Cost-Effectiveness of Vaccination against Invasive Pneumococcal Disease among People 50 through 64 Years of Age: Role of Comorbid Conditions and Race

17 June 2003 | Volume 138 Issue 12 | Pages 960-968

Background: Guidelines are increasingly recommending preventive services starting at 50 years of age, and policymakers are considering such a recommendation for pneumococcal polysaccharide vaccination. The finding that pneumococcal vaccination is cost-saving for people 65 years of age or older raises the question of the vaccination's implications for other older adults, especially black people, whose disease incidence exceeds that of nonblack people, and those with high-risk conditions.

Objective: To assess the implications of vaccinating black and nonblack people 50 through 64 years of age against invasive pneumococcal disease.

Design: Cost-effectiveness analysis.

Data Sources: Published literature for vaccination effectiveness and cost estimates; data on disease incidence and case-fatality rates from the Centers for Disease Control and Prevention.

Target Population: Hypothetical cohort 50 through 64 years of age with the 1995 U.S. age distribution.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: Pneumococcal polysaccharide vaccination compared with no vaccination.

Outcome Measures: Incremental medical costs and health effects, in quality-adjusted life-years per vaccinee.

Results of Base-Case Analysis: Vaccination saved medical costs and improved health among high-risk black people ($27.55 savings per vaccinee) and nonblack people ($5.92 savings per vaccinee), excluding survivors' future costs. For low-risk black and nonblack people and the overall general population, vaccination cost $2477, $8195, and $3434, respectively, to gain 1 year of healthy life.

Results of Sensitivity Analysis: Excluding survivors' future costs, in the general immunocompetent population, cost per quality-adjusted life-year in global worst-case results ranged from $21 513 for black people to $68 871 for nonblack people; in the high-risk population, cost ranged from $11 548 for black people to $39 000 for nonblack people. In the global best case, vaccination was cost-saving for black and nonblack people in the general immunocompetent and high-risk populations, excluding survivors' future costs. The cost-effectiveness range was narrower in probabilistic sensitivity analyses, with 95% probabilistic intervals ranging from cost-saving to $1594 for black people and from cost-saving to $12 273 for nonblack people in the general immunocompetent population. Costs per quality-adjusted life-year for low-risk people with case-fatality rates from 1998 were $2477 for black people and $8195 for nonblack people, excluding survivors' medical costs.

Conclusions: These results support the current recommendation to vaccinate high-risk people and provide useful information for considering extending the recommendation to the general population 50 through 64 years of age. Lack of evidence about the effectiveness of revaccination for people 65 years of age or older, when disease risks are higher, argues for further research to guide vaccination policy.

Editors' Notes Context Pneumococcal vaccination is cost-saving for people 65 years of age and older, but the cost-effectiveness of extending routine vaccination to people 50 through 64 years of age is unknown. Contribution This cost-effectiveness analysis suggests that routine pneumococcal vaccination for people 50 through 64 years of age costs about $2500 for black people and $8200 for nonblack people at low risk to gain a quality-adjusted year of life, and saves costs for people at high risk for pneumococcal disease. Implications Policymakers and clinicians should take these findings into account when considering extending routine pneumococcal vaccine to individuals younger than 65 years of age. –The Editors

 

Author and Article Information

From the Mount Sinai School of Medicine and Mailman School of Public Health, Columbia University, New York, New York; Massachusetts General Hospital, Boston, Massachusetts; and Centers for Disease Control and Prevention, Anchorage, Alaska, and Atlanta, Georgia.

Acknowledgments: The authors thank the Centers for Disease Control and Prevention staff, especially Ray Strikas, Walter Williams, and Walter Orenstein, for encouragement and guidance, and James Singleton for data on immunocompromised people; the United Network for Organ Sharing for data on transplant survivors; and Marshall McBean, University of Minnesota, and the Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration) for data on Medicare payment rates.

Grant Support: This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention through the Association of Schools of Public Health, project number S343-16/16.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Jane E. Sisk, PhD, Department of Health Policy, Mount Sinai School of Medicine, Room 2-34, 1425 Madison Avenue, New York, NY 10029; e-mail, jane.sisk{at}mssm.edu.

Current Author Addresses: Dr. Sisk: Department of Health Policy, Mount Sinai School of Medicine, Room 2-34, 1425 Madison Avenue, New York, NY 10029.

Dr. Whang: Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114.

Dr. Butler: Centers for Disease Control and Prevention, 4055 Tudor Centre Drive, Anchorage, AK 99508.

Dr. Sneller: Centers for Disease Control and Prevention, 1600 Clifton Road, MS C-61, Atlanta, GA 30333.

Dr. Whitney: Centers for Disease Control and Prevention, 1600 Clifton Road, MS C23, Atlanta, GA 30333.

Author Contributions: Conception and design: J.E. Sisk, J.C. Butler, V.-P. Sneller.

Analysis and interpretation of the data: J.E. Sisk, W. Whang, J.C. Butler, V.-P. Sneller, C.G. Whitney.

Drafting of the article: J.E. Sisk.

Critical revision of the article for important intellectual content: J.E. Sisk, W. Whang, J.C. Butler, V.-P. Sneller, C.G. Whitney.

Final approval of the article: J.E. Sisk, W. Whang, J.C. Butler, V.-P. Sneller, C.G. Whitney.

Provision of study materials or patients: J.C. Butler, V.-P. Sneller, C.G. Whitney.

Statistical expertise: W. Whang.

Obtaining of funding: J.E. Sisk, V.-P. Sneller.

Administrative, technical, or logistic support: J.E. Sisk, J.C. Butler, V.-P. Sneller.

Collection and assembly of data: J.E. Sisk, W. Whang, C.G. Whitney.