targeted, respectively). There is limited head-to-head real-world evidence comparing the effectiveness of these different approaches to prevention of severe outcomes with COVID-19. We compared mRNA-1273 with protein-based NVX-CoV2705 in insured US adults vaccinated during the 2024-2025 season. Methods: We conducted a retrospective matched cohort study in a large US claims database. Adults aged 18 years or older who received mRNA-1273 or NVX-CoV2705 between Aug 31, 2024 and Feb 28, 2025 were eligible. Recipients were exactly matched 2:1 on key demographic and clinical factors and then weighted with stabilized inverse probability of treatment weights. Outcomes were medically-attended COVID-19 and hospitalization with COVID-19 from day 7 after vaccination through up to 180 days of follow-up. We calculated comparative vaccine effectiveness (cVE) as 100 x (1-- hazard ratio). Results: Of 858,138 eligible mRNA-1273 recipients and 34,667 eligible NVX-CoV2705 recipients, 69,140 and 34,570, respectively, entered the matched cohort. Median (Q1, Q3) follow-up was 180 (163, 180) days for mRNA-1273 and 180 (162,180) for NVX-CoV2705. Medically attended COVID-19 occurred in 706 (1.02%) mRNA-1273 recipients and 512 (1.48%) NVX-CoV2705 recipients; adjusted cVE (95% CI) was 31.7% (23.4%, 39.1%). Hospitalization with COVID-19 occurred in 61 (0.09%) and 49 (0.14%) recipients, respectively; adjusted cVE (95% CI) was 40.7% (13.5%, 59.4%). In the 47,754 mRNA-1273 recipients matched to 23,877 NVX-CoV2705 recipients aged [&ge;]65, adjusted cVE (95% CI) was 25.7% (15.4%, 34.8%) against medically-attended COVID-19 and 41.7% (14.3%, 60.4%) against hospitalization with COVID-19. Conclusions: In this insured US adult population, mRNA-1273 demonstrated greater effectiveness against medically attended COVID-19 and hospitalization with COVID-19 than the protein-based NVX-CoV2705. These findings highlight the potential public-health importance of considering vaccine platform and variant selection when planning for upcoming seasons.

Introduction Cesarean delivery accounts for nearly one-third of U.S. births and is associated with substantial maternal morbidity and health care costs. Persistent racial disparities have been documented, yet the structural factors contributing to these differences remain incompletely understood. The extent to which insurance coverage shapes racial disparities in cesarean delivery remains unclear. Objective To evaluate the independent and interactive associations of race/ethnicity and insurance coverage with cesarean delivery in the United States. Methods Population-based retrospective cohort study using singleton live births recorded in the United States Vital Statistics Natality files from 2014 to 2024. Multivariable logistic regression was used to estimate the independent effects of race/ethnicity and insurance status on cesarean delivery, including interaction terms to test effect modification, using national birth certificate data. Models were adjusted for maternal demographics, clinical factors, and temporal covariates. Adjusted odds ratios, predicted probabilities, and absolute risk differences were derived from post-estimation marginal effects. The main outcome measure was cesarean delivery (yes vs no). Results Among 41,543,568 deliveries from 2014 to 2024, 13,312,221 (32.0%) were cesarean deliveries. After adjustment, both race and ethnicity and insurance status were independently associated with cesarean delivery. Compared with non-Hispanic White women, non-Hispanic Black women had higher odds of cesarean delivery (odds ratio [OR], 1.22; 95% CI, 1.22-1.23). Relative to uninsured women, those with private insurance had 59% higher odds of cesarean delivery (OR, 1.59; 95% CI, 1.58-1.60). Significant interaction effects were observed, indicating that insurance coverage modified racial and ethnic differences in cesarean delivery. Non-Hispanic Black women had the highest predicted probabilities across all insurance categories, with the largest absolute disparities observed among uninsured women. Conclusion Racial and ethnic differences in cesarean delivery persist in the United States and are modified by insurance coverage, suggesting that coverage-related differences may contribute to inequities in obstetric care.

Purpose: We evaluated healthcare resource utilization (HCRU) and costs in patients with eosinophilic granulomatosis with polyangiitis (EGPA). Methods: Patients with newly diagnosed EGPA (2017--2021), [&ge;]12 months' pre-diagnosis health plan enrollment, and [&ge;]1 inpatient or [&ge;]2 outpatient claims with an EGPA diagnosis were included. Follow-up was from EGPA diagnosis until disenrollment or database end. HCRU and health insurer payment costs during follow-up were compared with those for matched cohorts of general insured patients without EGPA (comparison A) and without EGPA but with severe uncontrolled asthma (SUA; comparison B). Results: In comparison A, all-cause HCRU was higher in the EGPA cohort (n = 213) versus matched patients (n = 779) for all clinical encounters/pharmacy claim types; annualized, mean total all-cause costs were 16-fold higher ($117,563/patient) versus matched patients ($7,520/patient). In comparison B, all-cause HCRU was higher for the EGPA cohort (n = 182) versus the matched SUA cohort (n = 640) for all clinical encounters/pharmacy claim types, with 5-fold higher mean total all-cause costs ($118,127/patient vs $22,286/patient). In both EGPA cohorts, HCRU and associated costs increased between the baseline and follow-up periods. Conclusions: These findings highlight the need for more effective treatments to reduce the clinical and economic burden of EGPA.

OBJECTIVE: To evaluate the return on investment (ROI) of a community based Diabetes Self Management Program (DSMP) enhanced with health related social needs (HRSN) screening and referrals, implemented by the New York City (NYC) Department of Health and Mental Hygiene with three community based organizations in highly impacted, under resourced neighborhoods. RESEARCH DESIGN AND METHODS: A retrospective cost benefit analysis from a public sector payer perspective was conducted among 171 adults with type 2 diabetes who completed a six week, peer led DSMP delivered by community health workers (CHWs) in English, Spanish, and Korean during 2018 2019. A time driven, activity based costing model captured direct implementation costs, CHW workforce turnover, and administrative overhead. Monetized benefits included avoided diabetes related complications, reductions in self reported emergency department (ED) visits and hospitalizations, and quality adjusted life year (QALY) gains from improved medication adherence. Univariate sensitivity analyses tested robustness under conservative assumptions. RESULTS: Total program costs were $179,224; monetized benefits totaled $1,824,213, yielding a net benefit of $1,644,989 and an ROI of 918%, approximately $10 returned per $1 invested. Excluding QALY gains, ROI remained 551%. Self reported ED visits declined from 149 to 82 and hospitalizations from 93 to 24 in the six months following intervention. Over 80% of participants reported housing instability; 72% were Medicaid covered and 16% uninsured. Sensitivity analyses confirmed a positive ROI under all conservative scenarios. CONCLUSIONS: A CHW led, community based DSMP integrated with HRSN screening and referrals delivered substantial economic and public health value among adults facing housing instability and structural barriers to care. Findings support inclusion of DSMP as a covered benefit in Medicaid managed care, value based payment arrangements, and housing access initiatives to advance equitable diabetes outcomes.

Background: Rising antimicrobial resistance in Neisseria gonorrhoeae threatens the effectiveness of existing therapies. Resistance-guided treatment (RGT) may reduce treatment failures, complications, and inappropriate use of last-line agents while slowing resistance emergence. Methods and Findings: We developed an individual-level stochastic simulation model of gonorrhea diagnosis and treatment in the United States, incorporating infection prevalence, symptom status, diagnostic accuracy, resistance profiles, treatment pathways, and partner management (costs in 2025 USD). We evaluated three resistance testing strategies, ciprofloxacin-only, ciprofloxacin+ceftriaxone, and triple-target (including a novel drug A), across a wide range of resistance scenarios. We quantified economic value across three dimensions: (1) per-episode direct medical cost savings, (2) system-level costs attributable to ceftriaxone resistance emergence among MSM, and (3) avoided costs of new antibiotic development, estimating the maximum per-test price at which RGT remains cost-neutral. Per-episode cost-neutrality thresholds ranged from near $0 when ceftriaxone resistance was absent to up to $45/test at 15% ceftriaxone resistance. At 50% ciprofloxacin and 5% ceftriaxone resistance, the population-weighted threshold was $4 (95% UI:$3-$8) for a CIP-only test and $11 (95% UI:$5-$14) for a triple-target test. Among MSM, incorporating system-level resistance emergence costs and avoided antibiotic development costs increased the total per-test value to $35-$145 for a single-target test and $84-$128 for a triple-target test, depending on whether prescribing practices shift when ceftriaxone resistance reaches 5%. Conclusions: Resistance-guided therapy offers economic benefits across multiple dimensions even at relatively high diagnostic prices, supporting investment in gonorrhea resistance testing to improve partner outcomes, delay resistance emergence, and enhance the long-term cost-efficiency of gonorrhea management.

Background: The 2025/2026 COVID-19 vaccine season introduced updated formulations targeting the LP.8.1 lineage. This study assessed the absolute vaccine effectiveness (aVE) of mRNA-1283 and BNT162b2 on COVID-19 outcomes in adults aged [&ge;]65 years. Methods: Background: The 2025/2026 COVID-19 vaccine season introduced updated formulations targeting the LP.8.1 lineage. This study assessed the absolute vaccine effectiveness (aVE) of mRNA-1283 and BNT162b2 on COVID-19 outcomes in adults aged [&ge;]65 years. Methods: This retrospective study used linked electronic health record and administrative claims data through Jan 31, 2026. Adults [&ge;]65 years who received the mRNA-1283 or BNT162b2 2025/2026 COVID-19 vaccine were matched to unvaccinated individuals. Inverse probability of treatment weighting was applied to matched cohorts of each vaccine to balance covariates. Each vaccine was evaluated independently against its own unvaccinated comparator group. aVE against COVID-19 related hospitalization and medically-attended COVID-19 was estimated using Cox proportional hazards models; aVE = 100 x (1 - hazard ratio [HR]). Results: We identified 233,072 mRNA-1283 recipients and 422,610 BNT162b2 recipients [&ge;]65 years. The aVE (95% confidence interval) of mRNA-1283 against COVID-19 related hospitalization and medically-attended COVID-19 was 59.3% (39.0%, 72.9%) and 42.0% (35.0%, 48.3%) among adults [&ge;]65 years and 66.9% (45.9%, 79.8%) and 50.2% (42.1%, 57.2%) in [&ge;]75 years, respectively. The aVE of BNT162b2 against COVID-19 related hospitalization and medically-attended COVID-19 was 48.3% (32.4%, 60.5%) and 41.2% (36.2%, 45.8%) in [&ge;]65 years and 45.9% (26.0%, 60.4%) and 44.0% (37.8%, 49.6%) in [&ge;]75 years, respectively. Conclusions: This is the first real-world evidence showing that mRNA-1283 prevents COVID-19-related hospitalizations and medically attended events in vulnerable older adults at highest risk of severe disease. These findings support mRNA-1283 as an important public health tool for reducing the ongoing burden of COVID-19.Results: We identified 233,072 mRNA-1283 recipients and 422,610 BNT162b2 recipients [&ge;]65 years. The aVE (95% confidence interval) of mRNA-1283 against COVID-19 related hospitalization and medically-attended COVID-19 was 59.3% (39.0%, 72.9%) and 42.0% (35.0%, 48.3%) among adults [&ge;]65 years and 66.9% (45.9 %, 79.8%) and 50.2% (42.1%, 57.2%) in [&ge;]75 years, respectively. The aVE of BNT162b2 against COVID-19 related hospitalization and medically-attended COVID-19 was 48.3% (32.4%, 60.5%) and 41.2% (36.2%, 45.8%) in [&ge;]65 years and 45.9% (26.0%, 60.4%) and 44.0% (37.8%, 49.6%) in [&ge;]75 years, respectively. Conclusions: This is the first real-world evidence showing that mRNA-1283 prevents COVID-19-related hospitalizations and medically attended events in vulnerable older adults at highest risk of severe disease. These findings support mRNA-1283 as an important public health tool for reducing the ongoing burden of COVID-19.

BackgroundArtificial intelligence and machine learning (AI/ML) are among the fastest-growing domains in NIH research funding, but whether children have shared equitably in this expansion is unknown. We characterized pediatric representation in NIH AI/ML funding from fiscal years (FY) 2020 to 2024. MethodsNIH grant data were obtained from Research Portfolio Online Reporting Tools Expenditures and Results bulk files for FY2020 to FY2024. AI/ML grants were identified using the NIH Research, Condition, and Disease Categorization "Machine Learning and Artificial Intelligence" category, and pediatric grants using the "Pediatric" category. Subprojects were excluded. Grants were deduplicated within each fiscal year by core project number for trend analyses and across all years retaining the most recent fiscal year for cross-sectional totals. Disease areas were identified by keyword searches of titles and abstracts. ResultsAcross FY2020 to FY2024, 5,624 unique NIH AI/ML grants totaling $3,371 million were identified. Of these, 836 grants (14.9%) were classified as pediatric, representing $401 million (11.9%) of total NIH AI/ML funding. Although this share was consistent with the historically reported overall NIH pediatric funding baseline of approximately 10% to 12%, it remained substantially below the US pediatric population share of approximately 22%. The pediatric share of NIH AI/ML funding declined from 12.3% in FY2020 to 10.8% in FY2024, despite growth in absolute pediatric funding. Indexed to FY2020, pediatric AI/ML funding grew approximately 2.6-fold compared with 3.0-fold growth in the total portfolio. Across disease areas, unadjusted adult/general-to-pediatric funding ratios ranged from 2.0-fold in mental health to 9.8-fold in cancer. ConclusionsPediatric representation in NIH AI/ML funding remained low and declined over time as the overall portfolio expanded. These findings suggest that growth in NIH AI/ML investment has not been matched by proportional gains for pediatric research.

BackgroundCarrier screening for inherited genetic disorders can reduce the burden of conditions that lead to childhood morbidity and mortality, including thalassaemia, cystic fibrosis, and spinal muscular atrophy. To be successful, national carrier screening programs should aim to maximise uptake, which may depend on population preferences for screening characteristics. In this study, we aimed to determine how expanded carrier screening in Singapore should be designed based on operational factors including suggested copayments, wait times, and disorders included in screening panels. MethodsWe elicited stated preferences for the design of a hypothetical national carrier screening program with seven attributes from 500 Singaporeans of reproductive age (18 to 54). A discrete choice experiment was applied using 30 choice tasks with 3 alternatives per task, divided between 3 blocks. The mixed multinomial logit model was used to estimate willingness-to-pay for each attribute level. Predicted uptake for three plausible screening programs was assessed, with copayment amounts from $0 to $1,200 in increments of $30. Impact on the annual national budget was calculated as a function of 25,000 expected eligible couples per year. All costs were reported in 2026 SGD. ResultsRespondents showed the strongest preferences for cost, followed by the number of diseases included in the panel, then wait times, with limited impact of remaining attributes. With no copayments, predicted uptake ranged from 85% [95% CI: 83% to 87%] to 90% [88% to 92%] for the basic and utility-maximising screening programs, respectively. This declined to 61% [56% to 66%] and 69% [65% to 73%] and, respectively, at a copayment of $1,200 per test. The model predicted higher uptake if a selection of screening alternatives were available, compared to a single program. The budget impact was highly dependent on population eligibility, copayments, and couples decision-making processes, but was unlikely to exceed $22.5m [$19.0m to $26.6m] per year unless expanded beyond married couples. ConclusionsThere was high predicted demand for carrier screening even as copayments increased. Successful strategies to improve uptake may include reducing copays and wait times, increasing the number of screening options available to prospective parents, and increasing program eligibility beyond pre-conception married couples.

Background Vaccine-preventable diseases (VPDs) continue to impose a significant health and economic burden globally, despite advances in immunization programs. Narrower to the context of Saudi Arabia, the current literature consistently shows that the high vaccination coverage has had the primary impact of reducing disease incidence. Regardless, the broader economic impact of VPDs and the financial benefits of immunization remain important for policy evaluation within Saudi Arabia. Methods This study employed a model-based economic evaluation using a societal perspective in order to carry out an estimation of the economic burden of measles, influenza, and pneumococcal diseases. We utilized the Cost of Illness (COI) approach for the purpose of quantifying direct medical costs and indirect productivity losses. On the other hand, the Value of Statistical Life (VSL) approach helped in the estimation of the monetary value of mortality reduction. A comparative framework analyzed current vaccination coverage against a counterfactual no-vaccination scenario for the calculation of the return on investment (ROI). Results The estimated annual economic burden of the three selected VPDs in the absence of vaccination was USD 385 (95% CI: 315-460) million. Immunization programs generated substantial economic benefits, with total benefits estimated at USD 1085 (95% CI: 815-1360) million annually. The calculated ROI was 9.0 (95% CI: 6.8-11.3), essentially an indication that for each dollar invested in vaccination, there was multiple economic returns yielded. Sensitivity analyses confirmed the robustness of these findings. Conclusion Immunization programs in Saudi Arabia provide significant economic and public health benefits and for this reason, sustained investment in vaccination is fundamentally essential towards the reduction of disease burden, improve population health, and ultimately support long-term economic productivity.

We aimed to evaluate disparities in perinatal ICU admissions at an urban medical center and to contextualize these findings relative to national U.S. data provided by the Centers for Disease Control and Prevention (CDC). To do so, we performed a retrospective review of all pregnant and < 6-week postpartum patients admitted to the ICU between October 2023 and June 2025. The cohort included 58 patients: 81% were non-Hispanic Black, and 91% were publicly insured. These local data can be compared to national data, which demonstrate higher rates of severe maternal morbidity (SMM) and ICU admission among Black patients and those insured by Medicaid. In 2023, the U.S. maternal mortality rate was 18.6 per 100,000 live births, down from 22.3 in 2022. However, significant disparities persist, with mortality rates of 50.3 per 100,000 among Black women compared with 14.5 per 100,000 among White women. The most frequently reported indications for obstetric ICU admission include hypertensive disorders of pregnancy, obstetric hemorrhage, and severe underlying medical comorbidities.

Background: Cardiac rehabilitation (CR) is a cost-effective, evidence-based intervention that improves outcomes for patients with heart failure (HF), yet access remains inequitable, particularly among Medicaid enrollees. This study evaluates the state-by-state variability in Medicaid coverage for CR services and examines the implications for health equity in vulnerable populations. Methods: We conducted a cross-sectional policy analysis of all 50 U.S. states to assess Medicaid coverage for outpatient CR services billed under CPT codes 93797 (without ECG monitoring) and 93798 (with ECG monitoring). Publicly available Medicaid documents were reviewed and supplemented with direct communication with state Medicaid agencies. States were categorized into full, partial/inconclusive, or no coverage. Geographic trends were visualized through heat maps and contextualized using state-level Medicaid enrollment data. Results: Marked disparities in CR coverage were identified. Only 41 states reimbursed for CPT 93797, and 43 for CPT 93798. Eight states lacked coverage for either code, predominantly in the South and Mountain West, including Arkansas, Georgia, Louisiana, Mississippi, Nevada, and Utah. States with the highest Medicaid enrollment (e.g., Louisiana, Arkansas) often provided no CR coverage, compounding access barriers for high-risk, low-income populations. Conclusions: The absence of standardized Medicaid coverage for CR contributes to systemic inequities in cardiovascular care, disproportionately impacting disadvantaged communities. Aligning Medicaid policies to ensure universal CR access--particularly through tele-rehabilitation and value-based care models--could reduce hospitalizations, improve survival, and promote health equity across the U.S.

Background Type 2 diabetes mellitus (T2DM) is a chronic disease that imposes a significant burden on healthcare systems and society. In Vietnam, the prevalence of T2DM is rapidly increasing; however, evidence on treatment expenditure derived from large administrative databases remains limited. This study was carried out provides an overview of total treatment expenditures for T2DM across hospital tiers between 2018 and 2022. Methods This cross-sectional descriptive study utilized retrospective health insurance (HI) data from 2018-2022. Data was collected and analyzed based on cost components (medications, diagnostic tests, hospital beds, etc.) across healthcare facilities classified by hospital level. Costs were converted to 2024 USD using the CCEMG-EPPI-Centre cost converter. Results Total expenditure increased from 227.17 million USD in 2018 to 425.53 million USD in 2022 with spending concentrated in Class I and Class II healthcare facilities, although their shares declined over time, while the proportions attributed to unclassified and special-class facilities increased. Drugs accounted for the largest share of expenditure (49.65%-78.95%), followed by laboratory tests (7.31%-19.89%) across all hospital classifications. Other components, including hospital beds, diagnostic imaging, procedures/surgeries, and medical supplies, contributed smaller proportions but increased over time in several facility groups. Conclusion The study indicates that medication costs constitute the largest share of treatment expenditure for type 2 diabetes mellitus at healthcare facilities, reflecting the long-term treatment requirements of this chronic disease. In addition, health expenditure remained concentrated in Class I and Class II healthcare facilities, although their shares declined over the study period, while the proportions attributed to unclassified and special-class facilities increased. These findings suggest the need to strengthen diabetes screening, treatment, and follow-up at lower-level healthcare facilities in order to reduce the burden on higher-level hospitals and improve the efficiency of healthcare resource allocation.

Objective: To determine the incidence and clinical characteristics of surgical complications during pregnancy in women with a history of bariatric surgery. Design: A nationwide, prospective, population-based cohort study. Setting: High-risk obstetric care in Belgium: 67.6% of maternity units participated, covering 65% of all births in the study period. Participants: Pregnant women with a history of bariatric surgery presenting with a surgical complication (internal hernia, intussusception, volvulus or adhesions; anastomotic ulcer or abscess; gastric band slippage; or incisional hernia) between January 2021 and December 2022. Results: Thirty-three women experienced 35 surgical complications. Internal herniation was most common (n=25), predominantly following Roux-en-Y gastric bypass. Mean gestational age at diagnosis was 27+6 weeks. All women underwent surgical exploration within 24 hours; bowel resection was required in two cases. Caesarean section occurred in 48.5%, with 13 preterm births and one neonatal death. One woman required intensive care. No maternal death occurred. Conclusion: Surgical complications following bariatric surgery in pregnancy are uncommon but carry significant obstetric risks. All observed complications occurred after procedures involving intestinal rerouting, predominantly Roux-en-Y gastric bypass. Prompt surgical management was associated with low maternal morbidity and no mortality, but frequently resulted in preterm birth and emergency caesarean section. These findings highlight the need for a low threshold for surgical evaluation of abdominal pain in pregnant women with previous bariatric surgery and suggest that procedure type is relevant when counselling women of reproductive age.

BackgroundZero-dose children, defined as those who have not received the first dose of a diphtheria-tetanus-pertussis-containing vaccine (DPT1), are a key indicator of inequitable access to immunization services. Nigeria remains one of the largest contributors to the global burden of zero-dose children. This study estimated the prevalence of zero-dose children aged 12-23 months and identified individual-and community-level determinants using the 2024 Nigeria Demographic Health Survey (NDHS). MethodsA secondary analysis of cross-sectional analysis was conducted using data from 4,711 children aged 12-23 months in the 2024 NDHS kids recode dataset. A multilevel mixed-effects logistic regression model was fitted to account for the hierarchical structure of the data. Four models were compared: null, individual-level, community-level, and combined models. Adjusted odds ratios (AORs) with 95% confidence interval (CI) were used to identify significant determinants at p<0.05. ResultsThe weighted prevalence of zero-dose children was 37.3% (95% CI: 35.1-39.6%). Significant factors included birth order, maternal age, maternal occupation, parental education, household wealth, antenatal attendance, postnatal care utilization, place of delivery, religion, distance to health facilities, and geographical region. Children whose mothers had higher educational attainment, attending antenatal care, deliver in the health facilities, and received postnatal care were significantly less likely to be zero-dose status. Conversely, children from poorer households, those facing distance barriers to health facilities, those belongings to Muslim and traditional religion group and those residing in certain geographical regions had higher odds of zero-dose children, with significant regional variations observed. Conclusionzero-dose vaccination remains highly prevalent in Nigeria and is strongly influenced by socioeconomic disadvantage, maternal healthcare utilization, religion, and regional inequities. Strengthening integrated maternal and child health services and improving access in underserved regions are essential to achieving equitable vaccination coverage.

Prenatal depression is a substantial contributor to maternal morbidity, and screening is an entry point to psychiatric assessment and treatment during pregnancy. Following updated guidelines and quality metrics for prenatal depression screening, we evaluated whether screening uptake differed by preferred language within a large U.S. healthcare system. We used electronic health record data to identify a retrospective cohort of deliveries at or beyond 20 weeks gestation in 2019-2024. We used logistic regression with a language-year interaction to estimate the adjusted marginal probabilities of screening by language preference. Among 99,526 pregnancies (82,632 individuals), screening increased substantially over time but increases differed across language groups (p<0.001). In 2019, screening probabilities were similar (English 0.50; Spanish 0.48; Another Language 0.50). By 2024, probabilities diverged (English 0.81; Spanish 0.66; Another Language 0.71). Unequal screening uptake can systematically under-identify prenatal depression among patients with non-English language preference, with implications for equitable access to psychiatric care.