Risk of Severe COVID-19 Outcomes Among Patients with Immune-Mediated Inflammatory Diseases or Malignancies: A Retrospective Analysis of Real-World Data in the United States.

INTRODUCTION: There are concerns that patients in an immunocompromised state may be at risk for increased coronavirus disease 2019 (COVID-19) severity. The aim of this study was to describe the characteristics of patients with COVID-19 and immune-mediated inflammatory diseases (IMIDs) or malignancies and evaluate their risk of developing severe COVID-19. METHODS: Cases of COVID-19 (ICD-10 code U07.1 or U07.2, or positive polymerase chain reaction or antigen test) among patients with IMIDs or malignancies were identified in the US-based Optum® Electronic Health Records database between 1 February 2020 and 3 March 2021. Age- and sex-standardized risks of severe COVID-19 were calculated by condition of interest. The risks were further adjusted by multiple covariates, and 95% confidence intervals were estimated. RESULTS: A total of 499,772 patients with COVID-19 were identified (mean [SD] age, 46.9 [20.7] years; 57.0% female). Patients with hematologic cancers (adjusted risk ratio [aRR] 2.0, 1.8-2.1), solid tumors (aRR 1.1, 1.1-1.1), or rheumatoid arthritis (aRR 1.2, 1.1-1.3) had a significantly higher risk of severe COVID-19 compared to the general population of patients with COVID-19. Patients with systemic lupus erythematosus (aRR 1.1, 0.9-1.2), psoriasis (aRR 1.0, 0.7-1.2), ulcerative colitis (aRR 0.9, 0.8-1.1), Crohn's disease (aRR 0.9, 0.7-1.0), or ankylosing spondylitis (aRR 0.8, 0.5-1.0) showed a comparable risk of severe COVID-19. Patients with atopic dermatitis (aRR 0.8, 0.7-0.9) or psoriatic arthritis (aRR 0.8, 0.6-1.0) showed a lower risk of severe COVID-19. CONCLUSIONS: The risk of developing severe COVID-19 varied between the studied IMIDs and malignancies. Patients with hematologic cancers, solid tumors, or rheumatoid arthritis had significantly increased risk for severe COVID-19 compared to the general population. These findings highlight the need to protect and monitor immunocompromised patients such as those with IMIDs or malignancies as part of the strategy to control the pandemic worldwide.

Comparison Between Health Insurance Claims and Electronic Health Records (EHRs) for Metastatic Non-small-cell Lung Cancer (NSCLC) Patient Characteristics and Treatment Patterns: A Retrospective Cohort Study.

BACKGROUND: The clinical landscape in non-small-cell lung cancer (NSCLC) treatment has rapidly evolved in recent years. Real-world data (RWD) can provide insights into current clinical practice. OBJECTIVE: This study examined the patient characteristics and treatment patterns of patients with metastatic NSCLC using RWD sources. METHODS: This was a retrospective cohort study using health insurance claims and electronic health records (EHRs). Adult patients treated for metastatic NSCLC during the period 2017 to September 2020 were followed from the earliest treatment date until a censoring event. RESULTS: The claims cohort included 7917 patients with a mean age of 70 years and a mean follow-up period of 373 days. The EHR cohort included 7087 patients with a mean age of 67 years and a mean follow-up period of 362 days. The five most common first-line therapies (LoT1) were the same for both cohorts: carboplatin + paclitaxel, pembrolizumab, carboplatin + pemetrexed + pembrolizumab, cisplatin + pemetrexed, and nivolumab. Mean LoT1 durations were 146 and 147 days in the claims and EHR cohorts, respectively. For patients who received a second LoT (LoT2), the five most common LoT2 were also the same in both cohorts: durvalumab, nivolumab, pembrolizumab, carboplatin + pembrolizumab + pemetrexed, and carboplatin + pemetrexed. Mean LoT2 durations were 157 and 158 days in the claims and EHR cohorts, respectively. CONCLUSIONS: LoTs between the claims and EHR cohorts were comparable and showed similar treatment patterns. Traditional platinum-containing chemotherapy was most common in LoT1, whereas programmed cell death protein-1 inhibitors became the most common choices in LoT2. Our findings suggest that RWD can reliably provide up-to-date insight into current treatment modalities and indicate that new clinical evidence is rapidly adopted in patients with NSCLC.

Adherence to hepatitis A and hepatitis B multi-dose vaccination schedules among adults in the United Kingdom: a retrospective cohort study.

BACKGROUND: Timely and complete vaccination with multi-dose schedules is of public health importance, because an incomplete vaccination series may yield suboptimal disease protection. However, data on adherence of adults to multi-dose vaccines are limited. We sought to estimate adherence to multi-dose hepatitis vaccination schedules among adults in the United Kingdom (UK). METHODS: This retrospective cohort study was conducted using anonymized electronic health record (EHR) data from the Clinical Practice Research Datalink (CPRD). Individuals aged 19 years and older at their first identified dose of hepatitis vaccine (2009-2016) were included if they had continuous EHR data for 12 months before the first identified hepatitis A dose or for 6 months before the first identified hepatitis B or combination hepatitis A/B dose. We estimated dose and series completion for each vaccine and adherence to recommended vaccination schedules, as well as adherence within additional prespecified time periods after the first vaccine dose, with sensitivity analyses restricted to adults who had available data for up to 24 months after the first dose. Median time to series completion was estimated using Kaplan-Meier methods. RESULTS: Mean (SD) age at initiation was 42 (16) years for hepatitis A (n = 374,881), 40 (16) years for hepatitis B (n = 71,634), and 38 (15) years for hepatitis A/B (n = 10,335). Women comprised 52 to 55% of each vaccine cohort. Overall, 42,294 adults (11%) completed the two-dose hepatitis A vaccine series within the recommended 12 months; and 15,564 (22%) and 1076 (10%) completed the three-dose hepatitis B and hepatitis A/B series, respectively, within the recommended 6 months. These percentages rose to only 23, 35, and 33%, respectively, when the follow-up periods were extended to 36 months for hepatitis A and to 30 months for hepatitis B and A/B vaccines. Median times to series completion within recommended schedules were not reached in any cohort. Sensitivity analyses supported the primary findings for the full cohorts. CONCLUSIONS: Adherence and series completion rates for hepatitis A and B vaccines in the UK are low. Identifying, understanding, and addressing barriers to series completion for multi-dose vaccines for adults in real-world settings are needed.

Impact of Out-of-Pocket Cost on Herpes Zoster Vaccine Uptake: An Observational Study in a Medicare Managed Care Population.

Herpes zoster (HZ) vaccination is approved for adults aged 50+ for the prevention of HZ, but it is underutilized. The objective of this study was to evaluate the association between out-of-pocket cost and HZ vaccine utilization. Adults aged 65 or older enrolled for at least 12 months in Medicare Advantage/Part D (MAPD) and Medicare Part D only (PDP) plans from 1 January 2007 to 30 June 2014 were selected. Abandonment was defined as a reversed claim for HZ vaccine with no other paid claim within 90 days. Out-of-pocket costs used were actual amounts recorded in the claim. Overall, the HZ vaccine abandonment rate was 7.3%. Mean out-of-pocket costs were higher for individuals who abandoned versus those who did not ($88 (±$55) versus $80 (± $49)). Logistic regression indicated individuals with out-of-pocket costs of $80⁻$90 were 21% more likely (OR = 1.21, 1.16⁻1.27 95% CI), and those with out-of-pocket costs >$90 were 90% more likely (OR = 1.90, 1.85⁻1.96 95% CI) to abandon than those with out-of-pocket costs <$80. The models also suggested that socioeconomic, racial, and ethnic disparities in vaccine abandonment existed. Different vaccine targeting efforts and pharmacy benefit design strategies may be needed to increase use, improve adherence, and minimize disparities.

Pneumococcal vaccination patterns among persons aged 65 years or older in the United States: A retrospective database analysis.

OBJECTIVE: This study investigated the patterns of pneumococcal disease vaccination, the time between two different pneumococcal vaccine doses and factors associated with series completion. METHODS: A retrospective claims database analysis was conducted using the Clinformatics DataMart™ database. Adults who turned 65 years between January 1st, 2013 to June 30th, 2017 and were continuously enrolled (≥15 months) in the Medicare Advantage plans to June 30th, 2017 were included in this study. Pneumococcal vaccination patterns included: PCV13-PPV23, PPV23-PCV13, or receiving PPV23 or PCV13 only. Pneumococcal vaccination series completion was defined as receiving PCV13-PPV23 or PPV23-PCV13 from 65 years old to June 30th, 2017 while non-completion was defined as receiving only PCV13 or only PPV23 from 65 years old to June 30th, 2017. A multivariable logistic regression model was used to identify factors associated with pneumococcal vaccination series completion. RESULTS: A total of 224,132 adults were included in this study. Most received no pneumococcal vaccination (49%), while 34.3% received only one vaccine. Series completion occurred in 16.8% of adults. Some adults received only one vaccination: 11.6% received PPV23 and 22.7% received PCV13. The mean time between vaccinations was 420.8 days (approximately 14 months) for the PCV-PPV23 series, and 595.5 days (approximately 20 months) for the PPV23-PCV13 series. Adults were significantly more likely to complete pneumococcal vaccination series if they had at least one doctor's office, outpatient visit, or pharmacy visit versus no visits, or received an influenza vaccination in the first year after turning 65 years than those who did not (All: P < 0.001). CONCLUSION: Despite the 2014 recommendation, percentages of pneumococcal vaccination series completion were found to be low, aligning with recent literature. This highlights the need to improve series completion, given the increased risk and associated economic burden of pneumococcal disease in adults aged ≥65 years.

Clinical and economic burden of pneumococcal disease in US adults aged 19-64 years with chronic or immunocompromising diseases: an observational database study.

BACKGROUND: Despite the widespread availability of pneumococcal vaccines, rates of pneumococcal disease are disproportionately high in adults with chronic and immunocompromising conditions. This study investigated pneumococcal disease rates and associated resource utilization and costs in this group. METHODS: A retrospective, observational study was conducted using the Truven Health MarketScan® Commercial Claims and Encounters database. The study population was adults aged 19-64 years with continuous health plan enrollment for at least one year before and at least one day after January 1st 2012, 2013 and/or 2014. Medical conditions were identified using ICD-9-CM diagnosis codes and grouped into at-risk (chronic) and high-risk (immunocompromising) conditions. Pneumococcal disease was stratified into all-cause pneumonia (ACP) and invasive pneumococcal disease (IPD). RESULTS: Thirty-six million adults aged 19-64 years were included in the study. 17% had a condition that put them at increased risk for pneumococcal disease. Rates of ACP and IPD in adults with at-risk conditions were 3.6 and 4.6 times the rate in healthy adults, respectively, and 5.3 and 10.5 for adults with high-risk conditions. Risk was particularly high in adults with ≥2 medical conditions: rates of ACP and IPD were 8.1 and 10.6 times higher in adults with at-risk conditions than healthy adults and 6.3 and 13.4 times higher in adults with high-risk conditions, respectively. Resource use and costs were substantially higher per episode of ACP in at-risk and high-risk adults, with costs reaching $6,534 and $9,168, compared to $4,725 for healthy adults. CONCLUSIONS: Pneumococcal disease rates in at-risk and high-risk adults are significantly higher than healthy adults leading to substantial economic burden.

Practice Patterns for Chronic Respiratory Diseases in the Asia-Pacific Region: A Cross-Sectional Observational Study.

BACKGROUND: Allergic rhinitis (AR), asthma, chronic obstructive pulmonary disease (COPD), and rhinosinusitis are common and little studied in the Asia-Pacific region. OBJECTIVES: We sought to investigate real-world practice patterns for these respiratory diseases in India, Korea, Malaysia, Singapore, Taiwan, and Thailand. METHODS: This cross-sectional observational study enrolled adults (age ≥18 years) presenting to general practitioners (GP) or specialists for physician-diagnosed AR, asthma, COPD, or rhinosinusitis. Physicians and patients completed study-specific surveys at one visit, recording patient characteristics, health-related quality of life (QoL), work impairment, and healthcare resource use. Findings by country and physician category (GP or specialist) were summarized. RESULTS: Of the 13,902 patients screened, 7,243 (52%) presented with AR (18%), asthma (18%), COPD (7%), or rhinosinusitis (9%); 5,250 of the 7,243 (72%) patients were eligible for this study. Most eligible patients (70-100%) in India, Korea, Malaysia, and Singapore attended GP, while most (83-85%) in Taiwan and Thailand attended specialists. From 42% (rhinosinusitis) to 67% (AR) of new diagnoses were made by GP. On average, patients with COPD reported the worst health-related QoL, particularly to GP. Median losses of work productivity for each condition and activity impairment, except for asthma, were numerically greater for patients presenting to GP vs. specialists. GP prescribed more antibiotics for AR and asthma, and fewer intranasal corticosteroids for AR, than specialists (p < 0.001 for all comparisons). CONCLUSIONS: Our findings, albeit mostly descriptive and influenced by between-country differences, suggest that practice patterns differ between physician types, and the disease burden may be substantial for patients presenting in general practice.

Adherence with and completion of recommended hepatitis vaccination schedules among adults in the United States.

INTRODUCTION: Adult vaccination coverage rates in the US are well below national targets, leaving many adults at increased risk. Additionally, typical vaccination coverage calculations do not adequately approximate population immunity as they do not consider whether multidose vaccines were administered within the recommended schedules. As timely administration of each dose optimizes overall vaccine effectiveness, we sought to document adherence to and completion of the hepatitis A (HepA), hepatitis B (HepB), and combined hepatitis A and hepatitis B (HepA-HepB) multidose vaccine schedule in an insured adult population in the US. METHODS: We conducted a retrospective database study of administrative claims from 2008 to 2015 (analyzed in 2017). Completion of 2 (HepA) and 3 doses (HepB and HepA-HepB), and adherence to the 2- and 3-dose recommended schedules were measured among individuals aged 19 years and older at first dose. The proportion of patients who completed 2 and 3 doses and were adherent to the recommended schedule were estimated using Kaplan-Meier methods. RESULTS: For HepA, 27.14% of initiating adults were adherent to the recommended schedule, and 32.05% had received a second dose by 42 months. Approximately one-third of adults who initiated the HepB or HepA-HepB series completed all 3 doses within 2 years of the minimum spacing (31.17% and 32.27%, respectively). Generally, completion and adherence were highest in individuals aged 60-64 years at the time of initiation. CONCLUSIONS: Hepatitis vaccine adherence and completion in adults is suboptimal. As a result, the majority of adults initiating each series may not be receiving the full protective benefit of these multidose vaccines.

Pneumococcal Vaccine Coverage in Adults Aged 19-64 Years, Newly Diagnosed With Chronic Conditions in the U.S.

INTRODUCTION: This study examined pneumococcal vaccine coverage in adults aged 19-64 years newly diagnosed with diabetes, chronic heart, lung, or liver disease. These conditions are indicated for pneumococcal vaccination by the Advisory Committee on Immunization Practices. METHODS: A retrospective cohort analysis was conducted in 2016 using the Truven Health MarketScan® database. The study population was adults aged 19-64 years with at least one new chronic condition during 2009-2013 and continuous health plan enrolment for 2 years before and 1 year after the initial diagnosis. Vaccine coverage by length of follow-up since diagnosis (ranging from 1 to 5 years) was summarized. Multivariate analyses were performed to understand factors associated with vaccination. RESULTS: A total of 552,942 adults aged 19-64 years with chronic conditions were identified. There were 8% of adults newly diagnosed with one of four chronic conditions that received a pneumococcal vaccination after 1 year of follow-up; the proportion increased to 20.1% among those with 5 years of follow-up data. Adults aged 50-64 years were more likely to be vaccinated than those aged 19-49 years. Adults with diabetes were more likely to be vaccinated than adults with chronic heart, lung, or liver disease. Adults enrolled in HMO plans were more likely to be vaccinated than adults in other plan types. A higher number of healthcare encounters increased the likelihood of vaccination. Adults who received influenza vaccination were also more likely to receive a pneumococcal vaccination. CONCLUSIONS: Vaccine coverage remains well below Healthy People 2020 targets. A substantial number of adults with chronic conditions remain unvaccinated and at risk for pneumococcal disease.

Attributable Healthcare Resource Utilization and Costs for Patients With Primary and Recurrent Clostridium difficile Infection in the United States.

Background: The economic burden of Clostridium difficile infection (CDI), the leading cause of nosocomial infectious diarrhea, is not well understood. The objective of this study was to estimate the healthcare resource utilization (HCRU) and costs attributable to primary CDI and recurrent CDI (rCDI). Methods: This is a database (MarketScan) study. Patients without CDI were matched 1:1 by propensity score to those with primary CDI but no recurrences to obtain HCRU and costs attributable to primary CDI. Patients with primary CDI but no recurrences were matched 1:1 by propensity score to those with primary CDI plus 1 recurrence in order to obtain HCRU and costs attributable to rCDI. Adjusted estimates for incremental cumulative hospitalized days and healthcare costs over a 6-month follow-up period were obtained by generalized linear models with a Poisson or gamma distribution and a log link. Bootstrapping was used to obtain 95% confidence intervals (CIs). Results: A total of 55504 eligible CDI patients were identified. Approximately 25% of these CDI patients had rCDI. The cumulative hospitalized days attributable to primary CDI and rCDI over the 6-month follow-up period were 5.20 days (95% CI, 5.01-5.39) and 1.95 days (95% CI, 1.48-2.43), respectively. The healthcare costs attributable to primary CDI and rCDI over the 6-month follow-up period were $24205 (95% CI, $23436-$25013) and $10580 (95% CI, $8849-$12446), respectively. Conclusions: The HCRU and costs attributable to primary CDI and rCDI are quite substantial. It is necessary to reduce the burden of CDI, especially rCDI.

Association of Osteoporosis Medication Use After Hip Fracture With Prevention of Subsequent Nonvertebral Fractures: An Instrumental Variable Analysis.

Importance: Osteoporosis medication treatment is recommended after hip fracture, yet contemporary estimates of rates of initiation and clinical benefit in the patient population receiving routine care are not well documented. Objectives: To report osteoporosis treatment initiation rates between January 1, 2004, and September 30, 2015, and to estimate the risk reduction in subsequent nonvertebral fractures associated with treatment initiation in patients with hip fracture. Design, Setting, and Participants: In this cohort study, data from a commercial insurance claims database from the United States were analyzed. Patients 50 years and older who had a hip fracture and were not receiving treatment with osteoporosis medications before their fracture were included. Exposure: Prescription dispensing of an osteoporosis medication within 180 days of a hip fracture hospitalization. Main Outcomes and Measures: Each initiation episode was matched with 10 nonuse episodes on person-time after the index hip fracture event to preclude immortal time bias and followed up for the outcome of nonvertebral fracture until change in exposure or a censoring event. An instrumental variable analysis using 2-stage residual inclusion method was conducted using calendar year, specialist access, geographical variation in prescribing patterns, and hospital preference. Results: Among 97 169 patients with a hip fracture identified, the mean (SD) age was 80.2 (10.8) years, and 64 164 (66.0%) were women. A continuous decline over the study years was observed in osteoporosis medication initiation rates from 9.8% (95% CI, 9.0%-10.6%) in 2004 to 3.3% (95% CI, 2.9%-3.8%) in 2015. In the effectiveness analyses, the hospital preference instrumental variable had a stronger association with treatment (pseudo R2 = 0.20) than the other 3 instrumental variables (specialist access: pseudo R2 = 0.04; calendar year: pseudo R2 = 0.05; and geographic variation: pseudo R2 = 0.07). Instrumental variable analysis with hospital preference suggested a rate difference of 4.2 events (95% CI, 1.1-7.3) per 100 person-years in subsequent fractures associated with osteoporosis treatment initiation compared with nonuse in an additive hazard model. Conclusions and Relevance: Low rates of osteoporosis treatment initiation after a hip fracture in recent years were observed. Clinically meaningful reduction in subsequent nonvertebral fracture rates associated with treatment suggests that improving prescriber adherence to guidelines and patient adherence to prescribed regimens may result in notable public health benefit.

Herpes zoster incidence and cost in patients receiving autologous hematopoietic stem-cell transplant.

OBJECTIVE: Among patients receiving autologous hematopoietic stem cell transplant (Auto-HSCT), this study estimated the incidence of herpes zoster (HZ), compared healthcare costs among patients with and without HZ, and evaluated antiviral prophylaxis (AP) use. RESEARCH DESIGN AND METHODS: A retrospective study was conducted using data from a large health plan to identify patients ≥18 years with ≥1 claim for an Auto-HSCT procedure during 2006-2011 (n = 2,530). Patients were followed from date of Auto-HSCT until risk-end date, defined as development of HZ, end of enrollment, death, or December 31, 2011. HZ incidence was calculated as cases observed after Auto-HSCT, divided by accrued time-at-risk in person-years (PY). AP use and duration were defined by prescription fills. One-year medical and pharmacy costs were calculated as combined health plan and patient paid amounts. MAIN OUTCOME MEASURES: HZ incidence and healthcare costs were calculated using administrative claims data. RESULTS: Overall HZ incidence was 62.2/1,000 PY (95% CI = 54.3-70.9). Most (72.3%) patients were prescribed AP. During the first 90-days post-Auto-HSCT, patients without AP had increased incidence (151.6/1,000 PY, 95% CI = 88.3-242.6) compared to those prescribed AP pre- (30.9/1,000 PY, 95% CI = 11.3-67.2) or post-Auto-HSCT (33.0/1,000 PY, 95% CI = 13.3-67.9). Total adjusted mean 1-year all-cause healthcare costs were $74,875 for patients who developed HZ and $70,279 for patients who did not (difference = $4,596 (cost ratio = 1.07, 95% CI = 0.86-1.32, p = .566)). CONCLUSIONS: HZ incidence was high, despite AP use. Mean annual healthcare costs were higher for patients with HZ, but the difference was not statistically significant. An effective vaccine against HZ could be useful in decreasing both incidence of and cost for HZ in this population.

Assessment of dog owner adherence to veterinarians' flea and tick prevention recommendations in the United States using a cross-sectional survey.

BACKGROUND: Adherence to a prescribed therapeutic regimen is a critical factor for achieving medication effectiveness and therefore treatment success. In the case of companion animal ectoparasite control, suboptimal owner adherence to medication recommendations is thought to be a common cause of treatment failure, and previous reports have found pet owners applying an average of 4.0-4.6 monthly flea and tick treatments per year to their dogs. This study investigated: US veterinary hospital self-reported flea and tick prevention recommendations; dog owner recollection of these recommendations; dog owner opinion on flea/tick recommendations and estimated owner flea and tick medication adherence based on veterinary hospital purchase records. RESULTS: Veterinarians at 24 veterinary hospitals in 4 United States regions provided their flea and tick prevention recommendations. Five hundred fifty-nine dog owners, clients of the 24 hospitals, completed a survey evaluating their recollection of the hospitals' recommendations and their opinions regarding required treatment frequency. Almost all veterinary hospitals in this study recommended 12 months of flea and tick prevention but only 62% of participating dog owners recalled this recommendation. The average owner response was that their dogs require 10.5 months of flea and tick prevention annually. Owner opinions were significantly different among U.S. regions with pet owners in the northeast U.S. believing that they needed significantly less canine flea and tick protection than pet owners in other parts of the United States. The estimated actual flea and tick prevention coverage was 6.1 months based on owner medication purchases over a 12-month period. CONCLUSIONS: In the United States, dog owner opinions and actions show that their flea and tick treatment adherence falls short of veterinarians' recommendations.

Duration of Antiviral Prophylaxis and Risk of Herpes Zoster among Patients Receiving Autologous Hematopoietic Stem Cell Transplants: A Retrospective, Observational Study.

INTRODUCTION: There are no real-world data on antiviral prophylaxis (AP) duration and risk of herpes zoster (HZ) given AP duration in patients receiving autologous hematopoietic stem cell transplants (auto-HSCT). The objectives of this study are to describe the duration of AP and to compare incidence of HZ by AP duration in auto-HSCT patients. METHODS: This is a retrospective, observational database (Marketscan®) study. This study included patients ≥18 years old who had auto-HSCT during 2009-2013, had chemotherapy within 60 days prior to auto-HSCT (latest chemotherapy date within the 60 days was the study enrollment date), and had continuous health plan enrollment for at least 365 days before and after the study enrollment date. AP duration was the sum of days supply of all AP prescriptions from 30 days before to 365 days after the study enrollment date. Patients were followed from the study enrollment date to the end of continuous health plan enrollment, death, or December 31, 2014 to assess HZ incidence. The Cox proportional hazards model was used to examine the association between the risk of HZ and AP duration. RESULTS: This study identified 1959 eligible auto-HSCT patients, of whom 93.0% were prescribed AP. Average AP duration was 220 days (SD = 122), while 200 (11%) patients had AP for ≥1 year. HZ incidence was 42.4/1000 person-years (PY) (95% CI 36.5, 49.0) for the overall auto-HSCT cohort. Among patients who received AP, duration of AP prescriptions and HZ incidence were inversely related. Compared with patients who were on AP for 1-89 days, patients with AP duration of 180-269 days [hazard ratio (HR) = 0.576, p = 0.019], 270-359 days (HR = 0.594, p = 0.023), and ≥360 days (HR = 0.309, p < 0.001) had significantly lower risk of HZ. CONCLUSION: Auto-HSCT patients are at increased risk for HZ, even when prescribed AP. A safe and effective vaccine against HZ for auto-HSCT patients could be a useful adjunctive prevention strategy.

Herpes Zoster Vaccine Coverage in Older Adults in the U.S., 2007-2013.

INTRODUCTION: This study aimed to assess the coverage of herpes zoster (HZ) vaccine among a large cohort of insured individuals aged ≥50 years from 2007 to 2013, and to determine the factors associated with being vaccinated for adults aged ≥60 years. METHODS: This was a retrospective, observational study using the MarketScan® database conducted in 2015. The study population was U.S. adults aged ≥60 years during 2007-2013 and 50-59 years during 2011-2013. The claims of each eligible subject were evaluated post-index date to assess HZ vaccine uptake. Multivariate analyses were performed to understand factors associated with receiving HZ vaccine. RESULTS: A total of 6,746,476 adults aged ≥60 years and 6,770,294 adults aged 50-59 years were identified. By 2013, 1.7% of adults aged 50-59 years, 23.9% of adults aged 60-64 years, and 14.5% of adults aged ≥65 years received HZ vaccine. Adults aged ≥65 years were less likely to receive HZ vaccine than those aged 60-64 years (hazard ratio [HR]=0.543; 95% CI=0.539, 0.547). Adults who were female, immunocompetent, and had more outpatient hospital, doctor office, and pharmacy visits were more likely to receive HZ vaccine. Adults who received influenza vaccine were more likely to receive HZ vaccine (HR=1.841; 95% CI=1.830, 1.853). CONCLUSIONS: Estimated HZ vaccine coverage is 19.5% in adults aged ≥60 years, which is lower than the Healthy People 2020 target of 30%. Providers should identify every opportunity for HZ vaccination to assure that older adults are protected from HZ, a vaccine-preventable disease.

Vaccine Coverage for United States Infants at Milestone Ages: Missed Opportunities for Vaccination.

We used a claims database to assess coverage for rotavirus (RV), diphtheria-tetanus-acellular pertussis, and pneumococcal conjugate vaccines among infants in the United States. Similar coverage was seen until 7 months of age, after which RV coverage lagged. Missed opportunities for vaccination at well-child visits were found to vary by age.

Initiation & completion rates of hepatitis A vaccination among US pediatric populations born between 2005 and 2009.

OBJECTIVES: To estimate hepatitis A vaccine series initiation and completion rates, assess time to vaccination, identify missed opportunities for the hepatitis A vaccine series, and examine factors associated with hepatitis A vaccine series initiation and completion. METHODS: We conducted a retrospective, observational study using three healthcare claims databases separately. The study population was comprised of children born between years 2005 and 2009 that were continuously enrolled for at least three and a half years from the date of birth. Every child was followed from date of birth for three and a half years for hepatitis A vaccination. RESULTS: There were 93,735 eligible children from Clinformatics Data Mart, 202,513 from MarketScan Commercial, and 207,545 from MarketScan Medicaid. The overall hepatitis A vaccine series initiation rate was 63.8-79.4% and completion rate was 45.1-66.8% across the three databases. About 62.8-90.1% of the children who never initiated hepatitis A vaccine had at least one well visit from 1 year to three and a half years old. Children were more likely to initiate and complete the hepatitis A vaccine series if they were from more recent birth cohorts, from states with a hepatitis A vaccination recommendation prior to the ACIP universal recommendation, from states with daycare/school entry requirements, were enrolled in an HMO health plan, had pediatricians as primary providers, had more doctor's office/well visits and received MMR/Varicella vaccines. CONCLUSION: In this study, approximately one in every three to five children remained unvaccinated against hepatitis A. Although the hepatitis A vaccine series initiation and completion improved from 2005 to 2009, vaccine coverage has stabilized in recent years. It is important for providers to identify every opportunity for hepatitis A vaccination and to assure that children get protection from this vaccine-preventable disease.

Clinical characteristics of patients with community-acquired complicated intra-abdominal infections: a prospective, multicentre, observational study.

In this prospective, observational, multicentre study using data from five countries (Columbia, The Philippines, Portugal, Taiwan and Thailand), the clinical impact of extended-spectrum ß-lactamase (ESBL)-producing organisms on hospitalised patients with community-acquired complicated intra-abdominal infections (CA-cIAIs) was compared with that of non-ESBL-producing organisms during the period April 2010 to December 2011. Adult patients (aged ≥18 years) requiring surgery or percutaneous drainage were enrolled and were followed during the first hospitalisation course. An unadjusted statistical comparison of risk factors for ESBL-positive and ESBL-negative patients was performed. Multivariate regression analyses were performed to assess whether length of stay (LOS) in hospital, clinical cure rate and some important clinical characteristics were associated with ESBL positivity. During the study period, a total of 105 adult patients from five countries were enrolled, of whom 17 (16.2%) had CA-cIAI due to ESBL-positive organisms and 88 (83.8%) had CA-cIAI due to ESBL-negative organisms. Escherichia coli was isolated in 73.3% of all samples. Infections were cured in 8 (47.1%) of the patients with CA-cIAI due to ESBL-positive organisms and in 59 (67.0%) of the patients with CA-cIAI due to ESBL-negative organisms (P=0.285). The median LOS was 11.6 days for patients with infections due to ESBL-negative organisms and 17.6 days for patients with infections due to ESBL-positive organisms (P=0.011). Multivariate logistic regression analysis revealed that pre-existing co-morbidities, but not ESBL positivity, were adversely associated with clinical cure of CA-cIAIs. In contrast, duration of hospitalisation was longer for patients with CA-cIAI due to ESBL-positive organisms.

Costs of adult vaccination in medical settings and pharmacies: an observational study.

BACKGROUND: Community pharmacies are a convenient setting for vaccinating adults against infectious diseases in the United States. Whether the costs paid for vaccination in pharmacies differ from those in medical settings is unclear. OBJECTIVE: To examine whether the direct medical costs paid for adult vaccination differ by vaccination setting. METHODS: This was an observational retrospective study using 2010 MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases. Adults receiving herpes zoster or shingles vaccine, pneumococcal vaccine 23-valent, or influenza vaccines were identified using Current Procedural Terminology codes and National Drug Code numbers from medical and pharmacy claims files, respectively, between January 1 and December 31, 2010, in 1 of the following 3 settings: physician offices; other medical settings (e.g., inpatient/outpatient hospitals, emergency rooms); and pharmacies. Patients were adults aged ≥60 years on the date of zoster vaccination and aged ≥19 years on the date of pneumococcal or influenza vaccinations. The final study samples meeting inclusion/exclusion criteria were 54,042 for zoster vaccine, 154,994 for pneumococcal vaccine, and 1,657,264 for influenza vaccine. The vaccination costs included the health plan and enrollee paid amounts for the product; vaccine administration; dispensing fee; and, where applicable, the visit. The mean (SD) vaccination costs paid per vaccine administration were estimated by vaccine and type of setting, overall, and by geographic region and type of health plan. The costs paid for the same vaccine across vaccination settings were compared using analysis of variance with post hoc tests (Tukey). RESULTS: Of those receiving zoster, pneumococcal, and influenza vaccines, 25%, 1%, and 7%, respectively, received the vaccines at a pharmacy. Compared with other U.S. regions, pharmacy-based vaccination for these 3 vaccines was generally more frequent in the West and the South. Overall, the mean (SD) costs paid per enrollee per vaccine administration at physician offices, other medical settings, and pharmacies were as follows: for zoster vaccine, $208.72 (42.10), $209.51 (50.83), and $168.50 (15.66), respectively (P <0.05); for pneumococcal vaccine, $65.69 (27.54), $72.11 (49.95), and $54.98 (9.72), respectively (P <0.05); and for influenza vaccine, $29.29 (15.29), $24.20 (13.12), and $21.57 (6.63), respectively (P <0.05). The mean amounts paid also differed by geographic region and type of health plan, with costs usually lower for the vaccinations given at pharmacies. CONCLUSIONS: The average direct costs paid per adult vaccination were lower in pharmacies compared with physician offices and other medical settings by 16%-26% and 11%-20%, respectively. These results were mostly consistent across geographic regions and types of health plans. These data may help payers and policymakers understand the economic value of adult vaccination in different settings, especially in pharmacies.

Healthcare expenses associated with multiple vs singleton pregnancies in the United States.

OBJECTIVE: The purpose of this study was to document cost that is associated with multiple births vs singleton births in the United States. STUDY DESIGN: This was a retrospective cohort study that used a claims database. Women 19-45 years old with live-born infants from 2005-2010 were identified. Infant deliveries were identified by International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. The cost entailed all payment made by insurers and patients. For mothers, the cost included expenses from 27 weeks before delivery to 1 month after delivery. For infants, the cost contained all expenses until their first birthday. Adjusted cost was estimated by generalized linear models after adjustment for the potential confounding variables with a gamma distribution and a log link. RESULTS: The analysis included 437,924 eligible deliveries. Of them, 97.02% were singletons; 2.85% were twins, and 0.13% was triplets or more. Women with multiple pregnancies had higher systemic and localized comorbidities compared with women with singleton pregnancies (P < .0001). Twins and triplets or more were more likely to have stayed in a neonatal intensive care unit than were singletons (P < .0001). On average, adjusted total all-cause health care cost was $21,458 (95% confidence interval [CI], $21,302-21,614) per delivery with singletons, $104,831 (95% CI, $103,402-106,280) with twins, and $407,199 (95% CI, $384,984-430,695) with triplets or more. CONCLUSION: Pregnancies with the delivery of twins cost approximately 5 times as much when compared with singleton pregnancies; pregnancies with delivery of triplets or more cost nearly 20 times as much.