Patient Characteristics and Costs Associated With COVID-19–Related Medical Care Among Medicare Fee-for-Service Beneficiaries

Hansen C.H., Michlmayr D., Gubbels S.M., Mølbak K., Ethelberg S.

SummaryBackground The degree to which infection with SARS-CoV-2 confers protection towards subsequent reinfection is not well described. In 2020, as part of Denmark's extensive, free-of-charge PCR-testing strategy, approximately 4 million individuals (69% of the population) underwent 10·6 million tests. Using these national PCR-test data from 2020, we estimated protection towards repeat infection with SARS-CoV-2. Methods In this population-level observational study, we collected individual-level data on patients who had been tested in Denmark in 2020 from the Danish Microbiology Database and analysed infection rates during the second surge of the COVID-19 epidemic, from Sept 1 to Dec 31, 2020, by comparison of infection rates between individuals with positive and negative PCR tests during the first surge (March to May, 2020). For the main analysis, we excluded people who tested positive for the first time between the two surges and those who died before the second surge. We did an alternative cohort analysis, in which we compared infection rates throughout the year between those with and without a previous confirmed infection at least 3 months earlier, irrespective of date. We also investigated whether differences were found by age group, sex, and time since infection in the alternative cohort analysis. We calculated rate ratios (RRs) adjusted for potential confounders and estimated protection against repeat infection as 1 – RR. Findings During the first surge (ie, before June, 2020), 533 381 people were tested, of whom 11 727 (2·20%) were PCR positive, and 525 339 were eligible for follow-up in the second surge, of whom 11 068 (2·11%) had tested positive during the first surge. Among eligible PCR-positive individuals from the first surge of the epidemic, 72 (0·65% [95% CI 0·51–0·82]) tested positive again during the second surge compared with 16 819 (3·27% [3·22–3·32]) of 514 271 who tested negative during the first surge (adjusted RR 0·195 [95% CI 0·155–0·246]). Protection against repeat infection was 80·5% (95% CI 75·4–84·5). The alternative cohort analysis gave similar estimates (adjusted RR 0·212 [0·179–0·251], estimated protection 78·8% [74·9–82·1]). In the alternative cohort analysis, among those aged 65 years and older, observed protection against repeat infection was 47·1% (95% CI 24·7–62·8). We found no difference in estimated protection against repeat infection by sex (male 78·4% [72·1–83·2] vs female 79·1% [73·9–83·3]) or evidence of waning protection over time (3–6 months of follow-up 79·3% [74·4–83·3] vs ≥7 months of follow-up 77·7% [70·9–82·9]). Interpretation Our findings could inform decisions on which groups should be vaccinated and advocate for vaccination of previously infected individuals because natural protection, especially among older people, cannot be relied on. Funding None.

Nicholson C.J., Wooster L., Sigurslid H.H., Li R.H., Jiang W., Tian W., Lino Cardenas C.L., Malhotra R.

Risk stratification of COVID-19 patients upon hospital admission is key for their successful treatment and efficient utilization of hospital resources. We sought to evaluate the risk factors on admission (including comorbidities, vital signs, and initial laboratory assessment) associated with ventilation need and in-hospital mortality in COVID-19.We established a retrospective cohort of COVID-19 patients from Mass General Brigham hospitals. Demographic, clinical, and admission laboratory data were obtained from electronic medical records of patients admitted to the hospital with laboratory-confirmed COVID-19 before May 19, 2020. Multivariable logistic regression analyses were used to construct and validate the Ventilation in COVID Estimator (VICE) and Death in COVID Estimator (DICE) risk scores.The entire cohort included 1042 patients (median age, 64 years; 56.8% male). The derivation and validation cohorts for the risk scores included 578 and 464 patients, respectively. We found four factors to be independently predictive for mechanical ventilation requirement (diabetes mellitus, SpO2:FiO2 ratio, C-reactive protein, and lactate dehydrogenase), and 10 factors to be predictors of in-hospital mortality (age, male sex, coronary artery disease, diabetes mellitus, chronic statin use, SpO2:FiO2 ratio, body mass index, neutrophil to lymphocyte ratio, platelet count, and procalcitonin). Using these factors, we constructed the VICE and DICE risk scores, which performed with C-statistics of 0.84 and 0.91, respectively. Importantly, the chronic use of a statin was associated with protection against death due to COVID-19. The VICE and DICE score calculators have been placed on an interactive website freely available to healthcare providers and researchers (https://covid-calculator.com/).The risk scores developed in this study may help clinicians more appropriately determine which COVID-19 patients will need to be managed with greater intensity.COVID-19 Fast Grant (fastgrants.org).

Katz M.H.

Lumley S.F., O’Donnell D., Stoesser N.E., Matthews P.C., Howarth A., Hatch S.B., Marsden B.D., Cox S., James T., Warren F., Peck L.J., Ritter T.G., de Toledo Z., Warren L., Axten D., et. al.

Abstract Background The relationship between the presence of antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the risk of subsequent reinfection remains unclear. Methods We investigated the incidence of SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) in seropositive and seronegative health care workers attending testing of asymptomatic and symptomatic staff at Oxford University Hospitals in the United Kingdom. Baseline antibody status was determined by anti-spike (primary analysis) and anti-nucleocapsid IgG assays, and staff members were followed for up to 31 weeks. We estimated the relative incidence of PCR-positive test results and new symptomatic infection according to antibody status, adjusting for age, participant-reported gender, and changes in incidence over time. Results A total of 12,541 health care workers participated and had anti-spike IgG measured; 11,364 were followed up after negative antibody results and 1265 after positive results, including 88 in whom seroconversion occurred during follow-up. A total of 223 anti-spike–seronegative health care workers had a positive PCR test (1.09 per 10,000 days at risk), 100 during screening while they were asymptomatic and 123 while symptomatic, whereas 2 anti-spike–seropositive health care workers had a positive PCR test (0.13 per 10,000 days at risk), and both workers were asymptomatic when tested (adjusted incidence rate ratio, 0.11; 95% confidence interval, 0.03 to 0.44; P=0.002). There were no symptomatic infections in workers with anti-spike antibodies. Rate ratios were similar when the anti-nucleocapsid IgG assay was used alone or in combination with the anti-spike IgG assay to determine baseline status. Conclusions The presence of anti-spike or anti-nucleocapsid IgG antibodies was associated with a substantially reduced risk of SARS-CoV-2 reinfection in the ensuing 6 months. (Funded by the U.K. Government Department of Health and Social Care and others.)

Yanez N.D., Weiss N.S., Romand J., Treggiari M.M.

Case-fatality from COVID-19 has been reported to be relatively high in patients age 65 years or older. We sought to determine the age-specific rates of COVID-19 mortality at the population level. We obtained information regarding the total number of COVID-19 reported deaths for six consecutive weeks beginning at the 50th recorded death, among 16 countries that reported a relatively high number of COVID-19 cases as of April 12, 2020. We performed an ecological study to model COVID-19 mortality rates per week by age group (54 years or younger, 55–64 years, and 65 years or older) and sex using a Poisson mixed effects regression model. Over the six-week period of data, there were 178,568 COVID-19 deaths from a total population of approximately 2.4 billion people. Age and sex were associated with COVID-19 mortality. Compared with individuals ages 54 years or younger, the incident rate ratio (IRR) was 8.1, indicating that the mortality rate of COVID-19 was 8.1 times higher (95%CI = 7.7, 8.5) among those 55 to 64 years, and more than 62 times higher (IRR = 62.1; 95%CI = 59.7, 64.7) among those ages 65 or older. Mortality rates from COVID-19 were 77% higher in men than in women (IRR = 1.77, 95%CI = 1.74, 1.79). In the 16 countries examined, persons age 65 years or older had strikingly higher COVID-19 mortality rates compared to younger individuals, and men had a higher risk of COVID-19 death than women.

Ioannou G.N., Locke E., Green P., Berry K., O’Hare A.M., Shah J.A., Crothers K., Eastment M.C., Dominitz J.A., Fan V.S.

Importance Identifying independent risk factors for adverse outcomes in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can support prognostication, resource utilization, and treatment. Objective To identify excess risk and risk factors associated with hospitalization, mechanical ventilation, and mortality in patients with SARS-CoV-2 infection. Design, Setting, and Participants This longitudinal cohort study included 88 747 patients tested for SARS-CoV-2 nucleic acid by polymerase chain reaction between Feburary 28 and May 14, 2020, and followed up through June 22, 2020, in the Department of Veterans Affairs (VA) national health care system, including 10 131 patients (11.4%) who tested positive. Exposures Sociodemographic characteristics, comorbid conditions, symptoms, and laboratory test results. Main Outcomes and Measures Risk of hospitalization, mechanical ventilation, and death were estimated in time-to-event analyses using Cox proportional hazards models. Results The 10 131 veterans with SARS-CoV-2 were predominantly male (9221 [91.0%]), with diverse race/ethnicity (5022 [49.6%] White, 4215 [41.6%] Black, and 944 [9.3%] Hispanic) and a mean (SD) age of 63.6 (16.2) years. Compared with patients who tested negative for SARS-CoV-2, those who tested positive had higher rates of 30-day hospitalization (30.4% vs 29.3%; adjusted hazard ratio [aHR], 1.13; 95% CI, 1.08-1.13), mechanical ventilation (6.7% vs 1.7%; aHR, 4.15; 95% CI, 3.74-4.61), and death (10.8% vs 2.4%; aHR, 4.44; 95% CI, 4.07-4.83). Among patients who tested positive for SARS-CoV-2, characteristics significantly associated with mortality included older age (eg, ≥80 years vs <50 years: aHR, 60.80; 95% CI, 29.67-124.61), high regional COVID-19 disease burden (eg, ≥700 vs <130 deaths per 1 million residents: aHR, 1.21; 95% CI, 1.02-1.45), higher Charlson comorbidity index score (eg, ≥5 vs 0: aHR, 1.93; 95% CI, 1.54-2.42), fever (aHR, 1.51; 95% CI, 1.32-1.72), dyspnea (aHR, 1.78; 95% CI, 1.53-2.07), and abnormalities in the certain blood tests, which exhibited dose-response associations with mortality, including aspartate aminotransferase (>89 U/L vs ≤25 U/L: aHR, 1.86; 95% CI, 1.35-2.57), creatinine (>3.80 mg/dL vs 0.98 mg/dL: aHR, 3.79; 95% CI, 2.62-5.48), and neutrophil to lymphocyte ratio (>12.70 vs ≤2.71: aHR, 2.88; 95% CI, 2.12-3.91). With the exception of geographic region, the same covariates were independently associated with mechanical ventilation along with Black race (aHR, 1.52; 95% CI, 1.25-1.85), male sex (aHR, 2.07; 95% CI, 1.30-3.32), diabetes (aHR, 1.40; 95% CI, 1.18-1.67), and hypertension (aHR, 1.30; 95% CI, 1.03-1.64). Notable characteristics that were not significantly associated with mortality in adjusted analyses included obesity (body mass index ≥35 vs 18.5-24.9: aHR, 0.97; 95% CI, 0.77-1.21), Black race (aHR, 1.04; 95% CI, 0.88-1.21), Hispanic ethnicity (aHR, 1.03; 95% CI, 0.79-1.35), chronic obstructive pulmonary disease (aHR, 1.02; 95% CI, 0.88-1.19), hypertension (aHR, 0.95; 95% CI, 0.81-1.12), and smoking (eg, current vs never: aHR, 0.87; 95% CI, 0.67-1.13). Most deaths in this cohort occurred in patients with age of 50 years or older (63.4%), male sex (12.3%), and Charlson Comorbidity Index score of at least 1 (11.1%). Conclusions and Relevance In this national cohort of VA patients, most SARS-CoV-2 deaths were associated with older age, male sex, and comorbidity burden. Many factors previously reported to be associated with mortality in smaller studies were not confirmed, such as obesity, Black race, Hispanic ethnicity, chronic obstructive pulmonary disease, hypertension, and smoking.

Marshall M.

Months after infection with SARS-CoV-2, some people are still battling crushing fatigue, lung damage and other symptoms of ‘long COVID’. Months after infection with SARS-CoV-2, some people are still battling crushing fatigue, lung damage and other symptoms of ‘long COVID’.

Mallapaty S.

A slew of detailed studies has now quantified the increased risk the virus poses to older people, men, and other groups. A slew of detailed studies has now quantified the increased risk the virus poses to older people, men, and other groups.

Carfì A., Bernabei R., Landi F.

This case series describes COVID-19 symptoms persisting a mean of 60 days after onset among Italian patients previously discharged from COVID-19 hospitalization.

Sun H., Ning R., Tao Y., Yu C., Deng X., Zhao C., Meng S., Tang F., Xu D.

Previous studies have reported that older patients may experience worse outcome(s) after infection with severe acute respiratory syndrome coronavirus-2 than younger individuals. This study aimed to identify potential risk factors for mortality in older patients with coronavirus disease 2019 (COVID-19) on admission, which may help identify those with poor prognosis at an early stage.Retrospective case-control.Fever ward of Sino-French New City Branch of Tongji Hospital, Wuhan, China.Patients aged 60 years or older with COVID-19 (n = 244) were included, of whom 123 were discharged and 121 died in hospital.Data retrieved from electronic medical records regarding symptoms, signs, and laboratory findings on admission, and final outcomes of all older patients with COVID-19, were retrospectively reviewed. Univariate and multivariate logistic regression analyses were used to explore risk factors for death.Univariate analysis revealed that several clinical characteristics and laboratory variables were significantly different (ie, P < .05) between discharged and deceased patients. Multivariable logistic regression analysis revealed that lymphocyte (LYM) count (odds ratio [OR] = 0.009; 95% confidence interval [CI] = 0.001-0.138; P = .001) and older age (OR = 1.122; 95% CI = 1.007-1.249; P = .037) were independently associated with hospital mortality. White blood cell count was also an important risk factor (P = .052). The area under the receiver operating characteristic curve in the logistic regression model was 0.913. Risk factors for in-hospital death were similar between older men and women.Older age and lower LYM count on admission were associated with death in hospitalized COVID-19 patients. Stringent monitoring and early intervention are needed to reduce mortality in these patients. J Am Geriatr Soc 68:E19-E23, 2020.

Bartsch S.M., Ferguson M.C., McKinnell J.A., O'Shea K.J., Wedlock P.T., Siegmund S.S., Lee B.Y.

With the coronavirus disease 2019 (COVID-19) pandemic, one of the major concerns is the direct medical cost and resource use burden imposed on the US health care system. We developed a Monte Carlo simulation model that represented the US population and what could happen to each person who got infected. We estimated resource use and direct medical costs per symptomatic infection and at the national level, with various “attack rates” (infection rates), to understand the potential economic benefits of reducing the burden of the disease. A single symptomatic COVID-19 case could incur a median direct medical cost of $3,045 during the course of the infection alone. If 80 percent of the US population were to get infected, the result could be a median of 44.6 million hospitalizations, 10.7 million intensive care unit (ICU) admissions, 6.5 million patients requiring a ventilator, 249.5 million hospital bed days, and $654.0 billion in direct medical costs over the course of the pandemic. If 20 percent of the US population were to get infected, there could be a median of 11.2 million hospitalizations, 2.7 million ICU admissions, 1.6 million patients requiring a ventilator, 62.3 million hospital bed days, and $163.4 billion in direct medical costs over the course of the pandemic.

Wu Z., McGoogan J.M.

This Viewpoint summarizes key epidemiologic and clinical findings from all cases of coronavirus disease 2019 (COVID-19) reported through February 11, 2020, in mainland China, and case trends in response to government attempts to control and contain the infection.

Bialek S., Boundy E., Bowen V., Chow N., Cohn A., Dowling N., Ellington S., Gierke R., Hall A., MacNeil J., Patel P., Peacock G., Pilishvili T., Razzaghi H., Reed N., et. al.

Globally, approximately 170,000 confirmed cases of coronavirus disease 2019 (COVID-19) caused by the 2019 novel coronavirus (SARS-CoV-2) have been reported, including an estimated 7,000 deaths in approximately 150 countries (1). On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic (2). Data from China have indicated that older adults, particularly those with serious underlying health conditions, are at higher risk for severe COVID-19-associated illness and death than are younger persons (3). Although the majority of reported COVID-19 cases in China were mild (81%), approximately 80% of deaths occurred among adults aged ≥60 years; only one (0.1%) death occurred in a person aged ≤19 years (3). In this report, COVID-19 cases in the United States that occurred during February 12-March 16, 2020 and severity of disease (hospitalization, admission to intensive care unit [ICU], and death) were analyzed by age group. As of March 16, a total of 4,226 COVID-19 cases in the United States had been reported to CDC, with multiple cases reported among older adults living in long-term care facilities (4). Overall, 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths associated with COVID-19 were among adults aged ≥65 years with the highest percentage of severe outcomes among persons aged ≥85 years. In contrast, no ICU admissions or deaths were reported among persons aged ≤19 years. Similar to reports from other countries, this finding suggests that the risk for serious disease and death from COVID-19 is higher in older age groups.

Berenson R.A., Sunshine J.H., Helms D., Lawton E.

The policy community generally has assumed Medicare Advantage (MA) plans negotiate hospital payment rates similar to those for commercial insurance products and well above those in traditional Medicare. After surveying senior hospital and health plan executives, we found, however, that MA plans nominally pay only 100-105 percent of traditional Medicare rates and, in real economic terms, possibly less. Respondents broadly identified three primary reasons for near-payment equivalence: statutory and regulatory provisions that limit out-of-network payments to traditional Medicare rates, de facto budget constraints that MA plans face because of the need to compete with traditional Medicare and other MA plans, and a market equilibrium that permits relatively lower MA rates as long as commercial rates remain well above the traditional Medicare rates. We explored a number of policy implications not only for the MA program but also for the problem of high and variable hospital prices in commercial insurance markets.

Levinsky N.G.

Expenditures for Medicare beneficiaries in the last year of life decrease with increasing age. The cause of this phenomenon is uncertain.To examine this pattern in detail and evaluate whether decreases in aggressiveness of medical care explain the phenomenon.Analysis of sample Medicare data for beneficiaries aged 65 years or older from Massachusetts (n = 34 131) and California (n = 19 064) who died in 1996.Medical expenditures during the last year of life, analyzed by age group, sex, race, place and cause of death, comorbidity, and use of hospital services.For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admissions and by markedly decreasing use of cardiac catheterization, dialysis, ventilators, and pulmonary artery monitors, regardless of cause of death. Decrease in the cost of hospital services accounts for approximately 80% of the decrease in Medicare expenditures with age in both states.Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.

Sander B., Mishra S., Swayze S., Sahakyan Y., Duchen R., Quinn K., Janjua N., Sbihi H., Kwong J.

Liew C., Ong S., Ng D.C.

The COVID-19 pandemic has burdened healthcare systems globally. To curb high hospital admission rates, only patients with genuine medical needs are admitted. However, machine learning (ML) models to predict COVID-19 hospitalization in Asian children are lacking. This study aimed to develop and validate ML models to predict pediatric COVID-19 hospitalization. We collected secondary data with 2200 patients and 65 variables from Malaysian aged 0 to 12 with COVID-19 between 1st February 2020 and 31st March 2022. The sample was partitioned into training, internal, and external validation groups. Recursive Feature Elimination (RFE) was employed for feature selection, and we trained seven supervised classifiers. Grid Search was used to optimize the hyperparameters of each algorithm. The study analyzed 1988 children and 30 study variables after data were processed. The RFE algorithm selected 12 highly predicted variables for COVID-19 hospitalization, including age, male sex, fever, cough, rhinorrhea, shortness of breath, vomiting, diarrhea, seizures, body temperature, chest indrawing, and abnormal breath sounds. With external validation, Adaptive Boosting was the highest-performing classifier (AUROC = 0.95) to predict COVID-19 hospital admission in children. We validated AdaBoost as the best to predict COVID-19 hospitalization among children. This model may assist front-line clinicians in making medical disposition decisions.

Kang J.A., Quigley D.D., Chastain A.M., Ma H.S., Shang J., Stone P.W.

This systematic review investigates disparities in COVID-19 outcomes (infections, hospitalizations, and deaths) between urban and rural populations in the United States. Of the 3,091 articles screened, 55 were selected. Most studies ( n = 43) conducted national analyses, using 2020 data, with some extending into 2021. Findings show urban areas had higher COVID-19 cases and hospitalizations in 2020, while rural areas saw increased cases in 2021 and mixed hospitalization results. Urban areas also had higher mortality rates in 2020, with rural rates rising in 2021 and 2022. Most studies did not explore reasons for urban/rural differences. The few that did found that vulnerable groups, including racially and ethnically minoritized populations, older adults, and those with comorbidities and lower socioeconomic status and vaccination rates, experienced exacerbated disparities in rural regions. COVID-19 outcomes varied over time and by area due to population density, healthcare infrastructure, and socioeconomic factors. Tailored interventions are essential for health equity and effective policies.

Zhu Y., Wang J., Wu C., Yu B., Liu T., Liu Y., Zhang L.

BackgroundIntensive care unit (ICU) beds played a crucial role in reducing mortality rates of patients with severe COVID-19. The surge in the number of patients led to a shortage of ICU beds, which may have exacerbated inequity of healthcare utilization. However, most attention has been focused on the horizontal equity in healthcare utilization, where individuals with the same needs receive the same services. Vertical equity, where individuals with higher needs receive more healthcare is often neglected, which might overestimate the equity. This study analyzes the vertical equity of ICU utilization among hospitalized patients with COVID-19.MethodsIn total, 18,547 hospitalized patients with COVID-19 in Maryland in 2020 were enrolled in this cross-sectional study. Logistic regression analysis was conducted to determine the independent factors affecting ICU utilization, and the Shapley value decomposition approach was implemented to assess the contribution of the independent variables to disparities in ICU admission. A concentration curve and concentration index were used to assess the vertical equity in healthcare utilization.ResultsICU utilization by patients with COVID-19 was significantly affected by Charlson Comorbidity Index (CCI), with odds ratios (OR) 1.09 [95% confidence intervals (CI): 1.07–1.10; p &lt; 0.001] in univariable analysis and 1.11 (95% CI: 1.09–1.13; p &lt; 0.001) in multivariable regression analysis. The most important contributors were household income (32.27%) and the CCI (22.89%) in the Shapley value decomposition analysis. The concentration curve was below the line of equity, and the concentration index was 0.094 (95% CI: 0.076–0.111; p &lt; 0.001), indicating that ICU utilization was concentrated among patients with a high CCI. These results were robust for all subgroup analyses.ConclusionAmong 18,547 hospitalized patients with COVID-19 in Maryland in 2020, ICU utilization was significantly affected by comorbid conditions. The concentration curve and concentration index also indicated that ICU utilization was more concentrated in patients with a higher CCI. The results was consistent with the principle of vertical equity, whereby healthcare resources are more concentrated on COVID-19 patients with higher health needs.

Johnson T.J., Longcoy J., Suzuki S., Isgor Z., Lynch E.B.

Introduction Although studies have evaluated the hospital cost of care associated with treating patients with COVID-19, there are no studies that compare the hospital cost of care among racial and ethnic groups based on detailed cost accounting data. The aims of this study were to provide a detailed description of the hospital costs of COVID-19 based on individual resources during the hospital stay and standardized costs that do not rely on inflation adjustment and evaluate the extent to which hospital total cost of care for patients with COVID-19 differs by race and ethnicity. Methods This study used electronic medical record data from an urban academic medical center in Chicago, Illinois USA. Hospital cost of care was calculated using accounting data representing the cost of the resources used to the hospital (i.e., cost to the hospital, not payments). A multivariable generalized linear model with a log link function and inverse gaussian distribution family was used to calculate the average marginal effect (AME) for Black, White, and Hispanic patients. A second regression model further compared Hispanic patients by preferred language (English versus Spanish). Results In our sample of 1,853 patients, the average adjusted cost of care was significantly lower for Black compared to White patients (AME = -$5,606; 95% confidence interval (CI), -$10,711 to -$501), and Hispanic patients had higher cost of care compared to White patients (AME = $8,539, 95% CI, $3,963 to $13,115). In addition, Hispanic patients who preferred Spanish had significantly higher cost than Hispanic patients who preferred English (AME = $11,866; 95% CI $5,302 to $18,431). Conclusion Total cost of care takes into account both the intensity of the treatment as well as the duration of the hospital stay. Thus, policy makers and health systems can use cost of care as a proxy for severity, especially when looking at the disparities among different race and ethnicity groups.

Ahmadabad A.D., Hosseini_Shokouh S.M., Mehdizadeh P., Meskarpour_Amiri M.

The outbreak of COVID-19 has led to substantial out-of-pocket (OOP) expenditures for households during treatment. This study aimed to investigate the OOP expenditures among hospitalized patients with COVID-19 through a systematic review and meta-analysis. A systematic review and meta-analysis were conducted following the PRISMA guidelines. Articles were retrieved from the PubMed, Scopus, and Google Scholar in the period of 2019–2022 and evaluated for quality using the STROBE guidelines. Homogeneity was assessed using the I2 index, and publication bias was examined using a funnel plot. Meta-analysis was performed using Stata 16. Results of the study have shown that a total of nine articles were included in the meta-analysis. The average OOP expenditure for hospitalized COVID-19 patients was found to be US $308.25 (95% CI: 4.17-620.67). The highest OOP expenditure was reported by CHAU (2021) (US $3171.28), followed by GRAG (2022) (US $1582.38), and the lowest by KOTWANI (2021) (US $56.35). According to the results obtained Significant inequality was observed in the OOP expenditures across different countries. Consistent policy recommendations should be made in international forums to reduce these costs in future pandemics for patients in both developed and developing nations.

AlManie S., AlHazami M., Ebrahim A., Attique M.

Park J., Joo H., Kim D., Mase S., Christensen D., Maskery B.A.

Background Community-based mask wearing has been shown to reduce the transmission of SARS-CoV-2. However, few studies have conducted an economic evaluation of mask mandates, specifically in public transportation settings. This study evaluated the cost-effectiveness of implementing mask mandates for subway passengers in the United States by evaluating its potential to reduce COVID-19 transmission during subway travel. Materials and methods We assessed the health impacts and costs of subway mask mandates compared to mask recommendations based on the number of infections that would occur during subway travel in the U.S. Using a combined box and Wells-Riley infection model, we estimated monthly infections, hospitalizations, and deaths averted under a mask mandate scenario as compared to a mask recommendation scenario. The analysis included costs of implementing mask mandates and COVID-19 treatment from a limited societal perspective. The cost-effectiveness (net cost per averted death) of mandates was estimated for three different periods based on dominant SARS-CoV-2 variants: Alpha, Beta, and Gamma (November 2020 to February 2021); Delta (July to October 2021); and early Omicron (January to March 2022). Results Compared with mask recommendations only, mask mandates were cost-effective across all periods, with costs per averted death less than a threshold of $11.4 million (ranging from cost-saving to $3 million per averted death). Additionally, mask mandates were more cost-effective during the early Omicron period than the other two periods and were cost saving in January 2022. Our findings showed that mandates remained cost-effective when accounting for uncertainties in input parameters (e.g., even if mandates only resulted in small increases in mask usage by subway ridership). Conclusions The findings highlight the economic value of mask mandates on subways, particularly during high virus transmissibility periods, during the COVID-19 pandemic. This study may inform stakeholders on mask mandate decisions during future outbreaks of novel viral respiratory diseases.

Barrot J., Bonelli M., Grassi B., Sauvagnat J.

We study whether state-level mandatory business closures implemented in response to the outbreak of the Covid-19 causally affect economic and health outcomes. Using plausibly exogenous variations in exposure to these restrictions, we find that they impose substantial losses to firms and workers, the former bearing approximately two thirds of the cost, consistent with firms partially insuring their workers. We show that mandatory business closures have a significant negative causal effect on mortality rates, particularly in areas featuring contact-intensive occupations. We discuss the assumptions under which the health benefits of business closures exceed their associated economic costs.

Faust J.S., Meyerowitz-Katz G.

Faramarzi A., Norouzi S., Dehdarirad H., Aghlmand S., Yusefzadeh H., Javan-Noughabi J.

Abstract Background The COVID-19 pandemic has caused a considerable threat to the economics of patients, health systems, and society. Objectives This meta-analysis aims to quantitatively assess the global economic burden of COVID-19. Methods A comprehensive search was performed in the PubMed, Scopus, and Web of Science databases to identify studies examining the economic impact of COVID-19. The selected studies were classified into two categories based on the cost-of-illness (COI) study approach: top-down and bottom-up studies. The results of top-down COI studies were presented by calculating the average costs as a percentage of gross domestic product (GDP) and health expenditures. Conversely, the findings of bottom-up studies were analyzed through meta-analysis using the standardized mean difference. Results The implemented search strategy yielded 3271 records, of which 27 studies met the inclusion criteria, consisting of 7 top-down and 20 bottom-up studies. The included studies were conducted in various countries, including the USA (5), China (5), Spain (2), Brazil (2), South Korea (2), India (2), and one study each in Italy, South Africa, the Philippines, Greece, Iran, Kenya, Nigeria, and the Kingdom of Saudi Arabia. The results of the top-down studies indicated that indirect costs represent 10.53% of GDP, while the total estimated cost accounts for 85.91% of healthcare expenditures and 9.13% of GDP. In contrast, the bottom-up studies revealed that the average direct medical costs ranged from US $1264 to US $79,315. The meta-analysis demonstrated that the medical costs for COVID-19 patients in the intensive care unit (ICU) were approximately twice as high as those for patients in general wards, with a range from 0.05 to 3.48 times higher. Conclusions Our study indicates that the COVID-19 pandemic has imposed a significant economic burden worldwide, with varying degrees of impact across countries. The findings of our study, along with those of other research, underscore the vital role of economic consequences in the post-COVID-19 era for communities and families. Therefore, policymakers and health administrators should prioritize economic programs and accord them heightened attention.

Sim J., Shin J., Lee H.J., Lee Y., Kim Y.A.

Purpose Since identified in December 2019, the novel coronavirus disease 2019 (COVID-19) has had a global impact on medical resource use and costs for patients with cancer in South Korea. This study aimed to identify the medical use and costs among patients with cancer during the COVID-19 pandemic, to predict these patterns in South Korea in the future. Methods We conducted a secondary claims data analysis using the National Health Insurance Service database for the calendar period of 2019–2020. Monthly relative percent changes in cancer incidence, medical use, and billing costs for medical care utilization by cancer type were calculated. Then, the medical use and costs after January 2020 were predicted using a time series model with data before the COVID-19 outbreak (2014–2019). Results The incidence of cancer diagnoses has seen a notable decline since the outbreak of the COVID-19 in 2020 as compared to 2019. Despite the impact of COVID-19, there hasn’t been a distinct decline in outpatient utilization when compared to inpatient utilization. While medical expenses for both inpatient and outpatient visits have slightly increased, the number of patients treated for cancer has decreased significantly compared to the previous year. In June 2020, overall outpatient costs experienced the highest increase (21.1%), while individual costs showed the most significant decrease (-4.9%) in June 2020. Finally, the number of hospitalisations and outpatient visits increased slightly from June–July in 2020, reducing the difference between the actual and predicted values. The decrease in the number of inpatient hospitalisations (-22~-6%) in 2020 was also high. Conclusions The overall use of medical services by patients with cancer decreased in 2020 compared with that in the pre-COVID-19 pandemic period. In the future, the government should consider how to recover from the COVID-19 pandemic, and establish permanent health policies for patients with cancer.

Nakhaee M., Khandehroo M., Esmaeili R.

Abstract Background Human communities suffered a vast socioeconomic burden in dealing with the pandemic of coronavirus disease 2019 (COVID-19) globally. Real-word data about these burdens can inform governments about evidence-based resource allocation and prioritization. The aim of this scoping review was to map the cost-of-illness (CoI) studies associated with COVID-19. Methods This scoping review was conducted from January 2019 to December 2021. We searched cost-of-illness papers published in English within Web of Sciences, PubMed, Google Scholar, Scopus, Science Direct and ProQuest. For each eligible study, extracted data included country, publication year, study period, study design, epidemiological approach, costing method, cost type, cost identification, sensitivity analysis, estimated unit cost and national burden. All of the analyses were applied in Excel software. Results 2352 records were found after the search strategy application, finally 28 articles met the inclusion criteria and were included in the review. Most of the studies were done in the United States, Turkey, and China. The prevalence-based approach was the most common in the studies, and most of studies also used Hospital Information System data (HIS). There were noticeable differences in the costing methods and the cost identification. The average cost of hospitalization per patient per day ranged from 101$ in Turkey to 2,364$ in the United States. Among the studies, 82.1% estimated particularly direct medical costs, 3.6% only indirect costs, and 14.3% both direct and indirect costs. Conclusion The economic burden of COVID-19 varies from country to country. The majority of CoI studies estimated direct medical costs associated with COVID-19 and there is a paucity of evidence for direct non-medical, indirect, and intangible costs, which we recommend for future studies. To create homogeneity in CoI studies, we suggest researchers follow a conceptual framework and critical appraisal checklist of cost-of-illness (CoI) studies.

Zwerwer L.R., Kloka J., van der Pol S., Postma M.J., Zacharowski K., van Asselt A.D., Friedrichson B.

Abstract Background While COVID-19 hospitalization costs are essential for policymakers to make informed health care resource decisions, little is known about these costs in western Europe. The aim of the current study is to analyze these costs for a German setting, track the development of these costs over time and analyze the daily costs. Methods Administrative costing data was analyzed for 598 non-Intensive Care Unit (ICU) patients and 510 ICU patients diagnosed with COVID-19 at the Frankfurt University hospital. Descriptive statistics of total per patient hospitalization costs were obtained and assessed over time. Propensity scores were estimated for length of stay (LOS) at the general ward and mechanical ventilation (MV) duration, using covariate balancing propensity score for continuous treatment. Costs for each additional day in the general ward and each additional day in the ICU with and without MV were estimated by regressing the total hospitalization costs on the LOS and the presence or absence of several treatments using generalized linear models, while controlling for patient characteristics, comorbidities, and complications. Results Median total per patient hospitalization costs were €3,010 (Q1 – Q3: €2,224—€5,273), €5,887 (Q1 – Q3: €3,054—€10,879) and €21,536 (Q1 – Q3: €7,504—€43,480), respectively, for non-ICU patients, non-MV and MV ICU patients. Total per patient hospitalization costs for non-ICU patients showed a slight increase over time, while total per patient hospitalization costs for ICU patients decreased over time. Each additional day in the general ward for non-ICU COVID-19 patients costed €463.66 (SE: 15.89). Costs for each additional day in the general ward and ICU without and with mechanical ventilation for ICU patients were estimated at €414.20 (SE: 22.17), €927.45 (SE: 45.52) and €2,224.84 (SE: 70.24). Conclusions This is, to our knowledge, the first study examining the costs of COVID-19 hospitalizations in Germany. Estimated costs were overall in agreement with costs found in literature for non-COVID-19 patients, except for higher estimated costs for mechanical ventilation. These estimated costs can potentially improve the precision of COVID-19 cost effectiveness studies in Germany and will thereby allow health care policymakers to provide better informed health care resource decisions in the future.

Paret K., Beyhaghi H., Herring W.L., Mauskopf J., Shane L.G., Rousculp M.D.

Policymakers in the United States (US) recommend coronavirus disease 2019 (COVID-19) vaccination with a monovalent 2023–2024 vaccine formulation based on the Omicron XBB.1.5 variant. We estimated the potential US population-level health and economic impacts of increased COVID-19 vaccine coverage that might be expected with the availability of a protein-based vaccine with simpler storage requirements in addition to messenger ribonucleic acid (mRNA) vaccines. A Markov model was developed to estimate 1-year COVID-19-related costs, cases, hospitalizations, and deaths with and without the availability of a protein-based vaccine option. The model population was stratified by age and risk status. Model inputs were sourced from published literature or derived from publicly available data. Our model estimated that a five-percentage-point increase in coverage due to the availability of a protein-based vaccine option would prevent over 500,000 cases, 66,000 hospitalizations, and 3000 COVID-19-related deaths. These clinical outcomes translated to 42,000 quality-adjusted life years (QALYs) gained and an incremental cost–effectiveness ratio of USD 16,141/QALY from a third-party payer perspective. In sensitivity analyses, outcomes were most sensitive to COVID-19 incidence and severity across age groups. The availability of a protein-based vaccine option in the US could reduce hospitalizations and deaths and is predicted to be cost-effective.