In a Kenyan public ICU, high mortality was noted despite the use of advanced therapies. MPM-II has acceptable discrimination but poor calibration. Modification of MPM-II or development of a new model using a prospective multicenter global collaboration is needed. Standardized triage and treatment protocols for high-risk diagnoses are needed to improve ICU outcomes.

Key Points Question Is the new, stratified payment adjustment method for the Hospital Readmission Reduction Program associated with an alteration in penalty distribution? Findings This cross-sectional study of 3173 hospitals found that the new payment adjustment method was associated with a reduction in the proportion of hospitals penalized for fiscal year 2019, which corresponds to performance from July 1, 2014, to June 30, 2017, from 79.07% of hospitals (2509 hospitals) to 75.04% (2381 hospitals) compared with the old, nonstratified method. Hospitals with the largest share of patients of low socioeconomic status had the largest reduction. Meaning The new payment adjustment method for the Hospital Readmission Reduction Program was associated with a more equitable distribution of penalties among hospitals, lessening the disproportionate burden carried by hospitals caring for patients of low socioeconomic status.

Background : The Affordable Care Act expanded Medicaid eligibility allowing low-income individuals greater access to healthcare. However, the uptake of state Medicaid expansion has been variable. It remains unclear how the Medicaid expansion was associated with the temporal trends in use of evidence-based cardiovascular drugs. Methods : We used the publicly available Medicaid Drug Utilization and Current Population Survey to extract filled prescription rates per 1000 Medicaid beneficiaries of statins, antihypertensives, P2Y12 inhibitors, and direct oral anticoagulants (DOAC). We defined expander states as those who expanded Medicaid on January 1, 2014, and non-expander states as those who had not expanded by December 31, 2018. Difference-in-differences (DID) analyses were performed to compare the association of the Medicaid expansion with per-capita cardiovascular drug prescription rates in expander versus non-expander states. Results : Between 2011 and 2018, the total number of prescriptions among all Medicaid beneficiaries increased, with gains of 89.7% in statins (11.0 to 20.8 million), 76% in antihypertensives (35.3 to 62.2 million), and 37% in P2Y12 inhibitors (1.7 to 2.3 million). Medicaid expansion was associated with significantly greater increases in quarterly prescriptions (per 1000 Medicaid beneficiaries) of statins [DID estimate (95% CI): 22.5 (16.5 to 28.6), P<0.001], antihypertensives [DID estimate (95% CI): 63.2 (47.3 to 79.1), P<0.001], and P2Y12 inhibitors [DID estimate (95% CI): 1.7 (1.2 to 2.2), P<0.001]. Between 2013 and 2018, more than 75% of the expander states had increases in prescription rates of both statins and antihypertensives. In contrast, 44% of non-expander states saw declines in statins and antihypertensives. The Medicaid expansion was not associated with higher DOAC prescription rates [DID estimate (95% CI) 0.9 [-0.3 to 2.1], P=0.142). Conclusions : The 2014 Medicaid expansion was associated with a significant increase in per-capita utilization of cardiovascular prescription drugs among Medicaid beneficiaries. These gains in utilization may contribute to long-term cardiovascular benefits to lower-income and previously underinsured populations.

IMPORTANCE Low-density lipoprotein cholesterol (LDL-C)-lowering therapies are a cornerstone of prevention in atherosclerotic cardiovascular disease. With the introduction of generic formulations and the release of new therapies, including proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, contemporary Medicare utilization of these therapies remains unknown. OBJECTIVE To determine trends in utilization and spending on brand-name and generic LDL-C-lowering therapies and to estimate potential savings if all Medicare beneficiaries were switched to available therapeutically equivalent generic formulations. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed prescription drug utilization and cost trend data from the Medicare Part D Prescription Drug Event data set from 2014 to 2018 for LDL-C-lowering therapies. A total of 11 LDL-C-lowering drugs with 25 formulations, including 16 brand-name and 9 generic formulations, were included. Data were collected and analyzed from October 2019 to June 2020. MAIN OUTCOMES AND MEASURES Number of Medicare Part D beneficiaries, annual spending, and spending per beneficiary for all formulations.RESULTS The total number of Medicare Part D beneficiaries ranged from 37 720 840 in 2014 to 44 249 461 in 2018. The number of Medicare beneficiaries taking LDL-C-lowering therapies increased by 23% (from 20.5 million in 2014 to 25.2 million in 2018), while the associated Medicare expenditure decreased by 46% (from $6.3 billion in 2014 to $3.3 billion in 2018). Lower expenditure was driven by greater uptake of generic statin and ezetimibe and a concurrent rapid decline in the use of their brand-name formulations. Medicare spent $9.6 billion on brand-name statins and ezetimibe and could have saved $2.1 billion and $0.4 billion, respectively, if brand-name formulations were switched to equivalent generic versions when available. The number of beneficiaries using PCSK9 inhibitors since their introduction in 2015 has been modest, although use has increased by 144%

Objective To estimate US public investment in the development of mRNA covid-19 vaccines. Design Retrospective cohort study. Setting Publicly funded science from January 1985 to March 2022. Data sources National Institutes of Health (NIH) Report Portfolio Online Reporting Tool Expenditures and Results (RePORTER) and other public databases. Government funded grants were scored as directly, indirectly, or not likely related to four key innovations underlying mRNA covid-19 vaccines—lipid nanoparticle, mRNA synthesis or modification, prefusion spike protein structure, and mRNA vaccine biotechnology—on the basis of principal investigator, project title, and abstract. Main outcome measure Direct public investment in research and vaccine development, stratified by the rationale, government funding agency, and pre-pandemic (1985-2019) versus pandemic (1 January 2020 to 31 March 2022). Results 34 NIH funded research grants that were directly related to mRNA covid-19 vaccines were identified. These grants combined with other identified US government grants and contracts totaled $31.9bn (£26.3bn; €29.7bn), of which $337m was invested pre-pandemic. Pre-pandemic, the NIH invested $116m (35%) in basic and translational science related to mRNA vaccine technology, and the Biomedical Advanced Research and Development Authority (BARDA) ($148m; 44%) and the Department of Defense ($72m; 21%) invested in vaccine development. After the pandemic started, $29.2bn (92%) of US public funds purchased vaccines, $2.2bn (7%) supported clinical trials, and $108m (<1%) supported manufacturing plus basic and translational science. Conclusions The US government invested at least $31.9bn to develop, produce, and purchase mRNA covid-19 vaccines, including sizeable investments in the three decades before the pandemic through March 2022. These public investments translated into millions of lives saved and were crucial in developing the mRNA vaccine technology that also has the potential to tackle future pandemics and to treat diseases beyond covid-19. To maximize overall health impact, policy makers should ensure equitable global access to publicly funded health technologies.