Faculty Bibliography

BACKGROUND:Health care facilities use predictive models to identify patients at risk of high future health care utilization who may benefit from tailored interventions. Previous predictive models that have focused solely on inpatient readmission risk, relied on commercial insurance claims data, or failed to incorporate social determinants of health may not be generalizable to safety net hospital populations. To address these limitations, we developed a payer-agnostic risk model for patients receiving care at the largest US safety net hospital system. METHODS:We transformed electronic health record and administrative data from 833,969 adult patients who received care during July 2016-July 2017 into demographic, utilization, diagnosis, medication, and social determinant variables (including homelessness and incarceration history) to predict health care utilization during the following year.We selected the final model by developing and validating multiple classification and regression models predicting 10+ acute days, 5+ acute days, or continuous acute days. We compared a portfolio of performance metrics while prioritizing positive predictive value for patients whose predicted utilization was among the top 1% to maximize clinical utility. RESULTS:The final model predicted continuous number of acute days and included 17 variables. For the top 1% of high acute care utilizers, the model had a positive predictive value of 47.6% and sensitivity of 17.3%. Previous health care utilization and psychosocial factors were the strongest predictors of future high acute care utilization. CONCLUSIONS:We demonstrated a feasible approach to predictive high acute care utilization in a safety net hospital using electronic health record data while incorporating social risk factors.

IMPORTANCE/UNASSIGNED:New York City, an early epicenter of the pandemic, invested heavily in its COVID-19 vaccination campaign to mitigate the burden of disease outbreaks. Understanding the return on investment (ROI) of this campaign would provide insights into vaccination programs to curb future COVID-19 outbreaks. OBJECTIVE/UNASSIGNED:To estimate the ROI of the New York City COVID-19 vaccination campaign by estimating the tangible direct and indirect costs from a societal perspective. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This decision analytical model of disease transmission was calibrated to confirmed and probable cases of COVID-19 in New York City between December 14, 2020, and January 31, 2022. This simulation model was validated with observed patterns of reported hospitalizations and deaths during the same period. EXPOSURES/UNASSIGNED:An agent-based counterfactual scenario without vaccination was simulated using the calibrated model. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Costs of health care and deaths were estimated in the actual pandemic trajectory with vaccination and in the counterfactual scenario without vaccination. The savings achieved by vaccination, which were associated with fewer outpatient visits, emergency department visits, emergency medical services, hospitalizations, and intensive care unit admissions, were also estimated. The value of a statistical life (VSL) lost due to COVID-19 death and the productivity loss from illness were accounted for in calculating the ROI. RESULTS/UNASSIGNED:During the study period, the vaccination campaign averted an estimated $27.96 (95% credible interval [CrI], $26.19-$29.84) billion in health care expenditures and 315 724 (95% CrI, 292 143-340 420) potential years of life lost, averting VSL loss of $26.27 (95% CrI, $24.39-$28.21) billion. The estimated net savings attributable to vaccination were $51.77 (95% CrI, $48.50-$55.85) billion. Every $1 invested in vaccination yielded estimated savings of $10.19 (95% CrI, $9.39-$10.87) in direct and indirect costs of health outcomes that would have been incurred without vaccination. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Results of this modeling study showed an association of the New York City COVID-19 vaccination campaign with reduction in severe outcomes and avoidance of substantial economic losses. This significant ROI supports continued investment in improving vaccine uptake during the ongoing pandemic.

BACKGROUND:COVID-19 vaccines have been available to all adults in the USA since April, 2021, but many adults remain unvaccinated. We aimed to assess the joint effect of a proof-of-vaccination requirement, incentive payments, and employer-based mandates on rates of adult vaccination in New York City (NYC). METHODS:We constructed a synthetic control group for NYC composed of other counties in the core of large, metropolitan areas in the USA. The vaccination outcomes for NYC were compared against those of the synthetic control group from July 26, 2021, to Nov 1, 2021, to determine the differential effects of the policies. Analyses were conducted on county-level vaccination data reported by the Centers for Disease Control and Prevention. The synthetic control group was constructed by matching on county-level preintervention vaccination outcomes, partisanship, economic attributes, demographics, and metropolitan area population. Statistical inference was conducted using placebo tests for non-treated counties. FINDINGS:The synthetic control group resembled NYC across attributes used in the matching process. The cumulative adult vaccination rate for NYC (in adults aged 18 years or older who received at least one dose of an authorised COVID-19 vaccine) increased from 72·5% to 89·4% (+16·9 percentage points [pp]) during the intervention period, compared with an increase from 72·5% to 83·2% (+10·7 pp) for the synthetic control group, a difference of 6·2 pp (95% CI 1·4-10·7), or 410 201 people (90 966-706 532). Daily vaccinations for NYC were consistently higher than those in the synthetic control group, a pattern that started shortly after the start of the intervention period. INTERPRETATION:The combination of a proof-of-vaccination requirement, incentive payments, and vaccine mandates increased vaccination rates among adults in NYC compared with jurisdictions that did not use the same measures. Whether the impact of these measures occurred by inducing more people to get vaccinated, or by accelerating vaccinations that would have occurred later, the increase in vaccination rates likely averted illness and death. FUNDING:None.

The New York City (NYC) Department of Health and Mental Hygiene, as a local health department, partnered with health plans to pay for provider-initiated outreach for Covid-19 vaccine counseling for unvaccinated people through a program called the Vaccine Outreach and Counseling Program (VOCP). The collective effort and use of emergency contracting "” with a budget of $35 million in funding from the government of NYC "” allowed for an idea-to-execution period of 6 weeks. Seven insurance companies covering more than 90% of the NYC Medicaid market and a significant portion of the NYC Medicare Advantage market (insurance products that have a disproportionately large representation of people of color in NYC) administered the program as an in-kind contribution to the effort. Providers implementing the VOCP reported that they felt counseling efforts were valuable in increasing vaccination uptake, but also described operational challenges. Shortly after launching the VOCP, the federal government reached out to the health department to learn more about the program. Two months later, the U.S. Centers for Medicare & Medicaid Services authorized state Medicaid programs to cover such counseling. New York State"™s Medicaid program subsequently adopted a reimbursement policy with similar guidance for counseling while addressing some of the operational challenges of the VOCP model.

The COVID-19 pandemic has caused massive disruptions in social life, created significant morbidity and mortality, and has exacerbated pre-existing disparities in health and welfare. In the United States, the pandemic has also catalyzed debate regarding how our health and social services infrastructure can be improved and bolstered going forward. An important part of these discussions revolves around the vulnerability experienced by immigrant populations during the pandemic. However, the debate has too often left unquestioned what fundamental standard of health is owed to immigrants. Here, we offer a set of proposals that can chart a course for a new standard of health for immigrants in the US, some of which, as a matter of statute, can ensure that the health of immigrant populations is not contingent on the policy prerogatives of various governmental administrations. Though these proposals would establish a novel standard for immigrant health, we argue that a broader approach is needed-encompassing local, state, and federal initiatives-to ensure that all members of society are provided fundamental resources and social support.