Cost of Measles Containment in an Ambulatory Peds Clinic
Measles cases were identified and classified using standard case definitions and classifications. Measles exposures were defined as having had contact with or having been in the same room as the ill patient up until 2 hours after the patient was present. Investigation activities were defined as time spent by employees in identifying and contacting exposed patients and employees, documenting evidence of immunity to measles, consulting with public health regarding response activities and responding to caretakers' concerns regarding exposure. Evidence of measles immunity was defined as serologic evidence of immunity, laboratory evidence of disease, birth date before 1957 or written confirmation of receipt of 1 measles vaccine after age 12 months for preschool aged patients and their caregivers or 2 measles vaccines after 12 months for school age children, adolescents and healthcare workers; healthcare personnel without evidence of immunity, regardless of post-exposure vaccine, are excluded from work from days 5 to 21 after their exposure. Costs to the health care system included costs attributed to the vaccine program and to private insurance.
The costs to the pediatric practice related to investigation, follow-up care and post-exposure prophylaxis response activities. Costs were calculated using data collected with a questionnaire administered to the lead health care worker who managed the response to the measles exposure and identified the personnel involved along with the time allocated to the response.
Activities identified in the response related to post-exposure prophylaxis included arranging passive vaccination with intravenous immunoglobulin (IVIG) for infants aged <6 months and identified ≤6 days after exposure (intramuscular immunoglobulin was unavailable in the local hospital) and active vaccination with MMR vaccine ≤72 hours after exposure for infants aged 6–11 months and for persons aged ≥ 12 months who did not have acceptable evidence of measles immunity. Investigation costs were calculated by multiplying the hours each employee spent on specific activities by their hourly wage. Caretakers' exposures were discussed during the initial phone calls with the families and contributed to the time spent during these phone calls, but caretakers were asked to check their vaccination status and to follow up with their physicians, and caretakers' vaccination records were not verified by the pediatric clinic. Employee follow-up costs were based on the bills the pediatric clinic paid for MMR vaccine doses and laboratory tests for employees.
Other costs not paid directly by the pediatric clinic but that might contribute to the total cost of the response were also tabulated. For example, because the pediatric clinic did not charge patients for vaccination visits resulting from this measles exposure, the estimated clinic costs were based on the vaccine administration reimbursement by the Centers for Medicare and Medicaid Services (CMS) reimbursement for code 90460 (for vaccination administration for children aged <18 years through any route with counseling by any heath care professional). Cost of the MMR vaccine for patients was based on the private-sector price of purchasing the vaccine in a pediatric clinic. Additionally, for follow-up care requiring an emergency department (ED) visit for IVIG, estimated charges were based on the lowest possible amount charged for the ED doctor visit, IV placement with medication push and IVIG at the local hospital treating the majority of our patients. These charges were converted into costs by using the Washington State average operating cost-to-charge ratio, which estimates the average monetary value of reimbursement for acute care urban hospitals.
This investigation was conducted as part of a measles case investigation by Public Health—Seattle & King County in collaboration with the affected pediatric clinic. The investigation was classified as nonresearch by the Washington State Institutional Review Board and the Centers for Disease Control and Prevention (CDC).
Materials and Methods
Definitions
Measles cases were identified and classified using standard case definitions and classifications. Measles exposures were defined as having had contact with or having been in the same room as the ill patient up until 2 hours after the patient was present. Investigation activities were defined as time spent by employees in identifying and contacting exposed patients and employees, documenting evidence of immunity to measles, consulting with public health regarding response activities and responding to caretakers' concerns regarding exposure. Evidence of measles immunity was defined as serologic evidence of immunity, laboratory evidence of disease, birth date before 1957 or written confirmation of receipt of 1 measles vaccine after age 12 months for preschool aged patients and their caregivers or 2 measles vaccines after 12 months for school age children, adolescents and healthcare workers; healthcare personnel without evidence of immunity, regardless of post-exposure vaccine, are excluded from work from days 5 to 21 after their exposure. Costs to the health care system included costs attributed to the vaccine program and to private insurance.
Cost Calculations
The costs to the pediatric practice related to investigation, follow-up care and post-exposure prophylaxis response activities. Costs were calculated using data collected with a questionnaire administered to the lead health care worker who managed the response to the measles exposure and identified the personnel involved along with the time allocated to the response.
Activities identified in the response related to post-exposure prophylaxis included arranging passive vaccination with intravenous immunoglobulin (IVIG) for infants aged <6 months and identified ≤6 days after exposure (intramuscular immunoglobulin was unavailable in the local hospital) and active vaccination with MMR vaccine ≤72 hours after exposure for infants aged 6–11 months and for persons aged ≥ 12 months who did not have acceptable evidence of measles immunity. Investigation costs were calculated by multiplying the hours each employee spent on specific activities by their hourly wage. Caretakers' exposures were discussed during the initial phone calls with the families and contributed to the time spent during these phone calls, but caretakers were asked to check their vaccination status and to follow up with their physicians, and caretakers' vaccination records were not verified by the pediatric clinic. Employee follow-up costs were based on the bills the pediatric clinic paid for MMR vaccine doses and laboratory tests for employees.
Other costs not paid directly by the pediatric clinic but that might contribute to the total cost of the response were also tabulated. For example, because the pediatric clinic did not charge patients for vaccination visits resulting from this measles exposure, the estimated clinic costs were based on the vaccine administration reimbursement by the Centers for Medicare and Medicaid Services (CMS) reimbursement for code 90460 (for vaccination administration for children aged <18 years through any route with counseling by any heath care professional). Cost of the MMR vaccine for patients was based on the private-sector price of purchasing the vaccine in a pediatric clinic. Additionally, for follow-up care requiring an emergency department (ED) visit for IVIG, estimated charges were based on the lowest possible amount charged for the ED doctor visit, IV placement with medication push and IVIG at the local hospital treating the majority of our patients. These charges were converted into costs by using the Washington State average operating cost-to-charge ratio, which estimates the average monetary value of reimbursement for acute care urban hospitals.
Human Subjects Review
This investigation was conducted as part of a measles case investigation by Public Health—Seattle & King County in collaboration with the affected pediatric clinic. The investigation was classified as nonresearch by the Washington State Institutional Review Board and the Centers for Disease Control and Prevention (CDC).
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