Respiratory syncytial virus knowledge, attitudes, and perceptions among adults in the United States

Respiratory syncytial virus (RSV) is associated with considerable morbidity and mortality among older adults (aged ≥60 years) and adults with certain chronic conditions in the United States (US). Despite this burden, no previous studies have assessed the knowledge, attitudes, and perceptions (KAP) of RSV among these populations. This study evaluates RSV-related KAP among US adults at increased risk of severe RSV infection. A cross-sectional, web-based survey was administered from May to June 2022 to better understand respiratory infection- and RSV-related KAP among US adults who are at risk of severe RSV infection. The survey included ≥200 adults in each of 4 subgroups: adults aged 60-89 years, and adults aged 18-59 years with ≥1 chronic cardiovascular condition, chronic pulmonary condition, or diabetes mellitus. Survey responses were analyzed descriptively overall and by subgroup, with exploratory logistic regression modeling used to evaluate characteristics associated with RSV awareness and concern. Among the 827 survey respondents, only 43.3% had ever heard of RSV (n = 358/827). The study identified key knowledge gaps (e.g. bacterial vs. viral nature of respiratory infections, RSV seasonality, common RSV symptoms, extent to which RSV causes respiratory infections in specific patient populations). Although 33.7% of RSV-aware adults (n = 120/356) reported being worried/very worried about RSV, 67.3% (n = 241/358) rarely consider RSV as a potential cause of their cold/flu-like symptoms. Results from this study highlight important knowledge gaps related to RSV, perceived risk, and severity of RSV. Findings can be used to support the development of tailored education efforts to support RSV prevention.

Public Health Impact of the Adjuvanted RSVPreF3 Vaccine for Respiratory Syncytial Virus Prevention Among Older Adults in the United States

INTRODUCTION

Respiratory syncytial virus (RSV) is an important cause of lower respiratory tract disease in older adults, resulting in substantial morbidity and mortality.

METHODS

This study estimates the public health impact of vaccination with the adjuvanted RSVPreF3 vaccine among adults aged ≥ 60 years in the United States (US). A static, multi-cohort Markov model was used to estimate RSV-related outcomes over a 3-year time horizon for scenarios with and without one-time RSV vaccination. The base-case analysis assumed the same vaccination coverage as for influenza vaccines, with key epidemiology and vaccine inputs obtained from the published literature and phase 3 clinical trial results for the adjuvanted RSVPreF3 vaccine. Model outcomes included the clinical burden of RSV (symptomatic RSV acute respiratory illness [RSV-ARI] cases [classified as upper or lower respiratory tract disease], pneumonia complications, and mortality) and RSV-related healthcare resource use (hospitalizations, emergency department visits, outpatient visits, and antibiotic prescriptions).

RESULTS

In the base-case analysis, approximately 56.7 million adults aged ≥ 60 years received the vaccine, resulting in 2,954,465 fewer symptomatic RSV-ARI cases over 3 years compared with no vaccination, including 321,019 fewer X-ray confirmed pneumonia cases and 16,660 fewer RSV-related deaths. Vaccination also prevented a substantial number of RSV-related hospitalizations (203,891), emergency department visits (164,060), outpatient visits (1,577,586), and antibiotic prescriptions (1,343,915) over the 3-year period. A considerable public health impact was observed across a range of sensitivity analyses.

CONCLUSIONS

These findings highlight the potential of the adjuvanted RSVPreF3 vaccine to substantially reduce RSV disease burden among US older adults aged ≥ 60 years.

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.

Burden of Herpes Zoster Among Patients with Psoriasis in the United States

INTRODUCTION

Patients with psoriasis (PsO) are at increased risk of herpes zoster (HZ), but recent data on the incidence of HZ among patients with PsO and the impact of HZ on healthcare resource use (HRU) and costs for patients with PsO have not been described.

METHODS

This retrospective, longitudinal, cohort study estimated HZ incidence in cohorts of adults with vs without PsO (PsO + vs PsO-) and HRU and costs among those with PsO, with vs without HZ (PsO + /HZ + vs PsO + /HZ-) using Optum's de-identified Clinformatics Data Mart Database during 2015-2020. Patients with psoriatic arthritis were excluded from all four cohorts. Comparisons between cohorts used generalized linear models to adjust outcomes based on various baseline characteristics.

RESULTS

The incidence rate of HZ was significantly higher in the PsO + (n = 144,115) vs PsO- (n = 23,837,237) cohorts at 11.35 vs 7.67 per 1000 patient-years; adjusted incidence rate ratio (aIRR): 1.21, 95% confidence interval (CI): 1.16-1.25. HRU (outpatient, emergency department, and inpatient) was significantly higher in the PsO + /HZ + (n = 1859) vs PsO + /HZ- (n = 78,664) cohorts during 1 month and 3 months after HZ diagnosis (e.g., outpatient visits during month: 2.83 vs 1.30 per patient; aIRR: 1.96; 95% CI 1.86-2.06). Mean all-cause costs were also significantly higher in the PsO + /HZ + vs PsO + /HZ- cohort during both month ($5020 vs $2715 per patient; adjusted cost difference: $1390; 95% CI $842-$1964) and 3 months ($12,305 vs $8256; adjusted cost difference: $1422; 95% CI $280-$2889) after HZ diagnosis.

CONCLUSION

These findings show the increased incidence of HZ among patients with PsO and the clinical and economic burdens of HZ in this population. Considering the high prevalence of PsO, insights into the impact of HZ in these patients provide valuable evidence to inform clinical decision-making.

The potential impact of increased recombinant zoster vaccine coverage on the burden of herpes zoster among adults aged 50-59 years

INTRODUCTION

Recombinant zoster vaccine (RZV) is recommended in the US for prevention of herpes zoster (HZ) in adults aged ≥50 years. Vaccination rates remain suboptimal for adults 50-59 years compared with adults ≥50 years overall. The objective of this study was to model changes in outcomes associated with improved RZV vaccination coverage in US adults 50-59 years.

METHODS

A multicohort Markov model compared a scenario using real-world vaccination coverage for US adults 50-59 years in 2020 versus scenarios assuming higher coverage. Outcomes, based on a lifetime horizon, included HZ cases and complications avoided, quality-adjusted life-years (QALY), and costs. Model inputs included HZ epidemiology, RZV vaccine efficacy, coverage, adverse events, and costs, based on published literature and US sources. Some inputs were updated from previous models, including real-world estimates of RZV coverage, series completion, and reflecting longer-term data on waning of vaccine efficacy. The model utilized a cohort size of 42,756,488 individuals based on the 2020 US population census.

RESULTS

The model projected that increasing RZV coverage in adults 50-59 years from 7.3 % to 14.6 % (to coverage for adults 60-64 years in 2020) would avoid an additional 504,468 HZ cases, 42,077 postherpetic neuralgia cases, and 56,247 cases of other HZ-associated complications. The increase in vaccine coverage would result in higher vaccination-related costs of $1,172,411,566, but the avoided HZ cases and complications would be expected to result in direct cost savings of $721,973,386 and indirect cost savings of $593,497,480 from avoided productivity loss. Overall, a gain of 5,230 discounted QALYs and cost savings of $143,059,299 from a societal perspective would be realized.

CONCLUSION

Modestly higher RZV coverage in US adults 50-59 years could reduce the clinical burden associated with HZ and may result in societal cost savings. These findings demonstrate the potential value of increasing RZV vaccination in this population.

Clinical and Economic Burden of Herpes Zoster in Patients with Rheumatoid Arthritis: A Retrospective Cohort Study Using Administrative Claims

OBJECTIVE

To estimate the incremental healthcare resource utilization (HRU) and cost burden posed by herpes zoster (HZ) in adult patients with rheumatoid arthritis (RA) in the United States.

METHODS

A retrospective cohort study was conducted using an administrative claims database containing commercial and Medicare Advantage with Part D data, between October 2015 and February 2020. Patients with RA and HZ (RA+/HZ+) or RA without HZ (RA+/HZ-) were identified based on diagnosis codes and relevant medications. Outcomes measured included HRU and medical, pharmacy, and total costs at month 1, quarter 1, and year 1 after the index date (HZ diagnosis for RA+/HZ+ cohort, randomly assigned for RA+/HZ- cohort). Generalized linear models incorporating propensity scores and other covariates were used to estimate differences in outcomes between cohorts.

RESULTS

A total of 1866 patients from the RA+/HZ+ cohort and 38,846 patients from the RA+/HZ- cohort were included. Hospitalizations and emergency department visits occurred more frequently in the RA+/HZ+ than the RA+/HZ- cohort, especially in the month after HZ diagnosis (adjusted incidence rate ratio [95% confidence interval (CI)] for hospitalizations: 3.4 [2.8; 4.2]; emergency department visits: 3.7 [3.0; 4.4]). Total costs were also higher in the month after HZ diagnosis (mean adjusted cost difference [95% CI]: $3404 [$2089; $4779]), with cost differences driven by increased medical costs ($2677 [$1692; $3670]).

CONCLUSIONS

These findings highlight the high economic burden of HZ among individuals with RA in the United States. Strategies to reduce the risk of HZ in patients with RA (such as vaccination) may serve to reduce this burden. Video abstract.

Economic and Clinical Burden of Herpes Zoster Among Patients With Inflammatory Bowel Disease in the United States

Background

Patients with ulcerative colitis (UC) or Crohn's disease (CD) are at increased risk of herpes zoster (HZ); however, relevant cost and healthcare resource utilization (HCRU) data are limited.

Methods

We estimated HCRU (hospitalization, emergency department [ED], and outpatient visits) and costs in patients with UC or CD, with and without HZ, using administrative claims data (October 2015-February 2020). HCRU and costs (2020 US dollars) were compared at 1 month, 1 quarter, and 1 year after the index date, using propensity score adjustment and generalized linear models.

Results

In total, 20 948 patients were included: UC+/HZ+ (n = 431), UC+/HZ- (n = 10 285), CD+/HZ+ (n = 435), and CD+/HZ- (n = 9797). Patients with HZ had higher all-cause HCRU rates and all-cause total healthcare costs relative to those without HZ. In the first month, adjusted incidence rate ratios (aIRRs) for hospitalizations and ED visits for patients with UC and HZ compared with UC alone were 2.87 (95% confidence interval [CI], 1.93-4.27) and 2.66 (95% CI,1.74-4.05), respectively; for those with CD and HZ, aIRRs were 3.34 (95% CI, 2.38-4.70) and 3.31 (95% CI, 2.32-4.71), respectively, compared with CD alone (all P < .001). Adjusted cost differences in UC and CD cohorts with HZ over the first month were $2189 and $3774, respectively, chiefly driven by higher inpatient costs. The incremental impact on HCRU and costs in cohorts with HZ predominantly occurred during the first quarter following diagnosis.

Conclusions

HZ is associated with increased HCRU and costs in patients with UC and CD, especially shortly after diagnosis.

Incidence of Herpes Zoster in Patients With Rheumatoid Arthritis in the United States: A Retrospective Cohort Study

OBJECTIVE

To estimate the incidence of herpes zoster (HZ) in patients with rheumatoid arthritis (RA) compared with the general population in the USA.

METHODS

This retrospective, longitudinal cohort study used data from an administrative claims database containing both commercial and Medicare Advantage Part D data, with a data period from October 2015 to February 2020. Patients were aged ≥ 18 years and divided into 2 cohorts: patients with RA and patients without RA. Diagnosis and procedure codes were used to identify HZ cases and calculate incidence rates (IRs) of HZ in the 2 cohorts. Data were stratified by age group (ie, 18-49, 18-29, 30-39, 40-49, 50-64, and ≥ 65 yrs) and RA therapy type. IR ratios (IRRs), adjusted by cohort baseline characteristics, were estimated using generalized linear models to compare the incidence of HZ between cohorts.

RESULTS

The overall IR of HZ was higher in the RA cohort (21.5 per 1000 person-years [PY]; N = 67,650) than in the non-RA cohort (7.6 per 1000 PY; N = 11,401,743). The highest IRs in both cohorts were observed in the age group of ≥ 65 yrs (23.4 and 11.4 per 1000 PY in the RA cohort and non-RA cohort, respectively). The overall adjusted IRR of HZ was 1.93 (95% CI 1.87-1.99, P < 0.001) for the RA cohort compared with the non-RA cohort. In the RA cohort, the highest IRs by medication class were observed in patients using corticosteroids and those using Janus kinase inhibitors.

CONCLUSION

These results highlight the increased incidence of HZ in patients with RA.

Incidence and risk of herpes zoster in patients with ulcerative colitis and Crohn's disease in the USA

Background

Patients with inflammatory bowel disease (IBD) are at increased risk of herpes zoster (HZ). We evaluated the incidence of HZ in ulcerative colitis (UC) and Crohn's disease (CD) patients and compared this with HZ incidence in a non-IBD population.

Methods

We conducted a retrospective cohort study (GSK study identifier: VEO-000043) of adults aged ≥18 years with UC and CD and without IBD who were identified from claims recorded in a US healthcare database between October 2015 and February 2020. Crude HZ incidence rates/1,000 person-years (PY) were calculated, and comparisons of HZ incidence rates between UC or CD and non-IBD cohorts were made using adjusted generalized linear models.

Results

The study population comprised a total of 29,928 UC, 25,959 CD, and 11,839,329 non-IBD patients. Crude overall HZ incidence rates were 13.64/1,000 PY (UC), 15.94/1,000 PY (CD), and 7.95/1,000 PY (non-IBD). UC and CD patients had increased HZ incidence rates, with adjusted incidence rate ratios of 1.35 (95% confidence interval [CI], 1.26-1.44) and 1.66 (95% CI, 1.56-1.77), respectively, compared with non-IBD patients. Stratified analysis indicated increased relative rates of HZ in progressively younger age strata in the UC and CD patients compared with non-IBD patients. HZ incidence rates were higher in UC and CD patients who had previously received thiopurines or methotrexate, TNF-inhibitors, or corticosteroids than in UC and CD patients who did not take those medicines.

Conclusion

UC and CD patients had increased HZ incidence rates compared with patients without IBD, demonstrating the importance of HZ prevention in IBD patients.

1370. The Impact of Increased Recombinant Zoster Vaccine Use on the Burden of Herpes Zoster Among Adults Aged 50 to 59 Years

Background

Recombinant zoster vaccine (RZV) was approved by the Food and Drug Administration for prevention of herpes zoster (HZ) in adults aged ≥50 years in 2017 and recommended for this population by the Advisory Committee on Immunization Practices (ACIP) in 2018. Since the ACIP recommendation, vaccination rates have been increasing but are suboptimal for adults aged 50-59 years compared to adults aged ≥50 years overall. The objective of this study was to model the change in outcomes associated with improved vaccination rates in this population.

Methods

A multicohort Markov model was used to compare a scenario using the real-world vaccination rate for adults in the US aged 50-59 years in 2020 to a scenario assuming a higher vaccination rate based on that of adults aged 60-64 years in 2020. Outcomes, based on a lifetime horizon, included HZ cases and complications averted, quality-adjusted life-years (QALY), and costs. Model inputs, including age-specific HZ epidemiology, RZV efficacy, real-world RZV series completion, utilities, and costs (direct and indirect), were based on published literature and US sources. The size of the population aged 50-59 years was based on 2020 US census estimates.

Schematic overview of Markov model structure

HZ: herpes zoster; PHN: postherpetic neuralgia

Results

For the 43 million adults aged 50-59 years, increasing the percentage who received at least one dose of RZV from the current estimate of 7.3% in 2020 to 14.6%, assuming 80% series completion, could avoid an additional 504,468 HZ cases. An estimated additional 42,077 post-herpetic neuralgia cases and an additional 56,247 other complication cases of HZ could be avoided. Based on the estimated cases and complications avoided, an additional 5,230 discounted QALYs would be gained. Direct costs could be reduced by an additional $638 million (M) and indirect costs by $493M. With incremental vaccination costs of approximately $1,032M, from a societal perspective, cost savings of $99M would be realized.

Conclusion

Increasing RZV vaccination among adults aged 50-59 years could reduce the burden associated with HZ cases, complications, and result in fewer QALY losses. From a societal perspective, cost savings could be achieved in this population in addition to improved clinical outcomes. These findings demonstrate the potential value of increasing RZV vaccination for adults in the US aged 50-59 years.

Disclosures

David Singer, PharmD, MS, The GSK group of companies: Employed|The GSK group of companies: Stocks/Bonds Ahmed Salem, MSc, The GSK group of companies: Employed Nikita Stempniewicz, MSc, The GSK group of companies: Employed Siyu Ma, PhD, MBBS, The GSK group of companies: Grant/Research Support Sara Poston, PharmD, The GSK group of companies: Employed|The GSK group of companies: Stocks/Bonds Desmond Curran, PhD, The GSK group of companies: Employed|The GSK group of companies: Stocks/Bonds.

Modeled impact of the COVID-19 pandemic and associated reduction in adult vaccinations on herpes zoster in the United States

Due to COVID-19, vaccinations dropped in 2020 and 2021. We estimated the impact of reduced recombinant zoster vaccine (RZV) use on herpes zoster (HZ) cases, complications, and quality-adjusted life-year (QALY) losses among older adults. Various scenarios were compared with Markov models using data from national sources, clinical trials, and literature. Missed series initiations were calculated based on RZV distributed doses. In 2020, 3.9 million RZV series initiations were missed, resulting in 31,945 HZ cases, 2,714 postherpetic neuralgia cases, and 610 lost QALYs. Scenarios further projected disease burden increases if individuals remain unvaccinated in 2021 or the same number of initiations are missed in 2021. Health professionals should emphasize the importance of vaccination against all preventable diseases during the COVID-19 era.

12. Modeled Impact of the COVID-19 Pandemic and Associated Reduced Adult Vaccinations on Herpes Zoster in the United States

Background

During the COVID-19 pandemic, adult vaccination in the United States (US) decreased substantially in 2020. Unlike other vaccine-preventable diseases where individuals may have experienced reduced risk due to COVID-related mitigation efforts (e.g., lockdown restrictions, use of face masks), individuals remained at risk of herpes zoster (HZ). This study projects the impact of reduced recombinant zoster vaccine (RZV) use on HZ cases and complications in the US.

Methods

A multi-cohort Markov model estimated the impact of missed RZV vaccinations, by comparing scenarios with and without missed vaccinations between Apr-Dec 2020, on cases of HZ, postherpetic neuralgia (PHN), and quality-adjusted life-years (QALYs) among US adults aged ≥ 50 years. Epidemiology, RZV efficacy, and utility inputs were obtained from standard US sources, clinical trial data, and published literature. Missed doses were estimated using data on RZV doses and an assumed 43% reduction in RZV vaccinations during the pandemic, based on publicly available data. Deterministic sensitivity and scenario analyses were conducted.

Results

In 2020, approximately 21 million (M) RZV distributed doses were expected, including an estimated 9.2M RZV series initiations in Apr-Dec. An estimated 3.9M RZV series initiations were missed, resulting in 31,945 projected HZ cases, 2,714 PHN cases, and 610 lost QALYs projected over a 1-year follow up. If individuals with missed RZV initiations remain unvaccinated in 2021, avoidable HZ cases will increase to 63,117 over 2 years. Further, if the same number of RZV initiations are missed in 2021, 95,062 avoidable HZ cases are expected. In a sensitivity analysis assuming 30% RZV reduction, 18,020 avoidable HZ cases and 1,531 PHN cases were observed over 1 year.

Conclusion

Adding to the substantial COVID-19 infection-related morbidity and mortality, reduced RZV use during the pandemic resulted in further burden from avoidable HZ cases. Health care providers should continue to emphasize the importance of vaccination against HZ and other preventable diseases during the pandemic.

Funding

GlaxoSmithKline Biologicals SA (GSK study identifier: [VEO-000222]).

Acknowledgement

Business & Decision Life Sciences c/o GSK (Coordination: Quentin Rayée).

Disclosures

Elizabeth M. La, PhD, The GSK group of companies (Employee, Shareholder) Desmond Curran, PhD, The GSK group of companies (Employee, Shareholder) Ahmed Salem, MSc, The GSK group of companies (Employee) David Singer, PharmD, MS, The GSK group of companies (Employee) Nicolas Lecrenier, Ing, PhD, The GSK group of companies (Employee, Shareholder) Sara Poston, PharmD, The GSK group of companies (Employee, Shareholder)

20. Cost-Effectiveness of Recombinant Zoster Vaccine for Vaccinating Immunocompromised Adults Against Herpes Zoster in the United States

Background

Individuals who are immunocompromised (IC) due to disease or therapy are at increased risk of herpes zoster (HZ), with HZ cases in IC populations also resulting in increased health care resource use and costs as compared with the immunocompetent population. This study assesses the cost-effectiveness of recombinant zoster vaccine (RZV) versus no vaccine for the prevention of HZ in IC adults aged ≥ 18 years in the United States (US).

Methods

A Markov model with a one-year cycle length was developed to follow a hypothetical cohort of one million IC individuals for a 30-year time horizon. The model estimates health and cost outcomes associated with RZV versus no vaccine. The base-case analysis considered hematopoietic stem cell transplant (HSCT) recipients who were assumed to remain IC for five years post-transplant. Second-dose compliance was assumed to be 100%, with efficacy and waning inputs based on clinical trial data. Epidemiological, cost, and utility inputs were obtained from standard US sources and published literature. Costs and quality-adjusted life-years (QALYs) were discounted at 3% per year. Sensitivity, threshold, and scenario analyses were conducted, including scenarios of four other IC conditions.

Results

In the modeled hypothetical cohort of one million HSCT recipients, RZV resulted in 116,790 fewer HZ cases and 21,446 fewer postherpetic neuralgia cases versus no vaccine, 5,545 fewer QALYs lost and a societal cost-savings of &5.4 million. The number needed to vaccinate to prevent one HZ case was estimated to be 9. HSCT population results were shown to be robust in sensitivity and threshold analyses. In scenario analyses, RZV was cost saving for renal transplant recipients. Incremental cost-effectiveness ratios for other IC populations were &33,268 per QALY gained for human immunodeficiency virus, &67,682 for breast cancer, and &95,972 for Hodgkin lymphoma.

Conclusion

Results suggest that RZV is a cost-effective option for vaccinating US IC adults for the prevention of HZ and associated complications.

Disclosures

Desmond Curran, PhD, The GSK group of companies (Employee, Shareholder) Ahmed Salem, MSc, The GSK group of companies (Employee) Stéphane Lorenc, NA, GSK group of companies (Consultant) Brandon Patterson, PharmD, PhD, GSK group of companies (Shareholder) Justin Carrico, BS, GSK group of companies (Consultant)RTI Health Solutions (Employee) Katherine A. Hicks, MS, BSPH, GSK group of companies (Consultant)RTI Health Solutions (Employee) Elizabeth M. La, PhD, The GSK group of companies (Employee, Shareholder) Sara Poston, PharmD, The GSK group of companies (Employee, Shareholder) Christopher F. Carpenter, MD, MHSA, GSK group of companies (Consultant)

National and State-Level Composite Completion of Recommended Vaccines Among Adolescents in the United States, 2015-2018

BACKGROUND

Routine adolescent vaccination recommendations in the United States include tetanus, diphtheria, and acellular pertussis, quadrivalent meningococcal conjugate vaccine, and human papillomavirus vaccines. Although coverage for these individual vaccines is known, limited data are available on composite completion for all three vaccines.

METHODS

This cross-sectional analysis of pooled 2015-2018 National Immunization Survey-Teen data used logistic regression to estimate model-adjusted composite vaccination completion nationally and by state among United States adolescents aged 17 years. National Immunization Survey-Teen data were combined with state-level data to estimate a multilevel model identifying factors associated with composite vaccination completion.

RESULTS

The pooled model-adjusted composite vaccination completion was 30.6% (95% confidence interval [CI], 30.13%-31.04%) nationally, varying from 11.3% in Idaho (6.91%-17.95%) to 56.4% (49.81%-62.82%) in Rhode Island. Individual-level factors with the greatest impact on composite completion were having a provider's recommendation for human papillomavirus vaccination (odds ratio, 3.24; 95% CI, 2.76-3.80) and a check-up visit at age 16-17 years (odds ratio, 2.35; 95% CI, 1.80-3.07), with other individual-level factors associated with completion including being Medicaid insured, female, Hispanic, or non-Hispanic black. State-level quadrivalent meningococcal conjugate vaccination mandates were also associated with an increased likelihood of composite vaccination completion (odds ratio, 1.64; 95% CI, 1.16-2.33).

CONCLUSIONS

Fewer than one-third of 17-year-old individuals have completed all three recommended vaccines, with rates varying by state. Although this study identified implementable strategies to improve composite completion, additional research is needed to further understand factors associated with adolescent vaccination completion.

The impact of community pharmacy utilization of immunization information systems on vaccination rates: Results of a clustered randomized controlled trial

BACKGROUND

Adult immunization rates in the United States remain low. More convenient access to immunization information systems (IIS) may improve vaccination rates.

OBJECTIVE

The objective of this multilevel, clustered, randomized controlled study was to measure the impact of providing pharmacists with software and training to query IIS for patient vaccine history/recommendations on adult influenza, pneumococcal, herpes zoster, and Td/Tdap vaccination rates.

METHODS

California Rite Aid pharmacy districts were randomized into intervention/control groups using stratified randomization based on baseline influenza vaccination rates. Store demographic characteristics were collected at baseline (January 1-December 31, 2018). During follow-up (April 1, 2019-March 31, 2020), intervention group stores received access to ImmsLink, software that allows health care providers to review immunization records from IIS and identify a patient's recommended vaccinations. The difference-in-difference between intervention and control groups compared the changes in vaccination rates from baseline to follow-up by calculating adjusted ratios of risk ratios (RRRs). Analysis was performed at the store level.

RESULTS

Thirty-six districts comprising 501 Rite Aid stores (intervention: n = 244 stores; control: n = 257) were included. We found no significant differences in vaccination rates between groups: influenza, 19-64 years (adjusted RRR 0.99 [95% CI 0.83-1.17]); influenza, ≥65 years (1.02 [0.86-1.22]); herpes zoster (1.07 [0.90-1.28]); pneumococcal (0.95, 0.80-1.14); and Td/Tdap (0.88, 0.73-1.05). Reasons that recommended vaccines were not given in the intervention group included patient being deferred to future visit, patient declining, patient having already received the vaccination, patient declining because of cost, or vaccine being unavailable. Overall, pharmacist engagement with ImmsLink was low.

CONCLUSION

Providing pharmacists with software and training to query IIS did not improve vaccination rates compared with control pharmacies in this study. Factors such as an inconvenient interface or inadequate training or motivation may have caused low engagement with the software and should be considered in future interventions.

State-Level Variations and Factors Associated with Adult Vaccination Coverage: A Multilevel Modeling Approach

BACKGROUND

Adult vaccination rates in the USA are generally low and fall short of public health goals.

OBJECTIVES

Our aim was to evaluate the effect of state-level characteristics on adult vaccination coverage in the USA.

METHODS

This study was a cross-sectional, retrospective analysis of 2015-2017 Behavioral Risk Factor Surveillance System data, conducted from March to October 2019 and including seasonal influenza; pneumococcal; tetanus, diphtheria, and acellular pertussis (Tdap); and herpes zoster (HZ) vaccines. Multilevel logistic regression models examined interstate vaccination coverage variability and assessed the impact of state-level characteristics, with model-adjusted coverage estimated.

RESULTS

Model-adjusted vaccination coverage varied by state, with 35.1-48.1% coverage for influenza (2017), 68.2-80.8% for pneumococcal (2017), 21.9-46.5% for Tdap (2016), and 30.5-50.9% for HZ (2017). Characteristics associated with vaccination included state-level insurance coverage, pharmacists' vaccination authority, vaccination exemptions, and adult immunization information systems participation, as well as individual-level measures of income and education. After adjusting for these factors, substantial interstate heterogeneity remained.

CONCLUSIONS

Model-adjusted coverage was generally low and varied by state. A small number of state-level characteristics partially explained interstate coverage variability. This and future research assessing additional state characteristics may help determine policies most likely to increase adult vaccination.

Meningococcal B vaccination coverage among older adolescents in the United States

BACKGROUND

Serogroup B meningococcal (MenB) vaccination recommendations for adolescents in the United States (US) include routine vaccination for all individuals at increased risk and vaccination for individuals not at increased risk aged 16-23 years (preferred age 16-18 years) based on shared clinical decision-making. The two licensed MenB vaccines require administration of ≥2 doses.

METHODS

This cross-sectional study analyzed 2017-2018 National Immunization Survey-Teen (NIS-Teen) data to evaluate ≥1 dose and ≥2 dose MenB vaccination coverage among adolescents aged 17 years. Multivariable logistic regression was used to further evaluate determinants of MenB vaccination.

RESULTS

Nationally, MenB vaccination coverage among 17-year-olds increased from 14.5% in 2017 to 17.2% in 2018 for ≥1 dose and from 6.3% to 8.4% for ≥2 doses. MenB vaccination coverage (2017-2018) was the lowest in the South (≥1 dose: 14.6%; ≥2 doses: 6.3%) and highest in the Northeast region (18.3% and 9.3%), with variation observed by census division. Adolescents were more likely to have received ≥1 dose of MenB vaccine if they had any Medicaid insurance (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.32-2.39) or had received human papillomavirus (OR, 1.94; 95% CI, 1.41-2.67) or meningococcal A, C, W, and Y (OR, 4.03; 95% CI, 2.92-5.56) vaccinations.

CONCLUSIONS

MenB first-dose coverage in the US is low, and even lower for a second dose, with regional variation. Being up to date with other routinely administered vaccines increased the likelihood of receiving MenB vaccination.

1414. #Vaccine Twitter Influencers: is it Just About Reach and Followers?

Background

A small number of powerful users (“influencers”) dominates conversations on social media platforms: less than 1% of Twitter accounts have at least 3,000 followers and even fewer have hundreds of thousands or millions of followers. Beyond simple metrics (number of tweets, retweets...) little is known about these “influencers”, particularly in relation to their role in shaping online narratives about vaccines. Our goal was to describe influential Twitter accounts that are driving conversations about vaccines and present new metrics of influence.

Methods

Using publicly-available data from Twitter, we selected posts from 1-Jan-2016 to 31-Dec-2018 and extracted the top 5% of accounts tweeting about vaccines with the most followers. Using automated classifiers, we determined the location of these accounts, and grouped them into those that primarily tweet pro- versus anti-vaccine content. We further characterized the demographics of these influencer accounts.

Results

From 25,381 vaccine-related tweets available in our sample representing 10,607 users, 530 accounts represented the top 5% by number of followers. These accounts had on average 1,608,637 followers (standard deviation=5,063,421) and 340,390 median followers. Among the accounts for which sentiment was successfully estimated by the classifier, 10.4% (n=55) posted anti-vaccine content and 33.6% (n=178) posted pro-vaccine content. Of the 55 anti-vaccine accounts, 50% (n=18) of the accounts for which location was successfully determined were from the United States. Of the 178 pro-vaccine accounts, 42.5% (n=54) were from the United States.

Conclusion

This study showed that only a small proportion of Twitter accounts (A) post about vaccines and (B) have a high follower count and post anti-vaccine content. Further analysis of these users may help researchers and policy makers better understand how to amplify the impact of pro-vaccine social media messages.

Disclosures

Jean-Etienne Poirrier, PhD, MBA, The GSK group of companies (Employee, Shareholder) Theodore Caputi, PhD, Good Analytics Inc. (Consultant) John Ayers, PhD, GSK (Grant/Research Support) Mark Dredze, PhD, Bloomberg LP (Consultant)Good Analytics (Consultant) Sara Poston, PharmD, The GlaxoSmithKline group of companies (Employee, Shareholder) Cosmina Hogea, PhD, GlaxoSmithKline (Employee, Shareholder)

87. Impact of State of Residence on Adult Vaccination Uptake: A Multilevel Modeling Approach

Background

Previous studies on adult vaccination coverage found inter-state variability that persists after adjusting for individual demographic factors. Assessing the impact of state-level factors may help improve uptake strategies. This study aimed to:

• Update previous estimates of state-level, model-adjusted coverage rates for influenza; pneumococcal; tetanus, diphtheria, and acellular pertussis (Tdap); and herpes zoster (HZ) vaccines (individually and in compliance with all age-appropriate recommended vaccinations)

• Evaluate effects of individual and state-level factors on adult vaccination coverage using a multilevel modeling framework.

Methods

Behavioral Risk Factor Surveillance System (BRFSS) survey data (2015–2017) were retrospectively analyzed. Multivariable logistic regression models estimated state vaccination coverage and compliance using predicted marginal proportions. BRFSS data were then combined with external state-level data to estimate multilevel models evaluating effects of state-level factors on coverage. Weighted odds ratios and measures of cluster variation were estimated.

Results

Adult vaccination coverage and compliance varied by state, even after adjusting for individual characteristics, with coverage ranging as follows:

• Influenza (2017): 35.1–48.1%

• Pneumococcal (2017): 68.2–80.8%

• Tdap (2016): 21.9–46.5%

• HZ (2017): 30.5–50.9%

Few state-level variables were retained in final multilevel models, and measures of cluster variation suggested substantial residual variation unexplained by individual and state-level variables. Key state-level variables positively associated with vaccination included health insurance coverage rates (influenza/HZ), pharmacists’ vaccination authority (HZ), presence of childhood vaccination exemptions (pneumococcal/Tdap), and adult immunization information system participation (Tdap/HZ).

Conclusion

Adult vaccination coverage and compliance continue to show substantial variation by state even after adjusting for individual and state-level characteristics associated with vaccination. Further research is needed to assess additional state or local factors impacting vaccination disparities.

Funding

GlaxoSmithKline Biologicals SA (study identifier: HO-18-19794)

Disclosures

Shannon Hunter, MS, GSK (Other Financial or Material Support, Ms. Hunter is an employee of RTI Health Solutions, who received consultancy fees from GSK for conduct of the study. Ms. Hunter received no direct compensation from the Sponsor.) Diana Garbinsky, MS, GSK (Other Financial or Material Support, The study was conducted by RTI Health Solutions, which received consultancy fees from GSK. I am a salaried employee at RTI Health Solutions and received no direct compensation from GSK for the conduct of this study..) Elizabeth M. La, PhD, RTI Health Solutions (Employee) Sara Poston, PharmD, The GlaxoSmithKline group of companies (Employee, Shareholder) Cosmina Hogea, PhD, GlaxoSmithKline (Employee, Shareholder)

179. Individual and State-level Factors Associated with Receipt of Multiple Recommended Adolescent Vaccines in the United States

Background

The Advisory Committee on Immunization Practices (ACIP) routinely recommends several adolescent vaccines, including human papillomavirus (HPV); quadrivalent meningococcal conjugate (MenACWY); and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines. Limited data are available on the percentage of adolescents receiving this complement of ACIP-recommended vaccines and factors that may increase likelihood of completion.

Methods

This study used 2015–18 pooled National Immunization Survey-Teen (NIS-Teen) data to estimate national and state-level completion rates by age 17 of a two-dose MenACWY series, two- or three- dose HPV series (depending on age at first vaccination), and a Tdap vaccine, using multivariable logistic regression modeling to adjust for individual characteristics. NIS-Teen data were then combined with public state-level data to construct a multilevel model evaluating effects of both individual- and state-level factors on completion.

Results

After adjusting for individual-level factors, the national completion rate for these ACIP-recommended vaccines by age 17 was 30.6% (95% confidence interval [CI]: 30.1–31.0%). However, rates for individual states varied substantially, from 11.3% in Idaho (CI: 6.9–18.0%) to 56.4% in Rhode Island (CI: 49.8–62.8%) (Figure 1).

In the multilevel model, individual characteristics associated with increased likelihood of receiving the recommended vaccines by age 17 included female gender, black or Hispanic race, Medicaid coverage (vs. private/other), last provider visit at age 16 or 17, generally having ≥1 provider visit in last year, and receiving a provider recommendation for HPV vaccination. Residing in a state with a MenACWY vaccination mandate for elementary and secondary schools was the only state-level variable that significantly increased the likelihood of completion (odds ratio: 1.6; CI: 1.2–2.3) (Figure 2).

Figure 1: Model-Adjusted Completion Rates of ACIP-Recommended HPV, MenACWY, and Tdap Vaccines by Age 17 Years in the United States, 2015–18. ACIP, Advisory Committee on Immunization Practices; HPV, human papillomavirus; MenACWY, quadrivalent meningococcal conjugate; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis. Note: Vaccination completion is based on completion of the HPV series (i.e., receipt of 2 doses for individuals aged 9–14 years at first vaccination or receipt of 3 doses for individuals aged 15 years or older at first vaccination), completion of the MenACWY series (i.e., receipt of 2 doses), and receipt of a Tdap vaccine. Note: Model-adjusted composite vaccination completion is adjusted for sex, race/ethnicity, mother’s educational attainment, health insurance status, continuity of health insurance coverage since age 11, whether the individual was 16 or 17 years old at their last checkup, number of physician or other healthcare professional visits in past 12 months, whether a doctor or other healthcare professional ever recommended that the individual receive HPV vaccination, and state. The model-adjusted estimate is generated by taking the average of the predicted probability of vaccination for each individual as if they were all from the same state (while retaining all other characteristics).

Figure 2: Individual-Level and State-Level Characteristics Associated with an Individual’s Completion of ACIP-Recommended HPV, MenACWY, and Tdap Vaccines by Age 17 Years in the United States, 2015–18. ACIP, Advisory Committee on Immunization Practices; CI, confidence interval; HCP, healthcare professional; HPV, human papillomavirus; MenACWY, quadrivalent meningococcal conjugate; ref, referent category; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis. Note: Bold characters and darker circles indicate significant results. Note: Vaccination completion is based on completion of the HPV series (i.e., receipt of 2 doses for individuals aged 9–14 years at first vaccination or receipt of 3 doses for individuals aged 15 years or older at first vaccination), completion of the MenACWY series (i.e., receipt of 2 doses), and receipt of a Tdap vaccine.

Conclusion

Recommended adolescent vaccine completion rates are suboptimal and highly variable across states. Provider recommendations, visits at 16–17 years of age, and state mandates for MenACWY are implementable strategies associated with completion of recommended adolescent vaccines.

Funding

GlaxoSmithKline Biologicals SA (study identifier: HO-19-19991)

Disclosures

Elizabeth M. La, PhD, RTI Health Solutions (Employee) Diana Garbinsky, MS, GSK (Other Financial or Material Support, The study was conducted by RTI Health Solutions, which received consultancy fees from GSK. I am a salaried employee at RTI Health Solutions and received no direct compensation from GSK for the conduct of this study..) Shannon Hunter, MS, GSK (Other Financial or Material Support, Ms. Hunter is an employee of RTI Health Solutions, who received consultancy fees from GSK for conduct of the study. Ms. Hunter received no direct compensation from the Sponsor.) Sara Poston, PharmD, The GlaxoSmithKline group of companies (Employee, Shareholder) Patricia Novy, PhD, GSK (Employee, Shareholder) Parinaz Ghaswalla, PhD, ORCID: 0000-0002-2883-5590, GlaxoSmithKline (Employee, Shareholder)

Vaccination in Older Adults: The When and Where

Despite the well-understood benefits of vaccination in older adults, national rates still fall below public health targets, especially among certain racial and ethnic groups. Recent scholarship examining healthcare use patterns in adults revealed that health care providers miss several opportunities to provide vaccination during regular healthcare encounters, including Medicare annual wellness visits. Several barriers to older adult vaccination have been identified, including lack of patient and provider understanding of the importance of vaccination, financial barriers to vaccines covered under Medicare Part D, and patient hesitancy about the safety and effectiveness of vaccines. Strategies to address these barriers will be discussed, including the use of national quality measures to strengthen incentives for adult vaccination. Part of a symposium sponsored by the Health Behavior Change Interest Group.

Impact of population aging on the burden of vaccine-preventable diseases among older adults in the United States

Despite vaccination recommendations, the burden of vaccine-preventable diseases remains high in older adults in the United States (US), contributing to substantial morbidity, mortality, and health care resource use and costs. To adequately plan for health care resource needs and to help inform vaccination policies, burden of disease projections that account for population aging over the coming decades are needed. As a first step, this exploratory study projects the burden of influenza, pertussis, herpes zoster, and pneumococcal disease in adults aged 50 y and older in the US, using a population-based modeling framework with separate decision trees for each vaccine-preventable disease. The model uses projected population estimates from the US Census Bureau to account for changes in the US population over time and then calculates expected numbers of cases and associated costs for each disease, keeping current estimates of age-specific disease incidence, vaccine coverage, and efficacy constant over time. This approach was used to focus the exploratory analysis on the burden of disease that may be expected due to population changes alone, assuming that all else remains unchanged. Due to population growth and the shifting age distribution over the next 30 y, the annual societal economic burden for the four vaccine-preventable diseases is projected to increase from approximately $35 billion to $49 billion, resulting in cumulative costs of approximately $1.3 trillion, as well as more than 1 million disease-related deaths. Given such notable burden, further efforts to increase vaccination coverage and effectiveness in older adults are needed.

The adult vaccination landscape in the United States during the Affordable Care Act era: Results from a large retrospective database analysis

BACKGROUND

Early provisions of the Affordable Care Act (ACA) reduced financial barriers to preventive care, including routinely recommended vaccines; however, vaccination coverage remains suboptimal. This study examined characteristics of routine adult vaccinations and potential missed opportunities for vaccinations through the lens of healthcare resource utilization among adults in the ACA era.

METHODS

This was a retrospective analysis of healthcare claims from the Truven Health MarketScan Commercial Claims and Encounters (CCAE), Medicare Supplemental (MS), and Multi-State Medicaid databases among adults aged 19 years or older. Influenza, Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis), herpes zoster (HZ), and pneumococcal vaccinations were identified between 2011 and 2016. Potential missed opportunities were defined as well-visits at which individuals were age-eligible for vaccination but did not receive it, assessed during recommended windows for each vaccine. Missed encounters were defined as having no well-visits. Multivariable logistic regression was used to identify factors associated with vaccination and potential missed opportunities.

RESULTS

Family/internal medicine and unknown/other providers administered most influenza, Tdap, and pneumococcal vaccinations, for the CCAE/MS and Medicaid cohorts, respectively. HZ vaccinations were primarily administered through pharmacies. The proportion of vaccination events increased in the pharmacy setting between 2011 and 2016. Having preventive care visits, non-well-visits, and receiving most care from a family/internal medicine practitioner were associated with increased odds of vaccination. Missed encounters were common in Medicaid enrollees. Potential missed opportunities were more prevalent in the CCAE/MS cohort than among Medicaid enrollees. Having non-well-visits was associated with a reduced likelihood of having a missed opportunity.

CONCLUSION

Since the ACA implementation, preventive care among adults was sporadic. Many adults had limited opportunities for vaccination. The large prevalence of missed opportunities suggests vaccination uptake could be improved. Better support for vaccination or referrals for providers who may not traditionally vaccinate could improve vaccine uptake.

Staphylococcus Aureus Nasal Carriage, Exit-Site Infection and Catheter Loss in Patients Treated with Continuous Ambulatory Peritoneal Dialysis (CAPD)

Over a three-year period, 217 episodes of bacterial peritonitis occurred in 183 patient years. Thirty-seven episodes were due to Staphylococcus aureus and 19 (51 %) of these required removal of the catheter to eradicate infection. This compared with catheter loss in 4/63 (6.3%) coagulase negative staphylococci infections ( p < 0.001); 7/67 (9.5%) culture negative peritonitis ( p < 0.001); and 10/30 (33.3%) episodes due to gram-negative organisms ( p < 0.05). Over half (51.3%) the episodes due to S. aureus were associated with exit-site infections, and this rose to 100% (10/10) with recurrent peritonitis ( p < 0.01).

A prospective analysis of nasal carriage and exit-site infections due to S. aureus was carried out in 87 patients. Exit-site infections were present in 21 (24%), almost entirely due to different strains as judged by sensitivity patterns and phage typing. Nasal carriage, defined as two positive swabs within the study period, was present in 20 (23%) patients. Fourteen (70%) of these had exit site infections due to the same strain as that isolated from the nose, whereas no patient grew different strains from either site. Nasal carriage increased the risk of infection sixfold ( p < 0.001).

Adherence to 5-alpha reductase inhibitor therapy for benign prostatic hyperplasia: clinical and economic outcomes

OBJECTIVE

Our goal was to quantify relationships between adherence to 5-alpha reductase inhibitors (5-ARIs), the risk of acute urinary retention (AUR) and prostate surgery, and medical costs related to patients with benign prostatic hyperplasia (BPH).

METHODS

Claims recorded over a period of 6.5 years in a nationwide managed care database were analyzed. We conducted time-to-event multivariate analysis to evaluate relationships between adherence (medication possession ratio [MPR] thresholds of 70% or higher, 75% or higher, and 80% or higher), persistence (length of therapy), and the risk of AUR and surgery. We compared mean monthly BPH-related medical costs in patients with MPRs at or above thresholds and those with MPRs below thresholds and determined changes in BPH-related costs associated with 30-day increments of therapy.

RESULTS

In AUR analyses (N = 17,293), meeting or exceeding MPR thresholds was associated with a reduced likelihood of AUR for 70% (hazard ratio [HR], 0.380), 75% (HR, 0.613), and 80% (HR, 0.519) (P < 0.05 for all). In prostate surgery analyses (N = 17,739), the likelihood of surgery was reduced with MPR thresholds of 70% or above (HR, 0.294), 75% or above (HR, 0.542), and 80% or above (HR, 0.436) (P < 0.05 for all). A longer duration of therapy was associated with a reduced likelihood of AUR (HR, 0.860) and surgery (HR, 0.884) (P < 0.05 for both). In both populations, adherence and persistence were also associated with significantly decreased BPH-related medical costs.

CONCLUSION

In patients with BPH who received 5-ARI therapy, greater adherence and persistence were associated with significantly reduced risks of AUR and prostate surgery and with significantly lower medical costs. Maximizing adherence may enable patients to realize the potential long-term benefits of 5ARIs.

Overexpression of Batf induces an apoptotic defect and an associated lymphoproliferative disorder in mice

Activator protein-1 (AP-1) is a dimeric transcription factor composed of the Jun, Fos and Atf families of proteins. Batf is expressed in the immune system and participates in AP-1 dimers that modulate gene expression in response to a variety of stimuli. Transgenic (Tg) mice overexpressing human BATF in T cells were generated using the human CD2 promoter (CD2-HA (hemagglutinin antigen) - BATF). By 1 year of age, over 90% of the mice developed a lymphoproliferative disorder (LPD). The enlarged lymph nodes characteristic of this LPD contain a polyclonal accumulation of T cells with a CD4⁺ bias, yet efforts to propagate these tumor cells in vitro demonstrate that they do not proliferate as well as wild-type CD4⁺ T cells. Instead, the accumulation of these cells is likely due to an apoptotic defect as CD2-HA-BATF Tg T cells challenged by trophic factor withdrawal in vitro resist apoptosis and display a pro-survival pattern of Bcl-2 family protein expression. As elevated levels of Batf expression are a feature of lymphoid tumors in both humans and mice, these observations support the use of CD2-HA-BATF mice as a model for investigating the molecular details of apoptotic dysregulation in LPD.

Impact of alvimopan (entereg) on hospital costs after bowel resection: results from a large inpatient database

PURPOSE

Delayed gastrointestinal (GI) recovery after bowel resection is associated with longer hospital stays and increased health care costs. Alvimopan (Entereg), a peripherally acting mu-opioid receptor antagonist, accelerates GI recovery after bowel-resection surgery. We undertook a study to evaluate the economic impact of alvimopan in clinical practice.

METHODS

We conducted a retrospective matched cohort study using data from a large national hospital database and identified adults who had undergone small-bowel or large-bowel resection with primary anastomosis. The patients were discharged between January 1, 2009, and June 30, 2009. The surgery was performed at a hospital where alvimopan was used at least once during the study period. We matched each alvimopan patient ("user") with two controls ("non-users"). The primary outcome of total hospital costs (including the cost of alvimopan) and secondary outcomes of cost components and length of stay were compared between groups.

RESULTS

The final study cohort included 480 alvimopan patients and 960 matched controls. The mean total hospital cost was $12,865 for alvimopan patients, compared with $13,905 for controls, for a difference of $1,040 (P = 0.033). There was a non-significant trend toward lower ileus-related costs between groups ($83 for alvimopan vs. $114 for controls, P = 0.086). Pharmacy and diagnostic radiology costs did not differ significantly. The mean length of stay was 5.6 days for alvimopan patients and 6.5 days for controls (P < 0.001).

CONCLUSION

Patients receiving alvimopan capsules had significantly lower total hospital costs compared with controls. Along with other initiatives to improve quality and reduce costs of surgical care, alvimopan might be a good choice for use in the perioperative management of patients who undergo segmental bowel resection with primary anastomosis.

Topiramate prescribing patterns among medicaid patients: Diagnosis, comorbidities, and dosing

BACKGROUND

Routine clinical practice data are useful for payers and formulary decision makers to make sound decisions regarding coverage policy. Based on a literature search, there has been scant research into topiramate prescribing patterns among Medicaid patients.

OBJECTIVE

The aim of this study was to describe diagnoses, demographic characteristics, additional co-existing diagnoses, and dosing among Medicaid patients prescribed topiramate.

METHODS

This descriptive, retrospective database analysis used data from South Carolina (SC) and Texas (TX) ambulatory Medicaid claims dated October 1, 2003, to December 31, 2004. Patients whose data were eligible for inclusion in the study were enrolled in Medicaid during the study period, had >or=2 topiramate prescriptions, were aged <65 years, and had evidence of a topiramate treatment-related diagnosis (possible diagnoses were identified through literature search and drug compendiums). Four cohorts were defined: (1) epilepsy only; (2) migraine only; (3) epilepsy and migraine; and (4) nonepilepsy/nonmigraine. Demographic characteristics, diagnoses, comorbidities, and daily dose of topiramate were summarized using descriptive statistics. The initial study analysis (period 1) was a 180-day window comprising the 90 days before and after the first available topiramate prescription claim was filed. A second, 360-day analysis (period 2) was completed comprising the 180 days before and after the index topiramate prescription date.

RESULTS

In the 180-day analysis, 2216 SC and 4766 TX Medicaid patients met the selection criteria. Cohort classification percentages were 32.3% and 39.6% (epilepsy only), 29.7% and 16.4% (migraine only), 10.7% and 9.2% (epilepsy and migraine), and 27.3% and 34.9% (nonepilepsy/nonmigraine) for SC and TX, respectively. Mean (SD) ages were 29.9 (15.9) (SC) and 27.1 (16.1) (TX) years. In the nonepilepsy/nonmigraine cohort, the most common diagnoses were bipolar disorder and depression. The median daily doses in the epilepsy-only cohort were 175 mg/d in the SC group and 200 mg/d in the TX group. In the migraine-only cohort, the median daily dose was 100 mg/d in SC and TX. Results for the 360-day analysis were similar.

CONCLUSIONS

In this descriptive study using data from 2 Medicaid populations, the majority of patients using topiramate had a diagnosis of epilepsy and/or migraine. Median dosages ranged from 175 to 200 mg/d in patients with epilepsy and 100 mg/d in those with migraine. Depression was a common comorbidity in the migraine cohort and the nonepilepsy/nonmigraine cohort.

Potentially inappropriate prescribing for elderly patients in 2 outpatient settings

Research has shown a high prevalence of potentially inappropriate medication prescribing (PIP) for elderly patients in outpatient settings, but little is known about whether a physician's practice setting influences prescribing attitudes. This study examines the prevalence of PIP among elderly patients in 2 out-patient practices, 1 located in a senior citizens center and 1 in a general family medicine clinic. The authors conducted a retrospective chart review of a random sample of 50 individuals aged 65 years or older from each practice. The 2003 version of the Beers criteria was used to identify PIP. Results show that some one fourth of the elderly sampled in both practices had 1 or more incidents of PIP. The most common potentially inappropriate drug classes prescribed were psychotropic agents and anti-inflammatory drugs. Demographic patient variables were not significantly associated with PIP. This study suggests that PIP may be prevalent across physician groups.

A multiobserver comparison of 99mTcO4 and 123I thyroid imaging

The thyroids of forty patients were imaged using 2 mCi(74 MBq) 99mTc pertechnetate (99mTcO4) followed within one week by 2 mCi (74 MBq) 123I Iodide. The images obtained were evaluated by eight observers for 6 morphological criteria and assigned to 6 diagnostic categories with a confidence grading on a seven level scale (grade 1 being that for maximum confidence). Images were obtained with 123I for the same counts and the same times as those with 99mTcO4 and compared using an index in which the number of diagnostic categories and the mean confidence grading within each category were taken into account. The mean index obtained for 99mTcO4 images (9.2) was significantly greater (P less than 0.05, thus representing a lower observer confidence and less interobserver diagnostic agreement) than the mean indices for 123I equal count images (5.6) and 123I equal time images (6.8). The diagnoses made on the basis of 123I images were more frequently concordant with the final diagnosis after six months follow up (75% for equal counts and 77% for equal time) than those with 99mTcO4(63%). The radioisotope of iodine most suited to modern nuclear medicine instrumentation and with the most favourable radiation dosimetry is 123I which is recommended for those areas of thyroid imaging where iodine is superior.