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Background: Multiple factors, such as less complex U.S. adult pneumococcal recommendations that could increase vaccination rates, childhood pneumococcal vaccination indirect effects that decrease adult vaccination impact, and increased vaccine hesitancy (particularly in underserved minorities), could diminish the cost‐effectiveness of programs to increase pneumococcal vaccination in older adults. Prior analyses supported the economic favorability of these programs. Methods: A Markov model compared no vaccination and current recommendations (either 20‐valent pneumococcal conjugate vaccine [PCV20] alone or 15‐valent pneumococcal conjugate vaccine plus the 23‐valent pneumococcal polysaccharide vaccine [PCV15/PPSV23]) without or with programs to increase vaccine uptake in Black and non‐Black 65‐year‐old cohorts. Pre‐pandemic population‐ and serotype‐specific pneumococcal disease risk and illness/vaccine costs came from U.S. databases. Program costs were $2.19 per vaccine‐eligible person and increased absolute vaccination likelihood by 7.5%. Delphi panel estimates and trial data informed vaccine effectiveness values. Analyses took a healthcare perspective, discounting at 3%/year over a lifetime time horizon. Results: Uptake programs decreased pneumococcal disease overall. In Black cohorts, PCV20 without program cost $216,805 per quality‐adjusted life year (QALY) gained compared with no vaccination; incremental cost‐effectiveness was $245,546/QALY for PCV20 with program and $425,264/QALY for PCV15/PPSV23 with program. In non‐Black cohorts, all strategies cost >$200,000/QALY gained. When considering the potential indirect effects from childhood vaccination, all strategies became less economically attractive. Increased vaccination with less complex strategies had negligible effects. In probabilistic sensitivity analyses, current recommendations with or without programs were unlikely to be favored at thresholds <$200,000/QALY gained. Conclusion: Current U.S. pneumococcal vaccination recommendations for older adults were unlikely to be economically reasonable with or without programs to increase vaccine uptake. Alternatives to current pneumococcal vaccines that include pneumococcal serotypes associated with adult disease should be considered. See related Editorial by Melissa K. Andrew in this issue. [ABSTRACT FROM AUTHOR]

Objectives To estimate the cost-effectiveness of an intervention to increase pneumococcal, influenza, and pertussis-containing vaccine uptake in adults aged 65 and older in primary care practices. Design Markov decision analysis model, comparing the cost-effectiveness of the 4 Pillars Practice Transformation Program with no intervention. Setting Diverse primary care practices in two U.S. cities. Participants Clinical trial participants aged 65 and older. Measurements Quality-adjusted life years ( QALYs), public health outcomes, and costs. Vaccination rates and intervention costs were derived from a randomized controlled cluster trial. Other parameters were derived from the medical literature and Centers for Disease Control and Prevention data. All parameters were individually and simultaneously varied over their distributions. Results With the intervention program and extrapolating over 10 years, there would be approximately 60,920 fewer influenza cases, 2,031 fewer pertussis cases, and 13,842 fewer pneumococcal illnesses in adults aged 65 and older. Total per-person vaccination and illness costs with the intervention were $23.93 higher than without the intervention, with a concurrent increase in effectiveness of 0.0031 QALYs, or $7,635 per QALY gained. In sensitivity analyses, no individual parameter variation caused the intervention to cost more than $50,000 per QALY gained. Conclusions Implementing an intervention based on the 4 Pillars Practice Transformation Program is a cost-effective undertaking in primary care practices for individuals aged 65 and older, with predicted public health benefits. [ABSTRACT FROM AUTHOR]