Selection of prosthetic aortic valves in the United States among elderly Medicare patients from 2006 to 2015.

BACKGROUND: Both biological and mechanical prosthetic valves are treatment choices for aortic valve replacement. We aimed to characterize the selection of prosthetic aortic valves among elderly Medicare patients. METHODS: This was a retrospective analysis of patients aged 65 years or older who underwent aortic valve replacement alone or in combination with other procedures in the 2006-2015 Medicare databases. Patients were continuously enrolled in Medicare Part A and B. We characterized the trends and regional variation of the selection of prosthetic valves. Multivariable logistic regression was used to evaluate the determinants that influenced the selection of prosthetic valves. RESULTS: During the study period, there were 272,921 Medicare patients aged 65 years or older who underwent aortic valve replacement and met the inclusion and exclusion criteria. The selection of mechanical aortic valves decreased from 32.0% in 2006 to 24.3% in 2015 (P < .01). In comparison with 18.5% from northeastern states, 34.6% of patients from southern states selected mechanical valves (P < .01). Major determinants of the selection of prosthetic valves include age, gender, region, hospital characteristics, and physician experience. Patients being older, male, living in the northeast region, operated on in a high-volume hospital, and by more experienced physicians were more likely to receive biological valves. CONCLUSIONS: A 24.1% decrease in the selection of mechanical aortic valves was observed among elderly Medicare patients from 2006 to 2015. A dramatic regional difference was observed in the choice of prosthetic valves across the nation.

Characteristics of vaccinating providers reported through Medicare claims in office-based settings: Volume of influenza and pneumococcal vaccinations.

Vaccination coverage among older adults is low in the United States. A recommendation from a provider is a strong predictor of vaccine receipt. Using Medicare Fee-For-Service data (2015-2017) this study characterized providers by the number of influenza and pneumococcal vaccines administered in physician offices, age, gender, and professional specialty to determine the volume of vaccines provided by individual providers and characteristics of these providers. Half of all vaccinations were provided by 10% of providers. The mean age of 224,483 and 165,710 unique influenza and pneumococcal providers respectively was 49 years (SD: 12 years) with males and females equally distributed. The highest vaccinating quartile of providers tended to be older, more likely male and more likely general physicians. Those who administered a high volume of one vaccine were likely to administer a high volume of the other. Providers administering vaccines in office-based settings can do more to increase vaccination coverage rates.

Patient characteristics of Medicare beneficiaries who report not getting influenza and pneumococcal vaccinations, 2001-2013.

Background: Despite long standing recommendations of pneumococcal and influenza vaccination for adults age 65 years and older and wide-spread availability to vaccination services, vaccination coverage in the United states is low. We sought to explore reasons patients reportedly did not receive these vaccines.Methods: We used publicly available data from the Medicare Current Beneficiary Survey, a continuous panel survey of a representative sample of the Medicare population, as well as Medicare enrollment data. We explored questions pertaining to influenza and pneumococcal vaccination status, self-reported reasons for being unvaccinated and patient perspectives toward health care utilization.Results: The majority of the respondents who did not receive vaccines for influenza or pneumococcal disease reported that they did not know it was needed or that their doctor did not recommend it. Respondents who were not vaccinated against influenza reported concerns about side effects. Coverage for both vaccines was lower among respondents in the Southeast region and among those who are dual-eligible or less engaged in healthcare utilization. Little difference was observed by gender, urban status, or Part C enrollment for influenza respondents. Higher pneumococcal vaccine coverage was found among females as well as those living in urban settings or enrolled in Medicare Part C.Conclusions: Implementation of the national guidelines calling for all health care professions - whether they provide vaccinations or not - to take steps to help ensure adults are fully immunized is critical. Tailored communication to beneficiaries that addresses the importance of both vaccines as well as key barriers, like side effects, is also needed.

Vaccination among Medicare-fee-for service beneficiaries: Characteristics and predictors of vaccine receipt, 2014-2017.

BACKGROUND: Vaccination coverage rates for older adults are low. To better understand utilization of Medicare vaccination benefits we examined a retrospective cohort of more than 26 million Medicare fee-for-service beneficiaries age 65 years and older from 2014 to 2017. METHODS: Multivariate logistic regression was used to obtain marginal effects (ME) describing the association between patient-level characteristics and the likelihood of vaccination. Vaccines routinely recommended by the Advisory Committee on Immunization Practices-seasonal influenza, 23-valent pneumococcal polysaccharide, 13-valent pneumococcal conjugate, and herpes zoster vaccines-were examined. Variables considered include demographics (e.g., age, sex, race), use of preventive services, frailty indicators, and co-morbidities. RESULTS: The mean beneficiary age (SD) for each vaccine examined-seasonal influenza (2016-2017), pneumococcal, and herpes zoster-was 75.0 (7.9) years, 74.5 (7.5) years, 74.5 (7.4) years respectively; and 43.7%, 43.2%, and 39.5% were males respectively. Adjusted marginal effects showed that Black beneficiaries were less likely to receive any of the three vaccines compared to White beneficiaries, while North American Native beneficiaries were most likely to receive a pneumococcal vaccine. Trends by race and sex were similar across all ages. Beneficiaries utilizing preventive services, particularly cardiovascular disease screening (ME of 13.8%, 15.6% and 1.5% for influenza, pneumococcal and herpes zoster vaccine respectively), other vaccinations, and the Medicare Annual Wellness Visit (ME of 9.8%, 15.3% and 0.4% respectively) were predictors of vaccination for all three vaccines. For herpes zoster vaccines, beneficiaries in rural settings (ME of 1.0%) and those who are dual-eligible for Medicare and Medicaid insurance (ME of 1.7%) were more likely to receive herpes zoster vaccine than beneficiaries in urban settings and those not dual-eligible, respectively. CONCLUSION: Medicare beneficiaries of certain demographic with selected comorbid conditions are less likely to receive routinely-recommended vaccines. Strategies and interventions can target such sub-populations of Medicare beneficiaries by optimizing the utilization of preventive services.

Receipt of other routinely recommended vaccines relative to receipt of seasonal influenza vaccines: Trends from medicare administrative data, 2013-2015.

Annual influenza vaccination campaigns emphasize the importance of getting vaccinated against influenza. These campaigns offer potential opportunities to raise awareness of all vaccines. We explored the peak timing of the receipt of influenza and other routinely recommended vaccinations. We examined administrative claims data of 31 million Medicare fee-for-service beneficiaries, eligible to receive vaccinations administered from 2013 to 2015 from Medicare Part B (medical insurance) and Medicare Part D (prescription drug benefit). From 2013 to 2015, 88% of over 50 million influenza vaccination claims occurred in September, October, and November. Claims for pneumococcal (42%), herpes zoster (36%), and tetanus-containing (32%) vaccines were also concentrated during these months. For pneumococcal vaccines, this concentration occurred across various provider settings, including traditional doctor's offices, pharmacies, and hospitals. Herpes zoster (92%) and tetanus-containing (72%) vaccines were largely administered in the pharmacy. Annual influenza vaccination efforts offer additional opportunities to assess, recommend, and administer other recommended vaccinations.

Influenza vaccination coverage estimates in the fee-for service Medicare beneficiary population 2006 - 2016: Using population-based administrative data to support a geographic based near real-time tool.

Older adults are at great risk of developing serious complications from seasonal influenza. We explore vaccination coverage estimates in the Medicare population through the use of administrative claims data and describe a tool designed to help shape outreach efforts and inform strategies to help raise influenza vaccination rates. This interactive mapping tool uses claims data to compare vaccination levels between geographic (i.e., state, county, zip code) and demographic (i.e., race, age) groups at different points in a season. Trends can also be compared across seasons. Utilization of this tool can assist key actors interested in prevention - medical groups, health plans, hospitals, and state and local public health authorities - in supporting strategies for reaching pools of unvaccinated beneficiaries where general national population estimates of coverage are less informative. Implementing evidence-based tools can be used to address persistent racial and ethnic disparities and prevent a substantial number of influenza cases and hospitalizations.

Beneficiary characteristics and vaccinations in the end-stage renal disease Medicare beneficiary population, an analysis of claims data 2006-2015.

BACKGROUND: The Advisory Committee on Immunization Practices (ACIP) routinely recommends three vaccines - influenza, hepatitis B, and pneumococcal vaccines - for End-Stage Renal Disease (ESRD) dialysis patients. METHODS: We sought to assess vaccination coverage among fee-for-service (FFS) Medicare beneficiaries with ESRD who received Part B dialysis services at any point from January 1, 2006 through December 31, 2015 (through June 30, 2016 for influenza). To assess influenza vaccination rates in a given influenza season, we restricted the population to beneficiaries who were continuously enrolled in Medicare Parts A and B throughout all twelve months of that season. To assess hepatitis B and pneumococcal vaccine coverage following dialysis initiation, we developed a Kaplan-Meier curve for all patients who began dialysis between 2006 and 2015. RESULTS: For influenza vaccination, we identified an average of approximately 325,000 ESRD dialysis beneficiaries enrolled through each influenza season from 2006-2015. Seasonal influenza vaccination rates steadily increased during the 10-year period, from 52% in 2006-2007 to 71% in 2015-2016. The greatest increases in influenza vaccination appear in non-white beneficiaries with overall utilization in non-whites higher than in whites (p < .001). For the hepatitis B and pneumococcal vaccinations, we identified over 350,000 ESRD dialysis beneficiaries who began dialysis over the 10-year study window. The probability of receiving a hepatitis B vaccine within the first three years of entering into the ESRD program was higher (77%) than the probability of receiving any pneumococcal vaccine (53%). 45% of ESRD patients completed at least one dose of the two hepatitis B series (three-dose or four-dose) at any time during the study period. CONCLUSIONS: Opportunities exist at regional and facility levels to improve vaccination coverage. Compliance to ACIP recommendations may directly affect risk for ESRD dialysis patients for complications from diseases that can be mitigated by vaccination.

Driving immunization through the Medicare Annual Wellness Visit: A growing opportunity.

INTRODUCTION: The Annual Wellness Visit (AWV) is a Medicare benefit designed to help prevent disease and disability based on individualized health and risk factors. METHODS: This study analyzes Medicare Part B fee-for-service claims from 2011 to 2016 to assess AWV and seasonal influenza and pneumococcal conjugate vaccinations utilization over time. RESULTS: Utilization of the AWV has increased from 8% of Medicare beneficiaries in 2011 to 19% in 2015. In each year, influenza and PCV13 vaccination rates are higher among those who utilize the benefit. More than one-third (33%) of patients who had an AWV in 2015 received a PCV13 vaccination in that same year, compared to 14% of those who did not. Similarly, the seasonal influenza vaccination rate was 64% among those with an AWV and 44% among those without. CONCLUSION: The AWV demonstrates promise for improving immunization rates among Medicare beneficiaries particularly at the point of care.

Pneumococcal Vaccination Among Medicare Beneficiaries Occurring After the Advisory Committee on Immunization Practices Recommendation for Routine Use Of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine for Adults Aged ≥65 Years.

On September 19, 2014, CDC published the Advisory Committee on Immunization Practices (ACIP) recommendation for the routine use of 13-valent pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years, to be used in series with 23-valent pneumococcal polysaccharide vaccine (PPSV23) (1). This replaced the previous recommendation that adults aged ≥65 years should be vaccinated with a single dose of PPSV23. As a proxy for estimating PCV13 and PPSV23 vaccination coverage among adults aged ≥65 years before and after implementation of these revised recommendations, CDC analyzed claims for vaccination submitted for reimbursement to the Centers for Medicare & Medicaid Services (CMS). Claims from any time during a beneficiary's enrollment in Medicare Parts A (hospital insurance) and B (medical insurance) since reaching age 65 years were assessed among beneficiaries continuously enrolled in Medicare Parts A and B during annual periods from September 19, 2009, through September 18, 2016. By September 18, 2016, 43.2% of Medicare beneficiaries aged ≥65 years had claims for at least 1 dose of PPSV23 (regardless of PCV13 status), 31.5% had claims for at least 1 dose of PCV13 (regardless of PPSV23 status), and 18.3% had claims for at least 1 dose each of PCV13 and PPSV23. Claims for either type of pneumococcal vaccine were highest among beneficiaries who were older, white, or with chronic and immunocompromising medical conditions than among healthy adults. Implementation of the National Vaccine Advisory Committee's standards for adult immunization practice to assess vaccination status at every patient encounter, recommend needed vaccines, and administer vaccination or refer to a vaccinating provider might help increase pneumococcal vaccination coverage and reduce the risk for pneumonia and invasive pneumococcal disease among older adults (2).

Babesiosis Occurrence among the Elderly in the United States, as Recorded in Large Medicare Databases during 2006-2013.

BACKGROUND: Human babesiosis, caused by intraerythrocytic protozoan parasites, can be an asymptomatic or mild-to-severe disease that may be fatal. The study objective was to assess babesiosis occurrence among the U.S. elderly Medicare beneficiaries, ages 65 and older, during 2006-2013. METHODS: Our retrospective claims-based study utilized large Medicare administrative databases. Babesiosis occurrence was ascertained by recorded ICD-9-CM diagnosis code. The study assessed babesiosis occurrence rates (per 100,000 elderly Medicare beneficiaries) overall and by year, age, gender, race, state of residence, and diagnosis months. RESULTS: A total of 10,305 elderly Medicare beneficiaries had a recorded babesiosis diagnosis during the eight-year study period, for an overall rate of about 5 per 100,000 persons. Study results showed a significant increase in babesiosis occurrence over time (p<0.05), with the largest number of cases recorded in 2013 (N = 1,848) and the highest rates (per 100,000) in five Northeastern states: Connecticut (46), Massachusetts (45), Rhode Island (42), New York (27), and New Jersey (14). About 75% of all cases were diagnosed from May through October. Babesiosis occurrence was significantly higher among males vs. females and whites vs. non-whites. CONCLUSION: Our study reveals increasing babesiosis occurrence among the U.S. elderly during 2006-2013, with highest rates in the babesiosis-endemic states. The study also shows variation in babesiosis occurrence by age, gender, race, state of residence, and diagnosis months. Overall, our study highlights the importance of large administrative databases in assessing the occurrence of emerging infections in the United States.

Posttransfusion purpura occurrence and potential risk factors among the inpatient US elderly, as recorded in large Medicare databases during 2011 through 2012.

BACKGROUND: Posttransfusion purpura (PTP) is a serious transfusion complication resulting in sudden thrombocytopenia with bleeding. The study's objective was to assess PTP occurrence and potential risk factors among the inpatient US elderly, ages 65 and older, during 2011 through 2012. STUDY DESIGN AND METHODS: This retrospective claims-based study utilized large Medicare databases for calendar years 2011 and 2012. Transfusions of blood and blood components were identified by recorded ICD-9-CM procedure codes and revenue center codes, and PTP was ascertained via ICD-9-CM diagnosis code. Our study evaluated PTP rates (per 100,000 inpatient transfusion stays) among elderly Medicare beneficiaries, overall and by age, sex, race, number of units, and blood components transfused. Multivariate regression analyses were used to assess potential risk factors. RESULTS: Among 4,336,338 inpatient transfusion stays for elderly beneficiaries during the study period, 78 had a PTP diagnosis code recorded, an overall rate of 1.8 per 100,000 stays. PTP occurrence varied by the blood components, units transfused, and other characteristics. Significantly higher odds of PTP were found for platelet (PLT)-containing transfusions, with greater number of units transfused, as well as for elderly with histories of cardiac arrhythmias (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.43-4.93), coagulopathy (OR, 1.79; 95% CI, 1.01-3.21), leukemia (OR, 2.37; 95% CI, 1.07-5.26), transplant (OR, 2.68; 95% CI, 1.41-5.09), and other conditions. CONCLUSION: Our population-based study suggests a substantially higher PTP risk with PLT-containing transfusions. The study also suggests increased PTP risk with greater number of units transfused as well as the importance of underlying health conditions and prior recipient alloimmunization for PTP occurrence among the elderly.

Early mortality after aortic valve replacement with mechanical prosthetic vs bioprosthetic valves among Medicare beneficiaries: a population-based cohort study.

IMPORTANCE: Early mortality for patients who undergo aortic valve replacement (AVR) may differ between mechanical and biological prosthetic (hereinafter referred to as bioprosthetic) valves. Clinical trials may have difficulty addressing this issue owing to limited sample sizes and low mortality rates. OBJECTIVE: To compare early mortality after AVR between the recipients of mechanical and bioprosthetic aortic valves. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of patients 65 years or older in the Medicare databases who underwent AVR from July 1, 2006, through December 31, 2011. In the mixed-effects models adjusting for physician and hospital random effects, we estimated odds ratios (OR) of early mortality to compare mechanical vs bioprosthetic valves. EXPOSURES: Mechanical or bioprostheticaortic valve replacement. MAIN OUTCOMES AND MEASURES: Early mortality was measured as death on the date of surgery, death within 1 to 30 or 31 to 365 days after the date of surgery, death within 30 days after the date of hospital discharge, and operative mortality (death within 30 days after surgery or at discharge, whichever is longer). RESULTS: Of the 66 453 Medicare beneficiaries who met inclusion criteria, 19 190 (28.88%) received a mechanical valve and 47 263 (71.12%) received a bioprosthetic valve. The risk for death on the date of surgery was 60% higher for recipients of mechanical valves than recipients of bioprosthetic valves (OR, 1.61 [95% CI, 1.27-2.04; P < .001]; risk ratio [RR], 1.60). The risk difference decreased to 16% during the 30 days after the date of surgery (OR, 1.18 [95% CI, 1.09-1.28; P < .001]; RR, 1.16). We found no differences within 31 to 365 days after the date of surgery and within the 30 days after discharge. The risk for operative mortality was 19% higher for recipients of mechanical compared with bioprosthetic valves (OR, 1.21 [95% CI, 1.13-1.30; P < .001]; RR, 1.19). The number needed to treat with mechanical valves to observe 1 additional death on the surgery date was 290; to observe 1 additional death within 30 days of surgery, 121. Consistent findings were observed in subgroup analyses of patients who underwent concurrent AVR and coronary artery bypass graft, but not in the subgroup undergoing isolated AVR. CONCLUSIONS AND RELEVANCE: In this cohort analysis of Medicare beneficiaries, use of mechanical aortic valves was associated with a higher risk for death on the date of surgery and within the 30 days after surgery compared with bioprosthetic aortic valves among patients who underwent concurrent AVR and coronary artery bypass graft but not isolated AVR.

Transfusion-related acute lung injury and potential risk factors among the inpatient US elderly as recorded in Medicare claims data, during 2007 through 2011.

BACKGROUND: Transfusion-related acute lung injury (TRALI) is a serious complication leading to pulmonary edema and respiratory failure. This study's objective was to assess TRALI occurrence and potential risk factors among inpatient US elderly Medicare beneficiaries, ages 65 and older, during 2007 through 2011. STUDY DESIGN AND METHODS: This retrospective claims-based study utilized large Medicare administrative databases. Transfusions were identified by recorded procedure and revenue center codes. TRALI was ascertained via ICD-9-CM diagnosis code. The study evaluated TRALI rates among the inpatient elderly overall and by calendar year, age, sex, race, blood components, and units transfused. Logistic regression analyses were used to assess potential risk factors. RESULTS: Of 11,378,264 inpatient transfusion stays for elderly Medicare beneficiaries, 2556 had a recorded TRALI diagnosis code, an overall rate of 22.46 per 100,000 stays. TRALI rates were higher for platelet (PLT)- and plasma-containing transfusions and increased by year and number of units transfused (p < 0.0001). Significantly higher odds of TRALI were also found for persons ages 65 to 79 years versus more than 79 years (OR, 1.19; 95% confidence interval CI, 1.09-1.29), females versus males (OR, 1.26; 95% CI, 1.16-1.38), white versus nonwhite (OR, 1.43; 95% CI, 1.27-1.66), and with 6-month histories of postinflammatory pulmonary fibrosis (OR, 1.89; 95% CI, 1.52-2.20), tobacco use (OR, 1.16; 95% CI, 1.00-1.26), and other diseases. CONCLUSION: Our study among the elderly suggests TRALI to be a severe event and identifies a substantially increased TRALI occurrence with greater number of units and with PLT- or plasma-containing transfusions. The study also suggests importance of underlying health conditions, prior recipient alloimmunization, and nonimmune mechanism in TRALI development among the elderly.