“Cost effectiveness analysis of school influenza vaccination program” Byung-Kwang (BK) Yoo, M.D., M.S., Ph.D. Assistant Professor Division of Health Policy and Outcomes Research Department of Community and Preventive Medicine University of Rochester School of Medicine and Dentistry 45th National Immunization Conference (NIC) Washington, D.C. March 31, 2011

Acknowledgement Disclosure Statement University of Rochester S Humiston, S Schaffer, P Szilagyi, C Long, W Russell, N Zhang CDC M Kolasa M Messonnier CDC Grant: U01P000195 Disclosure Statement Dr. Yoo (speaker) has no relevant financial relationships or conflicts of interest to disclose.

Background Expansion of target population of seasonal influenza vaccination Aged 6-23 mo (2004), up to 18 yr (2008) Limited capacity of traditional providers School-located seasonal influenza vaccination (SLV) might be more cost-effective

Objective To assess the cost-effectiveness of school-located seasonal influenza vaccination (SLV) from the intervention perspective. Major outcomes Cost per dose [2009 US$] Cost-effectiveness ratio (CER) [$-per-incremental-student-vaccinated in SLV schools, compared to control schools]

Methods 1 2009-2010 season in Monroe County, NY City of Rochester and its surrounding suburbs Randomized controlled trial Intervention: 21 (12 urban + 9 suburban) elementary schools (9,027 students) Control: 11 (6 urban + 5 suburban) schools (4,537 students) 2 vaccine clinics during school day at each school Also you may want to say that Monroe County contains the City of Rochester and its surrounding suburbs.  You don’t have to put this in the slide though

Methods 2 Total cost = (A) + (B) + (C) (A) School cost Material (paper & phone notice/newsletter) + labor (B) Project-coordinating cost collection, validation and follow-up of consent forms. (C) Vendor cost vaccine purchase + labor + over-head (*) Vendor = separate team from project-coordinating team Calculation of labor costs: [reported working hours] x [job-category specific hourly wage (at national ave. in $2009)]

Table 1. Vaccination rates in all schools SLV schools Control schools [students] [% total students] Total 9,027 100% 4,534 Vaccinated elsewherea 2,474 27% 1,339 30% Vaccinated at least 1st dose at schoolb,c 1,381 15% 0% Vaccinated anywhere 3,855 43% a: Identified as receiving at least the 1st dose outside the SLV schools in the New York State registry data b: Identified as receiving at least the 1st dose at the SLV schools either (i) in the New York State registry data or (ii) in the vendor’s data c: 1st doses = 1324, 2nd doses = 385, Total doses = 1709 (=19 % total students) Data source: 031011_0214_mcskipp_school_CEA_suiv_230pm_tom

Table 2. Cost Analysis [$ per dose]a Cost analysisa Cost [$ per dose] (A) School Cost $9.25 (B) Project Costb $23.22 (C1) Vendor Cost (excluding vaccine purchase) $20.07 (C2) Vendor Cost $25.60 (C3) Vendor Cost (assume VFC vaccine [$9.94 / dose])c $32.65 Total Cost: (A)+(B)+(C1)d $52.54 Total Cost: (A)+(B)+(C2) $58.06 Total Cost: (A)+(B)+(C3) $65.11 a: Based on 1,709 doses identified by the vendor’s data   b: Collection of consent forms. Meeting with school staffs, and vendors. Evaluation research cost was excluded c: $9.94 per dose is the average cost of non-VFC doses administered by the same vendor in this demonstration. Our past study, on the equivalent cost at pediatric clinics, used $8.80 as a main value (after adjusting with Medical Care Consumer Price Index (CPI) from 2006 to 2009) d: $52.08 is still higher than our past study on the equivalent cost at pediatric clinics: $21.44 with a range from $13.42 to $38.84 (after adjusting with Medical Care CPI from 2006 to 2009) Data source: 031011_0214_mcskipp_school_CEA_suiv_230pm_tom

(C1) Vendor Cost (excluding vaccine purchase) $20.07 $24.84 Table 3. Cost Analysis [$ per dose] a and Cost-effectiveness ratio (CER) [$-per-incremental-student-vaccinated at least 1st dose in SLV, compared to control schools] b Cost analysisa Cost-effectiveness analysisb Cost [$ per dose] CER = $65-$81 [$-per-incremental-student-vaccinated] (A) School Cost $9.25 $11.45 (B) Project Costc $23.22 $28.73 (C1) Vendor Cost (excluding vaccine purchase) $20.07 $24.84 (C2) Vendor Cost $25.60 $31.68 (C3) Vendor Cost (assume VFC vaccine [$9.94 / dose])d $32.65 $40.40 Total Cost: (A)+(B)+(C1)e $52.54 $65.02 Total Cost: (A)+(B)+(C2) $58.06 $71.85 Total Cost: (A)+(B)+(C3) $65.11 $80.58 a: Based on 1,709 doses identified by the vendor’s data   b: Based on 1381 students, identified as receiving at least the 1st dose at the SLV schools either (i) in the New York State registry data or (ii) in the vendor’s data c: Collection of consent forms. Meeting with school staffs, and vendors. Evaluation research cost was excluded d: $9.94 per dose is the average cost of non-VFC doses administered by the same vendor in this demonstration. Our past study, on the equivalent cost at pediatric clinics, used $8.80 as a main value (after adjusting with Medical Care Consumer Price Index (CPI) from 2006 to 2009) e: $52.08 is still higher than our past study on the equivalent cost at pediatric clinics: $21.44 with a range from $13.42 to $38.84 (after adjusting with Medical Care CPI from 2006 to 2009) Data source: 031011_0214_mcskipp_school_CEA_suiv_230pm_tom

% Reduction in program cost Table 4. Future goals based on break-even analysis Unit: Total cost excluding vaccine purchase [$ per dose] Increase school vaccination rate Vaccination at school [$ per dose] Number of doses [% total 9027 students] SLV demonstration 1,709 19% $52.54 Future goal-1 2,865 32% $38.84* Future goal-2 5,190 57% $21.44** Future goal-3 8,292 92% $13.42*** Decrease program cost % Reduction in program cost [$ per dose] SLV demonstration n/a $52.54 Future goal-4 26% $38.84* Future goal-5 59% $21.44** Future goal-6 76% $13.42*** NOTE: All cost adjusted with Medical Care CPI to indicate 2009 US dollar values   Interpretations: Future goals are to increase the number of school-vaccinated children from 1709 (19%) to at least 2865 (32%), and 5190 (57%) to be comparable to private pediatric clinics in terms of the cost per dose. Private pediatric practice [$ per dose] in 2009 US dollars (Yoo et al., Pediatrics, 2009) (*): 75th percentile; (**): Median; (***): 25th percentile

Factors affecting program cost-effectiveness ratio Indirect cost: e.g. Saving parents’ time/income to travel to practices  Favor SLV cost effectiveness ratio (CER) Spillover effect: Vaccination outside school Negative spillover: SLV (27%) 3% lower than Control (30%) SLV school vaccination rate (15%) SLV’s CER inflate/worsen by 20%(=3%/15%)

Conclusions and Implications 1 Effectiveness: vaccination rate (anywhere) 43% (from 30% (control) to 43% (SLV)) Program cost excluding vaccine purchase: $53 per dose [2009 US$] in SLV $21 per dose [2009 US$] in private practices $58-$65 per dose if including vaccine purchase Cost-effectiveness ratio of SLV $65-81 [per-incremental-student-vaccinated] Account. for negative spillover effect: inflate by 20%

Conclusions and Implications 2 Program cost distribution (excluding vaccine purchase): (A) School Cost (18%) (B) Project Cost (44%) (C1) Vendor Cost (38%) Future goals based on break-even analysis To be comparable with private practice cost School vaccination doses: 19%  57% in all students Program cost reduction by 60%

Limitations and Next steps Effect of 2009-10 H1N1 pandemic Seasonal flu vaccine supply was adequate Changed motivation for seasonal flu vaccine? Next steps Differential effect on suburban and city schools Suburban schools: higher effectiveness, higher revenue from insurers Account for indirect cost saving Parents’ time and income saved  Favor SLV cost effectiveness ratio