Tackling the Dual Economic and Public Health Crises Caused by Covid-19 in Baltimore: Early Lessons from the Baltimore Health Corps Pilot

On March 12, 2020, the first case of Covid-19 was diagnosed in Baltimore City. Its infection rate increased rapidly through March and into April and May, proving to be 4 times higher among Latino residents and 1.5 times higher among Black residents than the city's White population. At the same time, the city's unemployment rate surged from 4.9 percent in March to a peak of 11.6 percent in April 2020. In June, The Rockefeller Foundation supported the Baltimore City government in launching the Baltimore Health Corps (BHC), a pilot program to recruit, train, and employ 275 new community health workers who were unemployed, furloughed, or underemployed, living in neighborhoods hardest hit by the health crisis and especially those residents unemployed as a result of Covid-19. BHC used equitable recruitment and hiring practices to employ contact tracers, care coordinators, and support staff, with a focus on good jobs, fair pay, training, skill-building, and support to improve career trajectories. This report, compiling data and interviews midway through the project, is a look at some of the early successes and the challenges ahead

Comparing the cost-per-QALYs gained and cost-per-DALYs averted literatures [version 1; referees: 3 approved]

Background: We examined the similarities and differences between studies using two common metrics used in cost-effectiveness analyses (CEAs): cost per quality-adjusted life years (QALYs) gained and cost per disability-adjusted life year (DALY) averted. Methods: We used the Tufts Medical Center CEA Registry, which contains English-language cost-per-QALY gained studies, and  Global Cost-Effectiveness Analysis (GHCEA) Registry, which contains cost-per-DALY averted studies. We examined study characteristics including intervention type, sponsor, country, and primary disease, and also analysed the number of CEAs versus disease burden estimates for major diseases and conditions across three geographic regions. Results: We identified 6,438 cost-per-QALY and 543 cost-per-DALY studies published through 2016 and observed rapid growth in publication rates for both literatures. Cost-per-QALY studies were most likely to examine pharmaceuticals and interventions in high-income countries. Cost-per-DALY studies predominantly focused on infectious disease interventions and interventions in low and lower-middle income countries. We found discrepancies in the number of published CEAs for certain diseases and conditions in certain regions, suggesting “under-studied” areas (e.g., cardiovascular disease in Southeast Asia, East Asia, and Oceania and “overstudied” areas (e.g., HIV in Sub Saharan Africa) relative to disease burden in those regions. Conclusions: The number of cost-per QALY and cost-per-DALY analyses has grown rapidly with applications to diverse interventions and diseases.  Discrepancies between the number of published studies and disease burden suggest funding opportunities for future cost-effectiveness research

Comparing the cost-per-QALYs gained and cost-per-DALYs averted literatures [version 2; referees: 3 approved]

Background: We examined the similarities and differences between studies using two common metrics used in cost-effectiveness analyses (CEAs): cost per quality-adjusted life year (QALY) gained and cost per disability-adjusted life year (DALY) averted. Methods: We used the Tufts Medical Center CEA Registry, which contains English-language cost-per-QALY gained studies, and the Global Cost-Effectiveness Analysis (GHCEA) Registry, which contains cost-per-DALY averted studies. We examined study characteristics, including intervention type, sponsor, country, and primary disease, and also compared the number of published CEAs to disease burden for major diseases and conditions across geographic regions. Results: We identified 6,438 cost-per-QALY and 543 cost-per-DALY studies published through 2016 and observed rapid growth for both literatures. Cost-per-QALY studies most often examined pharmaceuticals and interventions in high-income countries. Cost-per-DALY studies predominantly focused on infectious disease interventions and interventions in low and lower-middle income countries. We found that while diseases imposing a larger burden tend to receive more attention in the cost-effectiveness analysis literature, the number of publications for some diseases and conditions deviates from this pattern, suggesting “under-studied” conditions (e.g., neonatal disorders) and “over-studied” conditions (e.g., HIV and TB). Conclusions: The CEA literature has grown rapidly, with applications to diverse interventions and diseases.  The publication of fewer studies than expected for some diseases given their imposed burden suggests funding opportunities for future cost-effectiveness research

PHYSICIAN PEER NETWORKS AND PATTERNS OF OPIOID-RELATED BEHAVIOR

Physicians are known to learn prescribing behavior from peers, although the extent and magnitude of peer influence on opioid prescribing is not well understood. Identifying the role peer networks play on influencing opioid prescribing, or opioid-related behavior, could elicit new understandings on how information in healthcare is spread and, in turn, lead to policy solutions and interventions to modify physician behavior in the direction of evidence-based medicine. The goal of this dissertation was to evaluate physicians prescribing opioids to patients in Medicare, or physicians receiving opioid industry payments, in order to determine if network-level characteristics are associated with patterns in opioid prescribing. This dissertation has three aims: (1) to determine whether patterns in opioid prescribing exist across physician networks and association with specialties, (2) to empirically demonstrate influence industry can have on clinical decision-making via targeted marketing within provider networks, and (3) to attempt to parse whether certain physicians with greater peer influence result in similar opioid prescribing among network peers. There are several findings and important implications related to this work. First, I find that primary care physicians who have more peer connections and more peers within a pain management specialty or surgery are more likely to have a higher median opioid prescribing rate across patient-sharing, hospital, and shared group clinic networks. Second, I find physicians who have any opioid payments are associated with three times the likelihood of at least one peer also having an opioid payment compared to physicians who did not have a similar payment. These physicians are more likely to belong to smaller and more interconnected patient-sharing networks. Finally, I perform a novel identification analysis of potential peer influencers to find certain provider-level characteristics that may shape peer prescribing behavior. The implications of this dissertation reveal that peer influence may serve as a potential mechanism for altering prescribing behavior and may be a lower-cost and efficacious way to increase adherence to evidence-based medicine