Impact of removing the healthcare mask mandate on hospital-acquired COVID-19 rates

BACKGROUND

Mandatory mask-wearing policies were one of several measures employed to reduce hospital-acquired SARS-CoV-2 infection throughout the pandemic. Many nations have removed healthcare mask mandates, but there remains a risk of new SARS-CoV-2 variants or epidemics of other respiratory viruses.

AIM

To demonstrate the impact of removing the healthcare mask mandate.

METHODS

SARS-CoV-2 infections were analysed in a large teaching hospital for 40 weeks in 2022 using a controlled interrupted time-series design. The intervention was the removal of a staff/visitor surgical mask-wearing policy for the most wards at week 26 (intervention group) with a subset of specific wards retaining the mask policy (control group). The hospital-acquired SARS-CoV-2 infection rate was adjusted by the underlying community infection rate.

FINDINGS

In the context of a surge in SARS-CoV-2 infection, removal of the mask mandate for staff/visitors was not associated with a statistically significant change in the rate of nosocomial SARS-CoV-2 infection in the intervention group (incidence rate ratio: 1.105; 95% confidence interval: 0.523-2.334; P = 0.79) and there was no post-intervention trend (1.013; 0.932-1.100; P = 0.76) to suggest a delayed effect. The control group also showed no immediate or delayed change in infection rate.

CONCLUSION

No evidence was found that removal of a staff/visitor mask-wearing policy had a significant effect on the rate of hospital-acquired SARS-CoV-2 infection. This does not demonstrate that masks were ineffective through the pandemic, but provides some objective evidence to justify the removal of healthcare mask mandates once there was widespread immunity and reduced disease severity.

Insurer costs of COVID-19 by disease severity and duration

OBJECTIVES

To analyze US commercial insurance payments associated with COVID-19 as a function of severity and duration of disease.

STUDY DESIGN

Retrospective database analysis.

METHODS

Patients with COVID-19 between April 1, 2020, and June 30, 2021, in the Merative MarketScan Commercial database were identified and stratified as having asymptomatic, mild, moderate (with and without lower respiratory disease), or severe/critical (S/C) disease based on the severity of the acute COVID-19 infection. Duration of disease (DOD) was estimated for all patients. Patients with DOD longer than 12 weeks were defined as having post-COVID-19 condition (PCC). Outcomes were all-cause payments (ACP) and disease-specific payments (DSP) for the entire DOD. Variables included demographic and comorbidities at the time of acute disease. Adjusted payments by disease severity were estimated using generalized linear models (γ distribution with log link).

RESULTS

A total of 738,339 patients were included (374,401 asymptomatic, 156,220 mild, 180,213 moderate, and 27,505 S/C cases). DSP increased from $217 (95% CI, $214-221) for asymptomatic cases to $2744 (95% CI, $2678-$2811) for moderate cases with lower respiratory disease and $28,250 (95% CI, $26,963-$29,538) for S/C cases. ACP increased from $505 (95% CI, $497-$512) for asymptomatic cases to $46,538 (95% CI, $44,096-$48,979) for S/C cases. The DSP and ACP further increased by $50,736 (95% CI, $45,337-$56,136) and $94,839 (95% CI, $88,029-$101,649), respectively, in S/C cases with PCC vs a DOD of fewer than 4 weeks.

CONCLUSIONS

COVID-19 payments for S/C cases were more than 10-fold greater than those of moderate cases and further increased by nearly $95,000 in S/C cases with PCC vs a DOD of fewer than 4 weeks.

Public health impact of recombinant zoster vaccine for prevention of herpes zoster in US adults immunocompromised due to cancer

Individuals who are immunocompromised (IC) due to therapy or underlying disease are at increased risk of herpes zoster (HZ). This study evaluates the public health impact of recombinant zoster vaccine (RZV) relative to no HZ vaccination for the prevention of HZ among adults aged ≥18 years diagnosed with selected cancers in the United States (US). A static Markov model was used to simulate three cohorts of individuals who are IC with cancer (time horizon of 30 years; one-year cycle length): hematopoietic stem cell transplant (HSCT) recipients, patients with breast cancer (BC; a solid tumor example), and patients with Hodgkin's lymphoma (HL; a hematological malignancy example). Cohort sizes reflect the estimated annual incidence of each condition in the US population (19,671 HSCT recipients, 279,100 patients with BC, and 8,480 patients with HL). Vaccination with RZV resulted in 2,297; 38,068; and 848 fewer HZ cases for HSCT recipients, patients with BC, and patients with HL, respectively (each versus no vaccine). Vaccination with RZV also resulted in 422; 3,184; and 93 fewer postherpetic neuralgia cases for HSCT, BC, and HL, respectively. Analyses estimated the quality-adjusted life years gained to be 109, 506, and 17 for HSCT, BC, and HL, respectively. To prevent one HZ case, the number needed to vaccinate was 9, 8, and 10, for HSCT, BC, and HL, respectively. These results suggest RZV vaccination may be an effective option to significantly reduce HZ disease burden among patients diagnosed with selected cancers in the US.

Cost-Effectiveness of Recombinant Zoster Vaccine for the Prevention of Herpes Zoster in Hematopoietic Stem Cell Transplant Recipients and Other Immunocompromised Adults in the United States

INTRODUCTION

Immunocompromised (IC) adults are at increased risk of developing herpes zoster (HZ) and HZ-related complications due to therapy or underlying disease. This study evaluated the cost effectiveness of recombinant zoster vaccine (RZV) versus no vaccine for the prevention of HZ in hematopoietic stem cell transplant (HSCT) recipients and other IC adults aged ≥ 18 years in the United States (US).

METHODS

A static Markov model simulated cohorts of IC individuals using a 1-year cycle length and 30-year time horizon to estimate the cost effectiveness of RZV. Inputs were sourced from clinical trial results and publicly available sources/literature. Modeled populations included US adult HSCT recipients (base case), patients with human immunodeficiency virus (HIV), patients with breast cancer, patients with Hodgkin's lymphoma, and renal transplant recipients. The model reported societal costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Sensitivity and threshold analyses were conducted.

RESULTS

In the base case of 19,671 US adult HSCT recipients, RZV resulted in total societal cost savings of US$0.1 million and 109 incremental QALYs versus no vaccine. RZV was a 'dominant strategy' versus no vaccine because vaccination resulted in cost savings with QALY gains. RZV was also cost saving in renal transplant recipients, and cost effective at a willingness-to-pay threshold of US$100,000 per QALY gained in patients with HIV, breast cancer, and Hodgkin's lymphoma, with ICERs of US$33,268, US$67,682, and US$95,972 per QALY gained, respectively, versus no vaccine.

CONCLUSIONS

Model results show RZV is potentially cost saving for the prevention of HZ in US adult HSCT recipients and US adults with selected immunocompromising conditions, and cost effective for others, supporting the use of RZV to prevent HZ and HZ-related complications in IC adults.

Health care costs of COVID-19 vs influenza and pneumonia

OBJECTIVES

To estimate payments for the treatment of COVID-19 compared with that of influenza or viral pneumonia (IP), from the perspective of the US payer.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

Patients with COVID-19 during the period from October 1, 2020, to February 1, 2021, or IP during the period from October 1, 2018, to February 1, 2019, in the IBM MarketScan databases were identified. The index was defined as the date of the first COVID-19 or IP diagnosis. Patients with COVID-19 were stratified by severity. Variables for all patients included demographics and comorbidities at the time of index and duration of disease. IP and COVID-19 cohorts were matched using propensity scores, and inflation-adjusted all-cause payments (ACP), and disease-specific payments (DSP) for IP vs COVID-19 were estimated using generalized linear models.

RESULTS

Matched cohorts included 6332 Medicare (female, 58.5%; mean [SD] age, 75.3 [7.6] years), and 397,532 commercially insured patients (female, 57.6%; mean [SD] age, 34.7 [16.7] years). ACP and DSP were significantly higher in the COVID-19 cohort vs IP cohort. Payments for severe/critical COVID-19 were significantly greater than those for IP, with adjusted marginal incremental DSP and ACP of $24,852 (95% CI, $21,573-$28,132) and $50,325 (95% CI, $43,932-$56,718), respectively. IP was significantly less expensive than moderate COVID-19 for commercial payers but not Medicare. IP was more expensive than mild COVID-19 for all payers.

CONCLUSIONS

Payments associated with severe/critical COVID-19 significantly exceeded those associated with IP. For Medicare, IP was more expensive than mild or moderate COVID-19. For commercial payers, IP was less expensive than moderate COVID-19 but more expensive than mild COVID-19.

Herpes Zoster Incidence and Burden in Adults With Type 2 Diabetes in the U.S.: A Retrospective Database Analysis

OBJECTIVE

Data on the real-world burden of herpes zoster (HZ) in adults with type 2 diabetes (T2D) in the U.S. are limited. We assessed HZ in patients with and without T2D and measured the impact of HZ on health care resource use (HCRU) and costs.

RESEARCH DESIGN AND METHODS

This retrospective cohort analysis used U.S. commercial claims data (sourced from claims incurred between 1 January 2012 and 31 July 2018). HZ incidence rates/1,000 person-years (PYs) were calculated in patients with and without T2D. HZ risk was evaluated using Poisson regression to generate adjusted incidence rate ratios (aIRRs). Patients with T2D with HZ were propensity score matched to patients with T2D only and to patients with HZ without T2D. HCRU and costs were compared across cohorts during a 1-year follow-up period. Cox proportional hazards analyses evaluated factors associated with HZ-related complications.

RESULTS

Crude HZ incidence rates in patients with and without T2D were 9.8/1,000 PY and 2.6/1,000 PY, respectively. T2D patients were almost twice as likely to be diagnosed with HZ (aIRR 1.84; 95% CI 1.82-1.85). HZ was associated with increased HCRU and health care costs. At 12 months, unadjusted incremental all-cause health care costs for patients with T2D with HZ versus patients with T2D without HZ were $5,216. The unadjusted incremental HZ-related health care costs for patients with T2D with HZ versus patients with HZ without T2D were $2,726. Age was the most important predictor for HZ-related complications.

CONCLUSIONS

Given the increased risk of HZ and HCRU and cost burden in patients with T2D, HZ prevention in patients with T2D may be beneficial.

Economic Burden of COVID-19: A Systematic Review

Objective

To review and qualitatively synthesize the evidence related to the economic burden of COVID-19, including healthcare resource utilization and costs.

Methods

A systematic review of studies that assessed the economic burden [eg, direct costs, productivity, macroeconomic impact due to non-pharmaceutical interventions (NPIs) and equity] of COVID-19 was conducted by searches in EMBASE, MEDLINE, MEDLINE-IN-PROCESS, and The Cochrane Library, as well as manual searches of unpublished research for the period between January 2020 to February 2021. Single reviewer data extraction was confirmed independently by a second reviewer.

Results

The screening process resulted in a total of 27 studies: 25 individual publications, and 2 systematic literature reviews, of narrower scopes, that fulfilled the inclusion criteria. The patients diagnosed with more severe COVID-19 were associated with higher costs. The main drivers for higher costs were consistent across countries and included ICU admission, in-hospital resource use such as mechanical ventilation, which lead to increase costs of $2082.65 ± 345.04 to $2990.76 ± 545.98. The most frequently reported indirect costs were due to productivity losses. On average, older COVID-19 patients incurred higher costs when compared to younger age groups. An estimation of a 20% COVID-19 infection rate based on a Monte Carlo simulation in the United States led to a total direct medical cost of $163.4 billion over the course of the pandemic.

Conclusion

The COVID-19 pandemic has generated a considerable economic burden on patients and the general population. Preventative measures such as NPIs only have partial success in lowering the economic costs of the pandemic. Implementing additional preventative measures such as large-scale vaccination is vital in reducing direct and indirect medical costs, decreased productivity, and GDP losses.

Factors influencing series completion rates of recombinant herpes zoster vaccine in the United States: A retrospective pharmacy and medical claims analysis

BACKGROUND/OBJECTIVES

Vaccination against herpes zoster (HZ) is an effective strategy in protecting the population against consequences of varicella zoster virus reactivation. Optimal immunogenicity with recombinant zoster vaccine (RZV) relies on completion of the 2-dose series within 2-6 months from the first dose. The objectives of this study were to estimate RZV completion rates and adherence with the recommended administration schedule in the general United States population aged at least 50 years and to evaluate factors influencing completion rates.

METHODS

Longitudinal, open-source pharmacy and medical claims databases were analyzed for adults aged at least 50 years with a first RZV prescription filled between October 2017 and September 2019. The data were linked to Experian Marketing Services Consumer View data to obtain information regarding race. Completion rates and adherence were calculated overall and stratified according to claim source, age class, sex, and payer type. Logistic regression models were built for each subpopulation of interest to identify factors correlating with completion rates.

RESULTS

Overall, cumulative completion rates were 70.41% and 81.80% at 6 and 12 months, respectively. Median time to second dose was approximately 4 months (4.08-5.13 months) and adherence 67.62%. Completion rates were lower in the medical claims database compared with the pharmacy claims database (48.98% vs. 73.23% at 6 months). Regression models confirmed that pharmacy claim was an independent factor for higher completion rates, while African American race and Medicaid status were associated with lower completion rates. Most comorbidities, including chronic obstructive pulmonary disease and type 2 diabetes mellitus, were associated with lower completion rates.

CONCLUSION

Pharmacists contribute substantially to the overall high RZV completion rates in the United States. However, completion rates can be improved, especially in people receiving their first RZV dose at a physician's office. Future strategies should aim at lowering barriers to completing vaccination series in African Americans, Medicaid beneficiaries, and people with comorbidities.

Increased Health Care Resource Utilization and Costs Associated with Herpes Zoster Among Patients Aged ≥50 Years with Chronic Obstructive Pulmonary Disease in the United States

Background

Patients with chronic obstructive pulmonary disease (COPD) are potentially at increased risk of herpes zoster (HZ). Little is known about the impact of an HZ episode on health care resource utilization (HRU) and costs among patients with COPD.

Methods

This retrospective cohort study of individuals aged ≥50 years in the United States (US) used administrative claims data from Optum's de-identified Clinformatics Data Mart Database for commercially insured and Medicare Advantage members (2013-2018). Two cohorts of patients with COPD, with HZ (COPD+/HZ+) and without HZ (COPD+/HZ-), were identified. All-cause and COPD-related HRU rates and costs (2018 US dollars) were compared between cohorts for up to 12 months of follow-up. Comparisons were controlled for baseline differences through propensity score adjustment.

Results

A total of 3415 COPD+/HZ+ and 35,360 COPD+/HZ- patients (mean ages 73.2 ± 9.0 and 72.4 ± 9.4 years, respectively) were identified. Patients in the COPD+/HZ+ versus COPD+/HZ- cohort had increased use of all-cause (adjusted incidence rate ratio [aIRR] 1.17; 95% confidence interval [CI] 1.14, 1.21) and COPD-related (aIRR 1.27; 95% CI 1.21, 1.34) medical services (both P<0.001) and higher mean total all-cause ($4140 versus $3749 per person per month [PPPM]; adjusted cost difference +$313 PPPM) and COPD-related ($1541 versus $1231 PPPM; +$152 PPPM) costs (both P<0.004) in the year after HZ.

Conclusions

HRU and cost burden is higher in patients with COPD with vs without HZ. These results could help to estimate the potential cost benefits of HZ vaccination among patients with COPD.

When Can We Lift Non‐Pharmaceutical Interventions with the Availability of COVID ‐19 Vaccine in the United States?

Research Objective

Study Design

Population Studied

Principal Findings

Conclusions

Implications for Policy or Practice

Primary Funding Source

Preferences for herpes zoster vaccination among adults aged 50 years and older in the United States: results from a discrete choice experiment

BACKGROUND

Most adults, and disproportionately fewer African-Americans, have not received herpes zoster (HZ) vaccination despite current recommendations. This study (GSK study identifiers: 208677/HO-17-18066) assessed HZ vaccination preferences among adults aged ≥ 50 years.

RESEARCH DESIGN AND METHODS

In this discrete choice experiment, respondents chose among a 'no vaccine' option and two HZ vaccine profiles, characterized by seven attributes, in a series of choice questions. Random-parameters logit results were used to predict likely vaccine uptake. Subgroup and latent class analysis of African-American's preferences were performed.

RESULTS

The preference weight for choosing HZ vaccines over no vaccine was statistically significant among the 1,454 respondents (71.9% whites; 25.2% African-Americans). Out-of-pocket (OOP) cost and vaccine effectiveness (VE) were the most important attributes. The African-American and the non-African-American subgroups had statistically significant differences in preferences (χ² = 59.91, p < 0.001), mainly driven by OOP cost and VE. Latent class analysis identified three groups of African-American respondents with systematically different preferences; two comprised likely-vaccinators, with one being more cost sensitive at lower price thresholds, and one likely non-vaccinators.

CONCLUSIONS

For all respondents, HZ vaccine choices were most sensitive to total OOP cost, followed by VE.

Estimated Public Health Impact of the Recombinant Zoster Vaccine

OBJECTIVE

To investigate the potential public health impact of adult herpes zoster (HZ) vaccination with the adjuvanted recombinant zoster vaccine (RZV) in the United States in the first 15 years after launch.

METHODS

We used a publicly available model accounting for national population characteristics and HZ epidemiological data, vaccine characteristics from clinical studies, and anticipated vaccine coverage with RZV after launch in 2018. Two scenarios were modeled: a scenario with RZV implemented with 65% coverage after 15 years and a scenario continuing with zoster vaccine live (ZVL) with coverage increasing 10% over the same period. We estimated the numbers vaccinated, and the clinical outcomes and health care use avoided yearly, from January 1, 2018, to December 31, 2032. We varied RZV coverage and investigated the associated impact on HZ cases, complications, and health care resource use.

RESULTS

With RZV adoption, the numbers of individuals affected by HZ was predicted to progressively decline with an additional 4.6 million cumulative cases avoided if 65% vaccination with RZV was reached within 15 years. In the year 2032, it was predicted that an additional 1.3 million physicians' visits and 14.4 thousand hospitalizations could be avoided, compared with continuing with ZVL alone. These numbers could be reached 2 to 5 years earlier with 15% higher RZV vaccination rates.

CONCLUSION

Substantial personal and health care burden can be alleviated when vaccination with RZV is adopted. The predicted numbers of HZ cases, complications, physicians' visits, and hospitalizations avoided, compared with continued ZVL vaccination, depends upon the RZV vaccination coverage achieved.

Early examination of real-world uptake and second-dose completion of recombinant zoster vaccine in the United States from October 2017 to September 2019

Shingrix (Recombinant zoster vaccine, RZV) was approved in October 2017 in the United States (US) for the prevention of herpes zoster in adults aged 50 years and older. The vaccine is administered in two doses, with the second dose administration recommended between two and six months after the first dose. Examination of uptake and series completion is important to ensure appropriate use, especially at the time of vaccine introduction. This report provides demographic characteristics of patients receiving RZV between October 2017 and September 2019, first- and second-dose uptake, and a cumulative estimation of second-dose completion by month for US adults aged 50 years and older. Monthly uptake increased rapidly since October 2017; overall, 7,097,441 first doses of RZV were administered along with 4,277,636 second doses during the observed timeframe. Among people with an observed first-dose administration, 70% and 80% completed the two-dose series within six and 12 months post initial dose, respectively. This evidence suggests that RZV has rapidly been adopted by a large population in the US and most are following manufacturer or policy recommendations regarding series completion. Further analyses are needed to explore potential patient, provider, and policy-relevant characteristics associated with second-dose completion that could serve as targets for further improvement.

The Epidemiology of Herpes Zoster in Immunocompetent, Unvaccinated Adults ≥50 Years Old: Incidence, Complications, Hospitalization, Mortality, and Recurrence

Background

Data on the epidemiology of herpes zoster (HZ), particularly in the unvaccinated immunocompetent population, are needed to assess disease burden and the potential impact of vaccination.

Methods

The study at a large health care organization comprised: (1) incidence estimated from immunocompetent adults aged ≥50 years unvaccinated with zoster vaccine live who had incident HZ in 2011–2015; (2) proportion of HZ-related nonpain complications assessed by double abstraction of electronic health records (EHRs) of 600 incident patients 2011–2015; (3) HZ-related hospitalizations among HZ patients diagnosed in 2015; (4) HZ-related death determined from automated data and EHRs; and (5) recurrent HZ identified from a cohort initially diagnosed with HZ in 2007–2008 and followed through 2016.

Results

HZ incidence rate was 9.92/1000 person-years (95% confidence interval [CI], 9.82–10.01). Proportions of cutaneous, neurologic, and other complications were 6.40% (95% CI,1.73%–11.07%), 0.77% (95% CI, .00%–2.36%), and 1.01% (95% CI, .00%–2.93%), respectively. Only 0.86% of patients had an HZ-related hospitalization. The case-fatality rate was 0.04%. Recurrence rate was 10.96/1000 person-years (95% CI, 10.18–11.79) with 10-year recurrence risk of 10.26% (95% CI, 9.36%–11.23%).

Conclusions

These recent HZ epidemiology data among an immunocompetent, unvaccinated population measure real-world disease burden.

1716. Prospective Multicenter Observational Cohort Study to Assess the Burden of Herpes Zoster Disease in the Eye: Baseline Results of Initial Patients

Background

Herpes Zoster Ophthalmicus (HZO) affects 10-20% of adults with herpes zoster; ≥ 50% of these cases manifest as serious ocular diseases. This 1-year prospective observational cohort study aims to determine patient-reported HZO symptoms as well as economic and quality of life burden among 300 HZO patients from 6 major US ophthalmology practices. Here, we report baseline data from 13 initial enrollees.

Methods

Inclusion criteria were: participants ≥ 18 years, diagnosis of clinically active HZO, English or Spanish speaking, be willing and able to respond to study assessments, not be enrolled in a concurrent interventional HZO trial. Information are collected via 1) a clinical assessment form completed by the practice (baseline) and 2) patient questionnaires (baseline, 3, 6, and 12 months) on symptoms, medications, healthcare use, vision function, depression, and work productivity impact. Baseline results are presented for patients recruited during the first 6 months of enrollment from the first 4 sites to go live: diagnoses, and patient-reported symptoms and outcomes (eight-item Patient Health Questionnaire [PHQ-8] for depressive symptoms, National Eye Institute 25-item Visual Function Questionnaire [NEI-VFQ-25] for vision-related quality of life, and Zoster Brief Pain Inventory [ZBPI] for pain).

Results

The mean age of participants is 71 years; 11 are female and 9 are retired. Seven participants are college graduates or hold other degrees. All have health insurance coverage, with most (10) having primary insurance through Medicare. HZO diagnoses (Table 1) were: keratitis (4), iridocyclitis (4), conjunctivitis (1), other HZO diagnosis (3), other ocular diagnosis (6). Patient-reported symptoms (Table 2) were: pain above the eye, sensitivity to light, redness, feeling of sand/grit in the eye (9 each). The mean overall PHQ-8 and NEI-VFQ-25 scores were 5.9 (Standard Deviation [SD]:4.5) and 74.6 (SD:13.9), respectively; the mean ZBPI score for worst pain severity was 3.3 (SD:3.8) (Table 3).

Table 1. HZO Diagnosis at Baseline based on Clinical Assessment Form (N=13)

Conclusion

This study represents the first large scale effort to quantify HZO burden. Findings will inform development of a formal patient-reported symptom scale for use in research and clinical practice.

Funding

GlaxoSmithKline Biologicals SA (GSK study identifiers: 209235/HO-17-17967)

Disclosures

Laura T. Pizzi, PharmD, MPH, ORCID: 0000-0002-7366-7661, GlaxoSmithKline (Research Grant or Support) Soham Shukla, PharmD, ORCID: 0000-0002-4139-0856, GSK (Employee)Rutgers University (Employee) Brandon J. Patterson, PharmD, PhD, GSK (Employee, Shareholder) Debora A. Rausch, MD, ORCID: 0000-0001-9759-2687, GSK (Employee) Philip O. Buck, PhD, MPH, ORCID: 0000-0002-3898-3669, GSK (Employee, Shareholder) Ann P. Murchison, MD, MPH, GSK (Grant/Research Support)

24. Economic Burden of Herpes Zoster Among Individuals with Chronic Obstructive Pulmonary Disease: A Retrospective Cohort Study

Background

Previous studies have evaluated the risk of developing herpes zoster (HZ) in patients with chronic obstructive pulmonary disease (COPD), but little is known about the impact of an acute HZ episode on healthcare resource utilization (HCRU) and costs among patients with COPD in the US.

Methods

A retrospective cohort study of individuals ≥50 years of age was conducted using administrative claims data from Optum Clinformatics for commercially insured and Medicare Advantage members (01/01/2013 – 12/31/2018). Two cohorts of patients with COPD, with (Cohort A) and without (Cohort B) HZ episodes, were identified (Fig.1). COPD and HZ were identified using ICD-9 and ICD-10 diagnosis codes. All-cause HCRU rates were compared between cohorts using adjusted incidence rate ratios (IRRs), calculated using generalized linear models assuming a negative binomial distribution. Differences in all-cause costs were estimated by fitting a two-part model with a logit model in the first part and a gamma distribution for the second part. Potential differences between cohorts were accounted for by propensity scores, calculated using patients’ demographics and clinical characteristics at baseline and included as a covariate in multivariable regression analyses.

Results

Among patients with COPD, 3,415 patients with HZ (mean age [standard deviation]=73.2 [9.0] years) and 35,360 without HZ (72.4 [9.4] years) were identified. Compared to patients with COPD but without HZ, patients with COPD and HZ had an increased rate of all-cause outpatient visits (adjusted IRR=1.18; 95% confidence interval [CI]=1.15–1.22; p< 0.001) and Emergency Department visits (1.28; 1.20–1.35; p< 0.001) as well as higher all-cause total costs (adjusted cost difference, per patient per month [PPPM]=$313; 95% CI=$110–536; p< 0.004), in the first year of the observation period. All-cause mean costs PPPM and differences between cohorts were higher closer to the date of HZ diagnosis (or an imputed date for Cohort B, Fig.2).

Figure 2: All-cause monthly costs

Conclusion

HCRU and cost burden is higher in patients ≥50 years old with COPD and HZ vs. without HZ. HZ vaccination may potentially reduce this burden among patients with COPD.

Funding

GlaxoSmithKline Biologicals SA (GSK study identifier: HO-19-19749)

Disclosures

Parinaz Ghaswalla, PhD, ORCID: 0000-0002-2883-5590, GlaxoSmithKline (Employee, Shareholder) Philippe Thompson-Leduc, MSc, ORCID: 0000-0001-9047-3941, Analysis Group, Inc. (Employee) Wendy Y. Cheng, MPH, PhD, ORCID: 0000-0002-8281-2496, GlaxoSmithKline (Other Financial or Material Support, I am an employee of Analysis Group, a consulting company that received research fund to conduct this study.) Min-Jung Wang, ScD, ORCID: 0000-0003-4432-3330, Analysis Group, Inc. (Employee, Other Financial or Material Support, Analysis Group received grant/research support from GSK) Michael Bogart, PharmD, ORCID: 0000-0002-1681-9710, GlaxoSmithKline (Employee, Shareholder) Brandon J. Patterson, PharmD, PhD, GSK (Employee, Shareholder) Mei-Sheng Duh, MPH, ScD, ORCID: 0000-0001-5035-6687, GlaxoSmithKline (Grant/Research Support) Suna Park, MS, GSK (Other Financial or Material Support, Analysis Group, Inc., where I am an employee, received funding for this study) Barbara P. Yawn, MD, Msc, ORCID: 0000-0001-7278-5810, GSK (Grant/Research Support, Scientific Research Study Investigator, Advisor or Review Panel member)

17. Assessment of Recombinant Zoster Vaccine Second Dose Completion in the United States

Background

Recombinant Zoster Vaccine (RZV) was licensed in the United States (US) in October 2017 for the prevention of herpes zoster in adults ≥ 50 years of age (YOA). The vaccine is administered in a two-dose sequence with a 2- to 6-month interval; however, the Center for Disease Control & Prevention has advised against restarting a series after the prescribed window. This study describes an assessment of 2nd dose completion and compliance of RZV in the US.

Methods

Primary analysis was conducted on a cohort ≥ 50 YOA who received an initial RZV dose between October 2017 and September 2018 as indicated in the IQVIA longitudinal prescription claims or medical claims databases. Subjects were required to have ≥ 1 year of observable time post initial dose. A sensitivity analysis was conducted using all eligible subjects regardless of observable time post initial dose. Endpoints of analyses were monthly and cumulative 2nd dose label-compliant proportions at 6 months and completers by 12-month intervals and time to completion from initial RZV vaccine administration with stratifications by age, sex, claim source and payer type.

Results

The primary sample included 1,225,088 subjects, while the sensitivity analysis included 7,097,441 (Table 1). Overall, 2nd RZV dose completion was 70.4% within 6 months and 81.8% within 12 months. Minimal variation for 12-month completion was demonstrated across age (77.2–84.5%), sex (81.7–81.9%), and Commercial vs. Medicare (80.9–83.0%). However, larger variations were seen across claim sources and other payer type, with medical claims (64.9%), Medicaid patients (72.8%) and Cash patients (74.7%) having lower rates at 12 months (Table 2). Overall, the average time to completion was around 4 months regardless of stratification except by claims source, with medical claims taking 5 months on average to complete. The sensitivity analysis of the variable follow-up cohort demonstrated findings consistent with that of the primary sample.

Conclusion

Assessment of RZV suggests high levels of completion across age, sex, payer type and claim sources. More effort is needed to understand barriers to completion rates in Medicaid patients and settings where vaccination claims are processed outside of the vaccine recipient’s pharmacy benefit.

Disclosures

Brandon J. Patterson, PharmD, PhD, GSK (Employee, Shareholder) Chi-Chang Chen, PhD, MSPharm, GSK (Research Grant or Support) Catherine B. McGuiness, MA, MS, GSK (Research Grant or Support)Pfizer (Shareholder) Lisa I. Glasser, MD, GSK (Employee, Shareholder) Kainan Sun, MS, PhD, GSK (Research Grant or Support) Philip O. Buck, PhD, MPH, ORCID: 0000-0002-3898-3669, GSK (Employee, Shareholder)

Incremental clinical and economic impact of recombinant zoster vaccination: real-world data in a budget impact model

BACKGROUND

In 2017, the FDA approved the adjuvanted recombinant zoster vaccine (RZV) for the prevention of herpes zoster (HZ) in immunocompetent adults aged 50 years and older. RZV joined zoster vaccine live (ZVL) as U.S.-marketed vaccines against HZ. The Advisory Committee on Immunization Practices preferentially recommended use of RZV over ZVL. In order to inform population-based decision makers (PBDMs) about the incremental clinical and economic impact of RZV adoption, budget impact (BI) models may be used. Populating such models with national data can inform PBDMs about the incremental value of RZV adoption nationally; however, heterogeneity across health plans requires the inclusion of plan-specific data to ensure the relevance of modeling outcomes for plan-specific decision makers.

OBJECTIVE

To investigate the clinical and economic outcomes associated with the adoption of RZV in nationally representative populations with commercial and Medicare coverage and to demonstrate the effect of the heterogeneity of health plans using real-world data from a large, integrated delivery network (IDN).

METHODS

We used a publicly available BI model. The model accounts for national and IDN-collected population characteristics (size, age distribution) and epidemiological data (incidence of HZ and complications, HZ recurrence rate), vaccine characteristics from randomized controlled trials and observational studies (efficacy, waning, second dose compliance for RZV, adverse event rate), national costs (vaccine, direct medical for HZ, complications, and vaccine adverse events), and current and anticipated vaccine coverage. We assessed incremental clinical (HZ cases and complications) and economic (per-member-per-month [PMPM] costs) impact at 5-year to 15-year time horizons, comparing scenarios where RZV is solely implemented with one where only ZVL is utilized.

RESULTS

Following the adoption of RZV, the incremental HZ cases avoided over 5 and 15 years were estimated to be 1,800 and 15,000 for a commercial plan, 3,800 and 21,000 for a Medicare plan, and 8,600 and 71,000 for a specific IDN. The incremental PMPM budget impact over the same time horizons was estimated to be $0.42 and $0.31, respectively, for a commercial plan, $0.35 and $0.10 for a Medicare plan, and $0.39 and $0.25 for a specific IDN. The differences in results across plans resulted from the population age distribution, the vaccine copay (applied in the Medicare scenario only), the vaccine coverage in the plan, and other plan-specific factors affecting disease epidemiology and costs per case of HZ.

CONCLUSIONS

Model projections indicated that RZV adoption avoided HZ cases and related complications, with the PMPM budget impact dependent on plan-specific factors. As health gains increased over time, the incremental costs incurred were found to decrease as the shorter-term costs of adopting the new vaccine were increasingly offset by the longer-term benefits of vaccination.

DISCLOSURES

GlaxoSmithKline Biologicals SA funded this study (GSK study identifier: HO-17-18378) and was involved in all stages of study conduct, including analysis of the data. GlaxoSmithKline Biologicals SA also paid all costs associated with the development and publication of this manuscript. Patterson, Van Oorschot, and Curran are employees of the GSK group of companies and hold shares in the GSK group of companies. Herring, Carrico, and Zhang are employees of RTI Health Solutions, which received funding via a contractual agreement with the GSK group of companies to perform the work contributing to this research. Ackerson, Bruxvoort, Sy, and Tseng are employees of Kaiser Permanente Southern California, which was contracted by the GSK group of companies for the conduct of this study and were members of the KPSC study team. Ackerson, Bruxvoort, Sy, and Tseng report research contracts with the following pharmaceutical companies unrelated to this study: Dynavax (Ackerson, Bruxvoort, and Sy); the GSK group of companies (Ackerson, Bruxvoort, Sy, and Tseng); Novavax (Ackerson, Sy, and Tseng); and Seqirus (Ackerson, Bruxvoort, Sy, and Tseng). Tseng reports having served as a paid consultant for the GSK group of companies. The authors declare no other financial and nonfinancial relationships and activities. Findings from this study were presented at AMCP Nexus 2019; October 29-November 1, 2019; National Harbor, MD.

2300. Incidence, Complications, and Recurrence of Herpes Zoster in Unvaccinated Adults ≥50 Years of Age

Background

More recent baseline epidemiological data for Herpes Zoster (HZ) in adults ≥ 50 years of age, obtained before the introduction of the adjuvanted Recombinant Zoster Vaccine (RZV), are needed for future evaluations of the impact of RZV on HZ epidemiology.

Methods

The study comprised five elements: (1) The incidence of HZ was estimated from immunocompetent adults ≥ 50 years of age not vaccinated with Zoster Vaccine Live who had incident HZ between 2011–2015. HZ was identified by International Classification of Diseases (ICD) codes from electronic health records (EHR) of 4.6 million Kaiser Permanente Southern California members; (2) Postherpetic neuralgia (PHN) was identified by validated survey and medical record review of laboratory-confirmed incident HZ cases recruited during 2012–2015 for HZ-related pain ≥ 90 days after initial HZ diagnosis; (3) HZ Ophthalmicus (HZO) with ocular complications was identified by ICD codes and keyword search in EHR among patients identified with HZO using a validated natural language processing algorithm; (4) The proportion of HZ-related non-PHN and non-HZO cutaneous, neurological or other complications was assessed by double abstraction of EHRs from a sample of 600 incident HZ cases; (5) Recurrent HZ was identified by having an HZ diagnosis with HZ antiviral medication ≥ 6 months after the most recent HZ diagnosis with HZ antiviral medication in a cohort initially diagnosed with HZ between 2007 and 2008 and followed through 2016.

Results

We identified 40,893 incident HZ cases with an overall incidence of 9.92 (95% confidence interval [CI]: 9.82–10.01) per 1000 person-years. The proportion of incident HZ cases with PHN and HZO with ocular involvement was 18.37% (95% CI: 14.90–21.84%) and 8.06% (95% CI: 7.80–8.32%), respectively. The proportion of cutaneous, neurological, and other complications was 7.20% (95% CI: 5.44–8.96%), 0.87% (95% CI: 0.79–0.95%), and 1.24% (95% CI: 1.15–1.33%), respectively. The incidence of recurrent HZ was 10.96/1000 person-years (95% CI: 10.18–11.79).

Conclusion

HZ is common among unvaccinated US adults ≥ 50 years of age, with PHN and HZO occurring most frequently among incident HZ cases.

Funding

GlaxoSmithKline Biologicals SA, GSK study identifier: HO-17-18378.

Disclosures

All authors: No reported disclosures.

Analysis of Vascular Event Risk After Herpes Zoster From 2007 to 2014 US Insurance Claims Data

OBJECTIVE

To estimate the risk of transient ischemic attack (TIA), stroke, and myocardial infarction in periods covering 4 weeks before to 52 weeks after herpes zoster (HZ) diagnosis in US adults.

PATIENTS AND METHODS

This retrospective study (GSK study identifier: HO-15-15771) with matched cohorts used the Truven Health MarketScan Commercial and Medicare claims data set linked with obesity and smoking status information. Patients 18 years and older at the date of HZ diagnosis and 1-year pre- and post-HZ diagnosis continuous insurance enrollment (from January 1, 2007, through December 31, 2014) were propensity score matched to controls in terms of demographic characteristics, risk factors for vascular events, other comorbid disorders, general health, obesity, and smoking status. A post hoc sensitivity analysis was performed not matching for obesity and smoking status information. Adjusted incidence rate ratios (IRRs) were estimated using multivariate Poisson models during an aggregate period (1-month before and after the index date).

RESULTS

A total of 23,339 patients with HZ were matched to 46,378 controls (mean age, 56 years; 45,173 [65%] women). During the aggregate period, patients with HZ were statistically significantly more likely to suffer a TIA: IRRs for all patients and patients aged 18 to 49 years were 1.56 (95% confidence interval [CI], 1.13-2.15) and 5.12 (95% CI, 1.37-19.10), respectively (P<.05); the respective IRRs for stroke were 1.40 (95% CI, 0.93-2.11) and 8.12 (95% CI, 0.93-71.27). In the sensitivity analysis, IRRs for TIA and stroke were statistically significantly increased regardless of age.

CONCLUSION

Herpes zoster was associated with an increased risk of composite events, TIA, and stroke in adults in the period around diagnosis. More research on the HZ and vascular risk association is needed.

GSK STUDY IDENTIFIER

HO-15-15771.

Cost-effectiveness of an adjuvanted recombinant zoster vaccine in older adults in the United States who have been previously vaccinated with zoster vaccine live

Zoster Vaccine Live (ZVL) is marketed in the US since 2008, and a non-live adjuvanted Recombinant Zoster Vaccine (RZV) was approved in 2017. Literature suggests that waning of ZVL efficacy may necessitate additional vaccination. The Advisory Committee on Immunization Practices recommended vaccination with RZV in immunocompetent adults aged 50+ years old, including those previously vaccinated with ZVL. The objective of this study was to determine the cost-effectiveness of vaccinating US adults aged 60+ years old, previously vaccinated with ZVL. The ZOster ecoNomic Analysis (ZONA) model, a deterministic Markov model, was adapted to follow a hypothetical 1 million(M)-person cohort of US adults previously vaccinated with ZVL. Model inputs included demographics, epidemiology, vaccine characteristics, utilities and costs. Costs and quality-adjusted life-years (QALYs) were presented over the lifetimes of the cohort from the year of additional vaccination, discounted 3% annually. The model estimated that, vaccination with RZV 5 years after previous vaccination with ZVL, would reduce disease burden compared with no additional vaccination, resulting in a gain of 1,633 QALYs at a total societal cost of $96M (incremental cost-effectiveness ratio: $58,793/QALY saved). Compared with revaccinating with ZVL, vaccination with RZV would result in a gain of 1,187 QALYs and societal cost savings of almost $84M. Sensitivity, scenario, and threshold analyses demonstrated robustness of these findings. Vaccination with RZV is predicted to be cost-effective relative to no additional vaccination, assuming a threshold of $100,000/QALY, and cost-saving relative to ZVL revaccination of US adults aged 60+ years old who have been previously vaccinated with ZVL.

Costs of herpes zoster complications in older adults: A cohort study of US claims database

BACKGROUND/OBJECTIVES

Herpes zoster (HZ) incidence increases with age, and the burden of HZ is expected to grow with aging of populations worldwide. We aim to determine the incremental healthcare resource utilization and associated costs of patients with common HZ-related complications other than postherpetic neuralgia (cutaneous, neurologic and ophthalmic) compared to uncomplicated HZ.

METHODS

We conducted a retrospective cohort study of commercial health insurance claims covering about 40 million immunocompetent individuals aged ≥50 years at study entry from all over the US, from 2008 to 2013, with follow-up for one year after HZ onset. All-cause healthcare resource utilization and direct healthcare costs were recorded and calculated from six months before until 12 months after HZ onset. The mean costs for HZ patients with complications were compared to the mean costs for patients with uncomplicated HZ. Multivariable regression analyses estimated mean incremental costs adjusted for demographics, comorbidities, type of complication and time period.

RESULTS

Over the five-year study period, 22,948 HZ patients (60% women, median age 62 years) who experienced at least one of the selected complications were compared to 213,232 patients (63% women, median age 61 years) with uncomplicated HZ. Overall, the mean annual incremental unadjusted costs for the patients with HZ-related complications were US$4716, ranging from US$2173 for ophthalmic to US$18,323 for neurologic complications. Most of the incremental costs associated with HZ complications were accrued during the first quarter after HZ onset. For each complication type the incremental costs increased with age up to, but not including the oldest group, aged ≥80 years.

CONCLUSIONS

Approximately 10% of immunocompetent older patients with HZ develop complications which considerably increase the economic burden of HZ. Vaccination of older adults will offset some of the burden of HZ, including costs associated with HZ-related complications.

National survey of pharmacy-based immunization services

INTRODUCTION

Pharmacists in the United States (U.S.) are authorized to administer vaccines. This study described: how and to what extent immunization services are offered, promoted, and documented in community pharmacies; reasons for referral to other locations for vaccination; and perceived barriers to immunization services.

METHODS

A mixed-mode (mail/electronic) survey of a stratified random sample of 1999 nationally-representative community pharmacies in the U.S. was conducted in April-July 2017. Survey instrument development was informed by validated scales and 10 in-depth interviews with community pharmacists; content and face validity were ensured via pre- (n = 5) and pilot-tests (n = 26) among community pharmacists. Potential non-response bias was investigated and descriptive statistics were used to analyze survey responses.

RESULTS

Of the 1999 community pharmacies, 119 pharmacies were deemed ineligible. Of those eligible pharmacies, complete responses were provided by 292 respondents, each representing a unique pharmacy (15.5% response rate). Respondents were evenly split male/female (52.5/47.5%) and about half were pharmacy managers (51.3%). The majority (79.5%) reported offering at least one type of vaccine in 2016, with the most commonly administered vaccine types (average doses in 2016) being: Influenza (484), Pneumococcal 13-valent conjugate (55), Herpes Zoster (41), and Pneumococcal polysaccharide (39). Two-thirds (66.7%) of immunizing pharmacies provided adolescent vaccinations. Most frequently reported referral reasons were patients' insurance not covering vaccine administration at the pharmacy and patients' age not within approved protocol, policy or state law. The majority of respondents did not perceive organizational and environmental factors as barriers; however, they reported patient-related factors, especially cost and insurance coverage, as important barriers.

CONCLUSIONS

The majority of U.S. community pharmacies reported offering at least one type of vaccine. The scope of pharmacy engagement in immunization services varied in terms of how and to what extent they were offered and documented. Addressing patient-related barriers is needed to further enhance pharmacy-based immunization services.

Hepatitis A, B, and A/B vaccination series completion among US adults: A claims-based analysis

Hepatitis A and B disease burden persists in the US. We assessed hepatitis A and hepatitis B vaccination series completion rates among 350,240 commercial/Medicare and 12,599 Medicaid enrollees aged ≥19 years. A vaccination series was considered as completed provided that the minimum interval between doses, as defined by the CDC, and the minimum number of doses were reached. We stratified completion rates by vaccine type (i.e. monovalent or bivalent) at initial vaccination for each cohort. In the commercial/Medicare cohort, the series completion rate was 32.0% for hepatitis A and 39.6% for hepatitis B among those who initiated with a monovalent vaccine, and it was 36.2% for hepatitis A and 48.9% for hepatitis B among those who initiated with a bivalent vaccine. In the Medicaid cohort, the series completion rate was 21.0% for hepatitis A and 24.0% for hepatitis B among those who initiated with a monovalent vaccine, and it was 19.0% for hepatitis A and 24.6% for hepatitis B among those who initiated with a bivalent vaccine. In conclusion, hepatitis A and B vaccination series completion rates were low, and appeared to be lower among Medicaid than among commercial/Medicare enrollees. Commercial/Medicare enrollees who initiated with a bivalent vaccine had higher series completion rates than those who initiated with monovalent vaccines – an observation that was not made among Medicaid enrollees.

Impact of an electronic medical record reminder on hepatitis B vaccine initiation and completion rates among insured adults with diabetes mellitus

OBJECTIVE

The Advisory Committee on Immunization Practices recommends Hepatitis B (HepB) vaccine for previously unvaccinated adults <60 years with diabetes mellitus. This observational retrospective cohort study assessed the impact of implementing electronic provider reminders on HepB vaccine initiation and 3-dose series completion rates among insured adults with diabetes aged 19-59 years old.

RESEARCH DESIGN AND METHODS

Difference-in-difference (DID) analyses compared changes in vaccine initiation and completion rates (ratio of the rate ratio [RRR] and 95% confidence interval [CI]) during 12 months pre- and post-implementation between intervention and control sites. We examined trends in vaccine initiation and completion rates by plotting monthly rates during the study period. We also calculated the overall HepB vaccine coverage rates with 95% CI among all adults with diabetes aged 19-59 years old at the start and end date of the study period.

RESULTS

Baseline HepB vaccine initiation and completion rates were similar at both the intervention and control sites. Gender, age, and race/ethnicity distributions within both sites were similar during the 12 months pre- and post-implementation. DID analyses demonstrated statistically significant differences in the changes of the annual vaccine initiation rates (RRR: 70.7, 95% CI: 62.8-79.6) and the third dose completion rates (RRR = 18.7, 95% CI: 14.2-24.8) between the two sites. The coverage increased significantly at the intervention site while it remained low at the control site.

CONCLUSIONS

Use of provider reminders is highly effective in increasing both HepB vaccine initiation and series completion rates among adults with diabetes.

Assessment of the Potential Herpes Zoster and Post Herpetic Neuralgia Case Avoidance with Vaccination in the United States

Background

Herpes zoster (HZ), commonly referred to as shingles, is a reactivation of latent varicella zoster virus in patients previously infected. Clinical characteristics of HZ include painful rash with potential complications, including post herpetic neuralgia (PHN). Care for HZ and PHN incurs significant costs and vaccination is beneficial. The aim of this study was to compare the impact on HZ and PHN case avoidance of two HZ vaccines, an available live-attenuated zoster vaccine (zoster vaccine live [ZVL]) vs. a candidate non-live adjuvanted HZ subunit vaccine (HZ/su), in the US population.

Methods

A Markov model called ZONA (ZOster ecoNomic Analyses) was developed following two age cohorts (≥60 years to represent the current ACIP recommendation and ≥65 years to represent the Medicare population) over their lifetimes from the year of vaccination. Demographic data were obtained from the US Census, whereas HZ incidence and the proportion of HZ individuals developing PHN were derived from published US-specific sources. Age-specific vaccine efficacy and waning rates were based on published clinical trial data. Vaccine coverage for both vaccines was assumed to be 30.6% and 34.2% in the two age cohorts, respectively, based on CDC data; compliance of the second dose of the HZ/su vaccine was 69%, based on data from clinical trials and Hepatitis B seconddose completion. Sensitivity analyses demonstrated robustness of the base analysis findings.

Results

In the US, for cohorts of 66.83 million (M) persons aged 60+ and 47.76M aged 65+ it was estimated that the HZ/su vaccine would reduce the number of HZ cases by 2.12M and 1.55M in the two age cohorts, respectively, compared with 0.65M and 0.45M using the ZVL. Furthermore, the HZ/su vaccine would reduce the number of PHN cases by 0.23M and 0.18M in the two age cohorts, respectively, compared with 0.10M and 0.09 using the ZVL. The number needed to vaccinate to prevent one HZ case were 10 and 11, in the respective cohorts, using the HZ/su vaccine compared with 31 and 37, in the respective cohorts, using the ZVL.

Conclusion

Due to higher and sustained vaccine efficacy, the candidate HZ/su vaccine demonstrated superior public health impact in the US compared with the currently available ZVL.

Disclosures

B. J. Patterson, GSK: Employee and Shareholder, GSK stock options or restricted shares and Salary; Pennsylvania Pharmacists Association: Scientific Advisor, stipend; P. O. Buck, GSK: Employee and Shareholder, GSK stock options or restricted shares and Salary; J. Carrico, RTI Health Solutions: Employee, Salary GSK: Research Contractor, Research support; K. A. Hicks, RTI: Employee, Salary GSK: Research Contractor, Research support; D. Curran, GSK: Employee and Shareholder, GSK stock options or restricted shares and Salary; D. Van Oorschot, GSK: Employee, Salary; J. E. Pawlowski, GSK: Employee and Shareholder, GSK stock options or restricted shares and Salary; B. Y. Lee, GSK: Consultant, Consulting fee; B. P. Yawn, GSK: Consultant and Scientific Advisor, Consulting fee

Population characteristics associated with pharmacy-based influenza vaccination in United States survey data

OBJECTIVES

To examine the population characteristics associated with the health behavior of receiving an influenza vaccine from a pharmacy-based setting.

DESIGN

Secondary analysis of data from states that participated in an optional influenza module in the 2014 Behavioral Risk Factor Surveillance System, a state-based observational survey of U.S. adults.

SETTING AND PARTICIPANTS

Analytic sample of 28,954 respondents from 8 states and Puerto Rico who reported receiving an influenza vaccination in the past year.

MAIN OUTCOME MEASURES

The main outcome was a self-reported categoric variable indicating the setting of the most recent seasonal influenza vaccination: doctor's office, pharmacy-based store, or other setting.

RESULTS

Multinomial logistic regression results showed that environmental, predisposing, enabling, and need factors in the Andersen model were salient features associated with odds of using pharmacy-based influenza vaccination settings instead of a doctor's office. Residents of states that allowed pharmacists as immunizers before 1999 reported greater use of pharmacy-based store settings (odds ratio [OR] 1.31). Compared with young adults, individuals 65 years of age and older were more likely to choose a pharmacy-based store than a doctor's office (OR 1.41) and less likely to use other community settings (OR 0.45). Compared with non-Hispanic whites, black respondents were less likely to use pharmacy-based store vaccination (OR 0.51), and multiracial and Hispanic respondents were more likely to use other settings (ORs 1.47 and 1.60, respectively). Enabling and need factors were also associated with setting.

CONCLUSION

Based on this dataset of selected states from 2014, almost one-fourth of U.S. adults who reported receiving an annual influenza vaccination did so from a pharmacy-based store; 35% reported using other community-based settings that may enlist pharmacists as immunizers. There were striking disparities in use of nontraditional vaccination settings by age and race or ethnicity. Pharmacists and pharmacies should address missed opportunities for vaccination by targeting outreach efforts based on environmental and predisposing characteristics.

Nurses' attitudes and behaviors on patient medication education

BACKGROUND

Medication education is vital for positive patient outcomes. However, there is limited information about optimal medication education by nurses during hospitalization and care transitions.

OBJECTIVE

Examine nurses' attitudes and behaviors regarding the provision of patient medication education. The secondary objectives were to determine if nurses' medication education attitudes explain their behaviors, describe nurses' confidence in patient medication knowledge and abilities, and identify challenges to and improvements for medication education.

METHODS

A cross sectional survey was administered to nurses servicing internal medicine, cardiology, or medical-surgical patients.

RESULTS

Twenty-four nurses completed the survey. Greater than 90% of nurses believed it is important to provide information on new medications and medical conditions, utilize resources, assess patient understanding and adherence, and use open ended question. Only 58% believed it is important to provide information on refill medications. Greater than 80% of nurses consistently provided information on new medications, assessed patient understanding, and utilized resources, but one-third or less used open-ended questions or provided information on refill medications. Most nurses spend 5-9 minutes per patient on medication education and their attitudes matched the following medication education behaviors: assessing adherence (0.57; p<0.01), providing information on new medications (0.52; p<0.05), using open-ended questions (0.51; p<0.01), and providing information on refill medications (0.39; p<0.05). Nurses had higher confidence that patients can understand and follow medication instructions, and identify names and purpose of their medications. Nurses had lower confidence that patients know what to expect from their medication or how to manage potential side effects. Communication, including language barriers and difficulty determining the patient's understanding of the information, was the most common challenge for nurses and they suggested utilization of translator services and patient-friendly drug information resources as a way to improve.

CONCLUSION

Nurses have positive attitudes toward patient medication education. However, their attitudes do not fully explain their behaviors and many nurses are spending limited time with patients on medication education. Enhancements to medication education could include resources on communication and collaboration with pharmacists.

Variables Affecting Pharmacy Students' Patient Care Interventions during Advanced Pharmacy Practice Experiences

Objective. To identify the temporal effect and factors associated with student pharmacist self-initiation of interventions during acute patient care advanced pharmacy practice experiences (APPE). Methods. During the APPE, student pharmacists at an academic medical center recorded their therapeutic interventions and who initiated the intervention throughout clinical rotations. At the end of the APPE student pharmacists completed a demographic survey. Results. Sixty-two student pharmacists were included. Factors associated with lower rates of self-initiated interventions were infectious diseases and pediatrics APPEs and an intention to pursue a postgraduate residency. Timing of the APPE, previous specialty elective course completion, and previous hospital experience did not result in any significant difference in self-initiated recommendations. Conclusion. Preceptors should not base practice experience expectations for self-initiated interventions on previous student experience or future intentions. Additionally, factors leading to lower rates of self-initiated interventions on infectious diseases or pediatrics APPEs should be explored.

Development and implementation of a transitions of care elective course

BACKGROUND

To develop and implement a transitions of care (TOC) course, assess students׳ knowledge, participation and communication skills during in-class activities, and obtain students׳ perspectives and feedback on the course. Educational Activity-this was a two-credit elective course offered to third professional year Doctor of Pharmacy students (P3) at the Philadelphia College of Pharmacy at the University of the Sciences. It was designed using an interactive, hands-on approach through the use of patient cases, simulation, interprofessional education, student presentations, and a capstone project. The content of the course included TOC concepts relevant to pharmacists practicing within different health care settings. Several assessments were used to evaluate the students using various rubrics and self-reflection. Quantitatively, the students achieved high grades on individual assignments ranging from B to A⁺. Critical analysis of the educational activity overall, the students described the course as a "great experience" based on the qualitative thematic analysis.

CONCLUSION

Developing and implementing a TOC elective provided P3 students with an opportunity to learn about pharmacists׳ role during various points of the TOC process and may have future implications in their performance on rotation and career choice.

Diffusion of Pharmacy-Based Influenza Vaccination Over Time in the United States

OBJECTIVES

To examine pharmacy-based influenza vaccination using diffusion of innovation theory.

METHODS

We used 1993 to 2013 Behavioral Risk Factor Surveillance System data to generate weighted prevalence rates of influenza vaccination, stratified by age (18-64 years vs ≥ 65 years) and state of residence. The diffusion of innovation theory adopter categories were residents of states allowing pharmacist vaccination before 1996 ("innovator/early adopters"), between 1996 and 1998 ("early majority"), between 1999 and 2004 ("late majority"), and in 2007 or later ("laggards").

RESULTS

For adults aged 18 to 64 years, vaccination rates were similar before the innovation (1993), diverged as the innovation reached the majority (2003), and were significantly lower for laggard states by 2013. Younger adults' vaccination rates steadily increased from 12% to 16% in 1993 to 29% to 36% in 2013. For older adults, there was no significant difference in vaccination rates between adopter categories in any year and no advantage associated with adoption category.

CONCLUSIONS

Key features of pharmacy-based vaccination, including relative advantage and compatibility, are most relevant to younger adults; different interventions are warranted for older adults.

Informal learning processes in support of clinical service delivery in a service-oriented community pharmacy

The evolving health care system necessitates pharmacy organizations' adjustments by delivering new services and establishing inter-organizational relationships. One approach supporting pharmacy organizations in making changes may be informal learning by technicians, pharmacists, and pharmacy owners. Informal learning is characterized by a four-step cycle including intent to learn, action, feedback, and reflection. This framework helps explain individual and organizational factors that influence learning processes within an organization as well as the individual and organizational outcomes of those learning processes. A case study of an Iowa independent community pharmacy with years of experience in offering patient care services was made. Nine semi-structured interviews with pharmacy personnel revealed initial evidence in support of the informal learning model in practice. Future research could investigate more fully the informal learning model in delivery of patient care services in community pharmacies.

Rural access to clinical pharmacy services

OBJECTIVES

To examine the impact of rural residence and primary care site on use of clinical pharmacy services (CPS) and to describe the use of clinical telepharmacy within the Veterans Health Administration (VHA) health care system.

METHODS

Using 2011 national VHA data, the frequency of patients with CPS encounters was compared across patient residence (urban or rural) and principal site of primary care (medical center, urban clinic, or rural clinic). The likelihood of CPS utilization was estimated with random effects logistic regression. Individual service types (e.g., anticoagulation clinics) and delivery modes (e.g., telehealth) were also examined.

RESULTS

Of 3,040,635 patients, 711,348 (23.4%) received CPS. Service use varied by patient residence (urban: 24.9%; rural: 19.7%) and principal site of primary care (medical center: 25.9%; urban clinic: 22.5%; rural clinic: 17.6%). However, in adjusted analyses, urban-rural differences were explained primarily by primary care site and less so by patient residence. Similar findings were observed for individual CPS types. Telehealth encounters were common, accounting for nearly one-half of patients receiving CPS. Video telehealth was infrequent (<0.2%), but more common among patients of rural clinics than those receiving CPS at medical centers (odds ratio [OR] = 9.7; 95% CI 9.0-10.5).

CONCLUSION

We identified a potential disparity between rural and urban patients' access to CPS, which was largely explained by greater reliance on community clinics for primary care than on medical centers. Future research is needed to determine if this disparity will be alleviated by emerging organizational changes, including expanding telehealth capacity and integrating pharmacists into primary care teams, and whether lessons learned at VHA translate to other settings.

Faculty Mentor Perspectives of a Formal Mentoring Program for Student Pharmacists: A Qualitative Study

Objective: To describe pharmacy faculty perspectives on participating in a formal mentoring program for student pharmacists. Methods: This qualitative study used ten, 45 to 60 minute semi-structured interviews conducted in November and December, 2012 with faculty mentors sampled randomly by strata of on-site off-site positions at a single public university college of pharmacy. Interviews were recorded and transcribed. Transcripts were coded using an inductively created consensus code list. The research team iteratively grouped codes into themes, developed summaries, and identified representative quotes. Results: Analysis of interviews produced three main themes. Mentor interaction was described as having an investigative or responsive orientation, which influenced mentor actions and perspectives for the relationship with the student mentee. Program structure and concerns included a perceived absence of clear program objectives. Mentor response to feedback focused on 3 feedback sources: administrators, peers, and students. Conclusions: Overall, faculty mentors in this program had different approaches to, expectations for, and experiences in their formal mentoring program participation. These differences are initial descriptions of mentor approaches toward mentoring interactions by faculty in a formal mentoring program. Colleges of pharmacy leaders and administrators may benefit from more clearly specifying and communicating program objectives in order to achieve results for mentees, mentors, and the organization.   Type: Original Research

A leadership elective course developed and taught by graduate students

OBJECTIVE

To develop and implement a flexible-credit elective course to empower student pharmacists to develop lifelong leadership skills and provide teaching practice opportunities for graduate students.

DESIGN

An elective course focusing on leadership development for second- and third-year doctor of pharmacy (PharmD) students was designed and taught by 4 graduate students under the mentorship of 2 faculty members. Student pharmacists could enroll in a 1-, 2-, or 3-credit-hour version of the course.

ASSESSMENT

Attainment of course objectives was measured using student pharmacist reflection papers and continuing professional development portfolios. Additionally, self-assessments of graduate students and faculty members delivering the course were conducted. In their responses on course evaluations, student pharmacists indicated they found the course a valuable learning experience. Graduate students found course development to be challenging but useful in developing faculty skills.

CONCLUSION

This flexible-credit elective course taught by graduate students was an innovative way to offer formal leadership instruction using limited college resources.

Three-year financial analysis of pharmacy services at an independent community pharmacy

OBJECTIVE

To assess the financial performance of pharmacy services including vaccinations, cholesterol screenings, medication therapy management (MTM), adherence management services, employee health fairs, and compounding services provided by an independent community pharmacy.

METHODS

Three years (2008-10) of pharmacy records were examined to determine the total revenue and costs of each service. Costs included products, materials, labor, marketing, overhead, equipment, reference materials, and fax/phone usage. Costs were allocated to each service using accepted principles (e.g., time for labor). Depending on the service, the total revenue was calculated by multiplying the frequency of the service by the revenue per patient or by adding the total revenue received. A sensitivity analysis was conducted for the adherence management services to account for average dispensing net profit.

RESULTS

7 of 11 pharmacy services showed a net profit each year. Those services include influenza and herpes zoster immunization services, MTM, two adherence management services, employee health fairs, and prescription compounding services. The services that realized a net loss included the pneumococcal immunization service, cholesterol screenings, and two adherence management services. The sensitivity analysis showed that all adherence services had a net gain when average dispensing net profit was included.

CONCLUSION

Most of the pharmacist services had an annual positive net gain. It seems likely that these services can be sustained. Further cost management, such as reducing labor costs, could improve the viability of services with net losses. However, even with greater efficiency, external factors such as competition and reimbursement challenge the sustainability of these services.

Pilot evaluation of a continuing professional development tool for developing leadership skills

BACKGROUND

Strategies are needed to assure essential nonclinical competencies, such as leadership, can be gained using a continuing professional development (CPD) framework.

OBJECTIVE

The objective of this study was to explore student pharmacists' utilization and perceived effectiveness of a CPD tool for leadership development in an elective course.

METHODS

Students completed 2 CPD cycles during a semester-long leadership elective using a CPD tool. A questionnaire was used to measure students' perceptions of utility, self-efficacy, and satisfaction in completing CPD cycles when using a tool to aid in this process.

RESULTS

The CPD tool was completed twice by 7 students. On average, students spent nearly 5 hours per CPD cycle. More than half (57.1%) scored themselves as successful or very successful in achieving their learning plans, and most (71.4%) found the tool somewhat useful in developing their leadership skills. Some perceived that the tool provided a systematic way to engage in leadership development, whereas others found it difficult to use.

CONCLUSIONS

In this pilot study, most student pharmacists successfully achieved a leadership development plan and found the CPD tool useful. Providing students with more guidance may help facilitate use and effectiveness of CPD tools. There is a need to continue to develop and refine tools that assist in the CPD of pharmacy practitioners at all levels.

Living with disability: patterns of health problems and symptom mediation of health consequences

BACKGROUND

People with disability experience a range of symptoms that may serve as an important linkage between disability and other health consequences. The aims of this study were to describe and compare symptom experiences of people with and without disability using a population-based sample and to test direct relationships between disability and health status and indirect effects of disability mediated through symptom experience.

METHODS

A Midwestern sample of 12,249 adults aged 40 and older responded to a cross-sectional survey. Data collected included symptom prevalence and frequencies for 21 commonly reported symptoms, self-perceived health status and physical functioning, number of medications, and demographic variables. Two mediation analyses were conducted using cumulative symptom frequency as the mediator between disability status and both self-rated health and physical functioning.

RESULTS

Adults with disability reported significantly greater prevalence and frequencies for all 21 symptoms, with pain and fatigue being the most common. The indirect effect through cumulative symptom frequency explained roughly half of the total effect of disability on general health status, and about one third of the total effect of disability on physical functioning.

CONCLUSIONS

This study found evidence supporting the diverse and significant symptom experience of people living with disability, especially for symptoms of pain and fatigue. Moreover, symptom experience was found to partially mediate the effects of disability on self-reported general health status and physical functioning. This provides support for symptoms serving as an important link to health outcomes in patients with disability.

Effect of premedication guidelines and leukoreduction on the rate of febrile nonhaemolytic platelet transfusion reactions

Platelet transfusion reactions were prospectively studied in haematology/oncology patients at five university teaching hospitals over three consecutive summers. The initial summer study provided baseline information on the use of premedications and the rate of platelet transfusion reactions (fever, chills, rigors and hives). Most (73%) platelet recipients were premedicated and 30% (95% CI 28-33%) of transfusions were complicated by reactions. The second study followed implementation of guidelines for premedicating platelet transfusions. Despite a marked reduction in premedication (50%), there was little change in the platelet transfusion reaction rate, 26% (95% CI 24-29%), or the type of reactions. The third study followed implementation of prestorage platelet leukoreduction while maintaining the premedication guidelines. The reaction rate decreased to 19% (95% CI 17-22%). For nonleukoreduced platelets, there was a statistically significant association between the platelet age and reaction rate (P = 0.04). For leukoreduced platelets, there was no statistically significant association between platelet age and reaction rate (P = 0.5). Plasma reduction of nonleukoreduced platelet products also reduced the reaction rate. These prospective studies document a high rate of platelet transfusion reactions in haematology/oncology patients and indicate premedication use can be reduced without increasing the reaction rate. Prestorage leukoreduction and/or plasma reduction of platelet products reduces but does not eliminate febrile nonhemolytic platelet transfusion reactions.