Exploring Definitions and Predictors of Severe Asthma Clinical Remission Post-Biologic in Adults.

RATIONALE: There is no consensus on criteria to include in an asthma remission definition in real-life. Factors associated with achieving remission post-biologic-initiation remain poorly understood. OBJECTIVES: To quantify the proportion of adults with severe asthma achieving multi-domain-defined remission post-biologic-initiation and identify pre-biologic characteristics associated with achieving remission which may be used to predict it. METHODS: This was a longitudinal cohort study using data from 23 countries from the International Severe Asthma Registry. Four asthma outcome domains were assessed in the 1-year pre- and post-biologic-initiation. A priori-defined remission cut-offs were: 0 exacerbations/year, no long-term oral corticosteroid (LTOCS), partly/well-controlled asthma, and percent predicted forced expiratory volume in one second ≥80%. Remission was defined using 2 (exacerbations + LTOCS), 3 (+control or +lung function) and 4 of these domains. The association between pre-biologic characteristics and post-biologic remission was assessed by multivariable analysis. MEASUREMENTS AND MAIN RESULTS: 50.2%, 33.5%, 25.8% and 20.3% of patients met criteria for 2, 3 (+control), 3 (+lung function) and 4-domain-remission, respectively. The odds of achieving 4-domain remission decreased by 15% for every additional 10-years asthma duration (odds ratio: 0.85; 95% CI: 0.73, 1.00). The odds of remission increased in those with fewer exacerbations/year, lower LTOCS daily dose, better control and better lung function pre-biologic-initiation. CONCLUSIONS: One in 5 patients achieved 4-domain remission within 1-year of biologic-initiation. Patients with less severe impairment and shorter asthma duration at initiation had a greater chance of achieving remission post-biologic, indicating that biologic treatment should not be delayed if remission is the goal. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Query mandates in prescription drug monitoring programs reduce opioid use among commercially insured patients with cancer.

BACKGROUND: Prescription drug monitoring programs (PDMPs) have been shown to reduce opioid use in the general and noncancer populations. However, evidence of PDMP impacts on patients with cancer remains limited. OBJECTIVE: The aim of the study was to examine the impact of PDMP mandates on individual-level opioid use among patients with cancer. METHODS: This is a retrospective cohort study of patients with newly diagnosed cancer aged 18-65 years in the IQVIA PharMetrics Plus database (IQVIA Inc; nationally representative data of the U.S. commercially insured population in 49 states) between 2013 and 2015. The primary exposure was PDMP rigor (ranked from highest to lowest rigor): provider query + registration, query only, registration only, and unexposed. The study outcomes included (1) prevalent use among all individuals; and among opioid users (2) total days supplied, (3) daily morphine equivalent dose (MED), and (4) cumulative MED. RESULTS: Of the eligible cohort (n=28,353), 37.5% (10,656) received opioids after a cancer diagnosis. The individuals exposed to these mandates were as follows: query + registration: 3899 (13.8%); query only: 3459 (12.2%); registration only: 2764 (9.7%); and no mandates: 18,231 (64.3%). The PDMP mandates had no effect on prevalent opioid use. Compared with unexposed patients, those subject to query mandates-alone or with registration mandates-experienced 12 fewer opioid days supplied and a lower mean cumulative MED (-662 mg and -702 mg, respectively), P < 0.01. Registration-only mandates were associated with 21 days more (P < 0.01) total days supplied and lower daily MED (1.1 mg; P < 0.05) but had no statistically significant effect on cumulative MED (-46 mg, P > 0.05). CONCLUSION: Query mandates are a stronger PDMP tool than registration mandates in reducing opioid days supplied and cumulative MED. Initiatives should target PDMP mandates toward intended patient groups to reduce high-risk opioid use without compromising adequate pain treatment.

The Etiology of Pneumonia From Analysis of Lung Aspirate and Pleural Fluid Samples: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study.

BACKGROUND: An improved understanding of childhood pneumonia etiology is required to inform prevention and treatment strategies. Lung aspiration is the gold standard specimen for pneumonia diagnostics. We report findings from analyses of lung and pleural aspirates collected in the Pneumonia Etiology Research for Child Health (PERCH) study. METHODS: The PERCH study enrolled children aged 1-59 months hospitalized with World Health Organization-defined severe or very severe pneumonia in 7 countries in Africa and Asia. Percutaneous transthoracic lung aspiration (LA) and pleural fluid (PF) aspiration was performed on a sample of pneumonia cases with radiological consolidation and/or PF in 4 countries. Venous blood and nasopharyngeal/oropharyngeal swabs were collected from all cases. Multiplex quantitative polymerase chain reaction (PCR) and routine microbiologic culture were applied to clinical specimens. RESULTS: Of 44 LAs performed within 3 days of admission on 622 eligible cases, 13 (30%) had a pathogen identified by either culture (5/44) or by PCR (11/29). A pathogen was identified in 12/14 (86%) PF specimens tested by either culture (9/14) or PCR (9/11). Bacterial pathogens were identified more frequently than viruses. All but 1 of the cases with a virus identified were coinfected with bacterial pathogens. Streptococcus pneumoniae (9/44 [20%]) and Staphylococcus aureus (7/14 [50%]) were the predominant pathogens identified in LA and PF, respectively. CONCLUSIONS: Bacterial pathogens predominated in this selected subgroup of PERCH participants drawn from those with radiological consolidation or PF, with S. pneumoniae and S. aureus the leading pathogens identified.

Prevalence and Newly Diagnosed Rates of Multimorbidity in Older Medicare Beneficiaries with COPD.

Few studies have quantified the multimorbidity burden in older adults with chronic obstructive pulmonary disease (COPD) using large and generalizable data. Such evidence is essential to inform evidence-based research, clinical care, and resource allocation. This retrospective cohort study used a nationally representative sample of Medicare beneficiaries aged 65 years or older with COPD and 1:1 matched (on age, sex, and race) non-COPD beneficiaries to: (1) quantify the prevalence of multimorbidity at COPD onset and one-year later; (2) quantify the rates [per 100 person-years (PY)] of newly diagnosed multimorbidity during in the year prior to and in the year following COPD onset; and (3) compare multimorbidity prevalence in beneficiaries with and without COPD. Among 739,118 eligible beneficiaries with and without COPD, the average number of multimorbidity was 10.0 (SD = 4.7) and 1.0 (SD = 3.3), respectively. The most prevalent multimorbidity at COPD onset and at one-year after, respectively, were hypertension (70.8% and 80.2%), hyperlipidemia (52.2% and 64.8%), anemia (42.1% and 52.0%), arthritis (39.8% and 47.7%), and congestive heart failure (CHF) (31.3% and 38.8%). Conditions with the highest newly diagnosed rates before and following COPD onset, respectively, included hypertension (39.8 and 32.3 per 100 PY), hyperlipidemia (22.8 and 27.6), anemia (17.8 and 20.3), CHF (16.2 and 13.2), and arthritis (12.9 and 13.2). COPD was significantly associated with increased odds of all measured conditions relative to non-COPD controls. This study updates existing literature with more current, generalizable findings of the substantial multimorbidity burden in medically complex older adults with COPD-necessary to inform patient-centered, multidimensional care.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1968815 .

Association of C-Reactive Protein With Bacterial and Respiratory Syncytial Virus-Associated Pneumonia Among Children Aged <5 Years in the PERCH Study.

BACKGROUND.: Lack of a gold standard for identifying bacterial and viral etiologies of pneumonia has limited evaluation of C-reactive protein (CRP) for identifying bacterial pneumonia. We evaluated the sensitivity and specificity of CRP for identifying bacterial vs respiratory syncytial virus (RSV) pneumonia in the Pneumonia Etiology Research for Child Health (PERCH) multicenter case-control study. METHODS.: We measured serum CRP levels in cases with World Health Organization-defined severe or very severe pneumonia and a subset of community controls. We evaluated the sensitivity and specificity of elevated CRP for "confirmed" bacterial pneumonia (positive blood culture or positive lung aspirate or pleural fluid culture or polymerase chain reaction [PCR]) compared to "RSV pneumonia" (nasopharyngeal/oropharyngeal or induced sputum PCR-positive without confirmed/suspected bacterial pneumonia). Receiver operating characteristic (ROC) curves were constructed to assess the performance of elevated CRP in distinguishing these cases. RESULTS.: Among 601 human immunodeficiency virus (HIV)-negative tested controls, 3% had CRP ≥40 mg/L. Among 119 HIV-negative cases with confirmed bacterial pneumonia, 77% had CRP ≥40 mg/L compared with 17% of 556 RSV pneumonia cases. The ROC analysis produced an area under the curve of 0.87, indicating very good discrimination; a cut-point of 37.1 mg/L best discriminated confirmed bacterial pneumonia (sensitivity 77%) from RSV pneumonia (specificity 82%). CRP ≥100 mg/L substantially improved specificity over CRP ≥40 mg/L, though at a loss to sensitivity. CONCLUSIONS.: Elevated CRP was positively associated with confirmed bacterial pneumonia and negatively associated with RSV pneumonia in PERCH. CRP may be useful for distinguishing bacterial from RSV-associated pneumonia, although its role in discriminating against other respiratory viral-associated pneumonia needs further study.

Benralizumab in Severe Eosinophilic Asthma and Chronic Rhinosinusitis with Nasal Polyps: The Real-World, Multi-Country RANS Observational Study.

Purpose: Real-world evidence of benralizumab effectiveness on nasal polyps (NP) and asthma outcomes in patients with severe eosinophilic asthma (SEA) and comorbid chronic rhinosinusitis with NP are limited. The objective of this study was to assess NP and asthma outcomes in benralizumab-treated patients with SEA and comorbid NP in a real-world setting. Patients and Methods: RANS was a retrospective, multi-country observational study (ClinicalTrials.gov: NCT05180357) using medical chart reviews of adults with SEA and comorbid NP. Total NP Score (NPS), SinoNasal Outcome Test-22 (SNOT-22) total score, annualized exacerbation rate (AER), and 6-item Asthma Control Questionnaire (ACQ-6) and Asthma Control Test (ACT) scores during the 12 months pre-index (baseline) and post-index (follow-up) were measured. Clinically meaningful improvement from baseline following treatment, in terms of total NPS (≥1-point reduction), SNOT-22 total (≥8.9-point reduction), ACQ-6 (≥0.5-point reduction) or ACT (≥3-point increase) scores, were reported. Results: A total of 233 patients were included. Baseline mean (standard deviation [SD]) NPS and SNOT-22 total scores were 3.8 (2.4) and 47.5 (22.6), respectively. The mean change (95% confidence interval [CI]) from baseline was -1.2 (-1.7, -0.6) for NPS, and -19.8 (-23.6, -15.9) for SNOT-22. The AER (95% CI) was 1.2 (0.96, 1.41) at baseline and 0.2 (0.13, 0.28) at follow-up. Mean (SD) ACQ-6 and ACT scores were 1.6 (1.3) and 15.0 (5.2) at baseline and 0.8 (1.0) and 22.0 (3.9) at follow-up, respectively. The proportion of patients who achieved clinically meaningful improvements in NPS, SNOT-22 total, ACQ-6, and ACT scores was 49.1%, 67.6%, 56.6%, and 81.1%, respectively. Conclusion: In this real-world study, improvements in NP and asthma outcomes in patients with SEA and comorbid NP were observed during the 12 months following benralizumab initiation.

Exploring Definitions and Predictors of Response to Biologics for Severe Asthma.

BACKGROUND: Biologic effectiveness is often assessed as response, a term that eludes consistent definition. Identifying those most likely to respond in real-life has proven challenging. OBJECTIVE: To explore definitions of biologic responders in adults with severe asthma and investigate patient characteristics associated with biologic response. METHODS: This was a longitudinal cohort study using data from 21 countries, which shared data with the International Severe Asthma Registry. Changes in four asthma outcome domains were assessed in the 1-year period before and after biologic initiation in patients with a predefined level of prebiologic impairment. Responder cutoffs were 50% or greater reduction in exacerbation rate, 50% or greater reduction in long-term oral corticosteroid daily dose, improvement in one or more category in asthma control, and 100 mL or greater improvement in FEV1. Responders were defined using single and multiple domains. The association between prebiologic characteristics and postbiologic initiation response was examined by multivariable analysis. RESULTS: A total of 2,210 patients were included. Responder rate ranged from 80.7% (n = 566 of 701) for exacerbation response to 10.6% (n = 9 of 85) for a four-domain response. Many responders still exhibited significant impairment after biologic initiation: 46.7% (n = 206 of 441) of asthma control responders with uncontrolled asthma before the biologic still had incompletely controlled disease postbiologic initiation. Predictors of response were outcome-dependent. Lung function responders were more likely to have higher prebiologic FeNO (odds ratio = 1.20 for every 25-parts per billion increase), and shorter asthma duration (odds ratio = 0.81 for every 10-year increase in duration). Higher blood eosinophil count and the presence of type 2-related comorbidities were positively associated with higher odds of meeting long-term oral corticosteroid, control, and lung function responder criteria. CONCLUSIONS: Our findings underscore the multimodal nature of response, showing that many responders experience residual symptoms after biologic initiation and that predictors of response vary according to the outcome assessed.

A Framework for Automatic Clustering of EHR Messages Using a Spatial Clustering Approach.

Although Health Level Seven (HL 7) message standards (v2, v3, Clinical Document Architecture (CDA)) have been commonly adopted, there are still issues associated with them, especially the semantic interoperability issues and lack of support for smart devices (e.g., smartphones, fitness trackers, and smartwatches), etc. In addition, healthcare organizations in many countries are still using proprietary electronic health record (EHR) message formats, making it challenging to convert to other data formats-particularly the latest HL7 Fast Health Interoperability Resources (FHIR) data standard. The FHIR is based on modern web technologies such as HTTP, XML, and JSON and would be capable of overcoming the shortcomings of the previous standards and supporting modern smart devices. Therefore, the FHIR standard could help the healthcare industry to avail the latest technologies benefits and improve data interoperability. The data representation and mapping from the legacy data standards (i.e., HL7 v2 and EHR) to the FHIR is necessary for the healthcare sector. However, direct data mapping or conversion from the traditional data standards to the FHIR data standard is challenging because of the nature and formats of the data. Therefore, in this article, we propose a framework that aims to convert proprietary EHR messages into the HL7 v2 format and apply an unsupervised clustering approach using the DBSCAN (density-based spatial clustering of applications with noise) algorithm to automatically group a variety of these HL7 v2 messages regardless of their semantic origins. The proposed framework's implementation lays the groundwork to provide a generic mapping model with multi-point and multi-format data conversion input into the FHIR. Our experimental results show the proposed framework's ability to automatically cluster various HL7 v2 message formats and provide analytic insight behind them.

Patterns of opioid use in commercially insured patients with cancer.

OBJECTIVES: In an era of heightened opioid prescribing scrutiny, ensuring safe and adequate pain management is challenging. Understanding opioid use in patients with cancer can facilitate effective pain management regimens while minimizing safety concerns. This study characterized patterns of and factors associated with opioid use following a new cancer diagnosis. STUDY DESIGN: Retrospective cohort study. METHODS: Our study included patients with a new cancer diagnosis aged 18 to 64 years in IQVIA PharMetrics Plus 2007-2013 who were continuously enrolled 12 months before receiving their cancer diagnosis and 24 months after. Study outcomes included opioid prevalence and measures of potentially high-risk opioid use (total days supplied, number of prescriptions, and morphine equivalent daily dose [MEDD]). Descriptive analyses and logistic regression were implemented. RESULTS: Of 191,616 eligible individuals, 93,739 (48.9%) received opioid prescriptions; of these, 56,025 (59.8%) were new opioid users. Opioid users received 4.6 prescriptions on average, covering 65 total days with a mean MEDD of 31.8 mg. Only 2387 (2.5%) patients received higher than recommended (≥ 90 mg) MEDD. Predictors of opioid use post cancer included prior opioid use, select comorbidities, use of nonopioid pain treatment adjuvants (muscle relaxants, sedative/hypnotics, anticonvulsants, antidepressants, and steroids), cancer site, and metastatic cancer. CONCLUSIONS: Fewer than half of patients received opioids in the 2 years following cancer onset. Among users, we found a relatively small proportion of potentially problematic opioid use. Further research is warranted to assess the adequacy of cancer pain treatment and determinants of high-risk opioid use.

Prediction of treatment nonadherence among older adults with chronic obstructive pulmonary disease using Medicare real-world data.

BACKGROUND: Suboptimal maintenance medication (MM) adherence remains a clinical problem among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To inform risk-based personalized decision-making, this study sought to develop and validate prediction models of nonadherence to COPD MMs for Medicare beneficiaries. METHODS: This was a retrospective cohort study of beneficiaries aged 65 years and older with COPD and inhaled MMs. Nonadherence (proportion of days covered < 0.8) was measured in 12 months following the first MM fill after COPD diagnosis. Logistic and least absolute shrinkage selector operator regressions were implemented, and area under the receiver operating characteristic curve (AUROC) evaluated model accuracy, as well as positive predictive values and negative predictive values. Our models evaluated different sets of predictors for two cohorts: those with an MM prescription before COPD diagnosis (prevalent users) and those without (new users). RESULTS: Among 16,157 prevalent and 40,279 new users of MMs, 11,271 (69.8%) and 34,009 (84.4%), respectively, were nonadherent. The best-performing logistic models achieved AUROCs of 0.8714 and 0.881, positive predictive values of 0.881 and 0.881, and negative predictive values of 0.559 and 0.578, respectively, for prevalent and new users. The least absolute shrinkage selector operator models had similar accuracy. Models with baseline-only predictors had average performance (AUROC < 0.72). The most important predictors were initial MM adherence, short-acting bronchodilator use, and asthma. CONCLUSIONS: To our knowledge, this study is the first to develop predictive models of nonadherence to COPD MMs. Generated models achieved good discrimination and underlined the importance of early adherence. Well-performed models can be useful for care decision-making and interventions to improve COPD medication adherence after the first critical few months following a treatment episode. DISCLOSURES: All authors declared no conflicts of interest.

Staffing and Protective Equipment Access Mitigated COVID-19 Penetration and Spread in US Nursing Homes During the Third Surge.

OBJECTIVES: During the last quarter of 2020-despite improved distribution of personal protective equipment (PPE) and knowledge of COVID-19 management-nursing homes experienced the greatest increases in cases and deaths since the pandemic's beginning. We sought to update COVID-19 estimates of cases, hospitalization, and mortality and to evaluate the association of potentially modifiable facility-level infection control factors on odds and magnitude of COVID-19 cases, hospitalizations, and deaths in nursing homes during the third surge of the pandemic. DESIGN: Cross-sectional analysis. SETTING AND PARTICIPANTS: Facility-level data from 13,156 US nursing home facilities. METHODS: Two series of multivariable logistic regression and generalized linear models to examine the association of infection control factors (personal protective equipment and staffing) on incidence and magnitude, respectively, of confirmed COVID-19 cases, hospitalizations, and deaths in nursing home residents reported in the last quarter of 2020. RESULTS: Nursing homes experienced steep increases in COVID-19 cases, hospitalizations, and deaths during the final quarter of 2020. Four-fifths (80.51%; n = 10,592) of facilities reported at least 1 COVID-19 case, 49.44% (n = 6504) reported at least 1 hospitalization, and 49.76% (n = 6546) reported at least 1 death during this third surge. N95 mask shortages were associated with increased odds of at least 1 COVID-19 case [odds ratio (OR) 1.21, 95% confidence interval (CI) 1.05-1.40] and hospitalization (1.26, 95% CI 1.13-1.40), as well as larger numbers of hospitalizations (1.11, 95% CI 1.02-1.20). Nursing aide shortages were associated with lower odds of at least 1 COVID-19 death (1.23, 95% CI 1.12-1.34) and higher hospitalizations (1.09, 95% CI 1.01-1.17). The number of nursing hours per resident per day was largely insignificant across all outcomes. Of note, smaller (<50-bed) and midsized (50- to 150-bed) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed occupancy rates >75% increased odds of experiencing a COVID-19 case (1.48, 95% CI 1.35-1.62) or death (1.25, 95% CI 1.17-1.34). CONCLUSIONS AND IMPLICATIONS: Adequate staffing and PPE-along with reduced occupancy and smaller facilities-mitigate incidence and magnitude of COVID-19 cases and sequelae. Addressing shortcomings in these factors is critical to the prevention of infections and adverse health consequences of a next surge among vulnerable nursing home residents.

Respiratory events associated with concomitant opioid and sedative use among Medicare beneficiaries with chronic obstructive pulmonary disease.

BACKGROUND: Opioids and sedatives are commonly prescribed in chronic obstructive pulmonary disease (COPD) patients for symptoms of dyspnoea, pain, insomnia, depression and anxiety. Older adults are advised to avoid these medications due to increased adverse events, including respiratory events. This study examines respiratory event risks associated with concomitant opioid and sedative use compared with opioid use alone in older adults with COPD. METHODS: A 5% nationally representative sample of Medicare beneficiaries with COPD and opioid use between 2009 and 2013 was used for this retrospective cohort study. Current and past concomitant use were identified using drug dispensed within 7 days from the censored date: at respiratory event, at death, or at 12 months post index. Concomitant opioid and sedative use were categorised into no overlap (opioid only), 1 to 10, 11 to 30, 31 to 60 and >60 days of total overlap. The primary outcome was hospitalisation or emergency department (ED) visits for respiratory events (COPD exacerbations or respiratory depression). Propensity score matching was implemented and semi-competing risk models were used to address competing risk by death. RESULTS: Among 48 120 eligible beneficiaries, 1810 (16.7%) concomitant users were matched with 9050 (83.3%) opioid only users. Current concomitant use of 1 to 10, 11 to 30 and 31 to 60 days was associated with increased respiratory events (HRs (95% CI): 2.8 (1.2 to 7.3), 9.3 (4.9 to 18.2) and 5.7 (2.5 to 12.5), respectively), compared with opioid only use. Current concomitant use of >60 days or past concomitant use of ≤60 days was not significantly associated with respiratory events. Consistent findings were found in sensitivity analyses, including in subgroup analysis of non-benzodiazepine sedatives. Additionally, current concomitant use significantly increased risk of death. CONCLUSION: Short-term and medium-term current concomitant opioid and sedative use significantly increased risk of respiratory events and death in older COPD Medicare beneficiaries. Long-term past concomitant users, however, demonstrated lower risks of these outcomes, possibly reflecting a healthy user effect or developed tolerance to the effects of these agents.

Changes in Opioid Utilization Following Tumor Necrosis Factor Inhibitor Initiation in Patients with Rheumatoid Arthritis.

INTRODUCTION: Pain control is one of the most important aspects of rheumatoid arthritis (RA) management from the patient's perspective. Newer generations of RA treatment including tumor necrosis factor inhibitor (TNFi) have the potential to alleviate pain and thus reduce opioid utilization. However, patterns of opioid utilization before and after TNFi initiation have not been well characterized. This study aims to examine multiple measures of change in opioid utilization after the initiation of TNFi. METHODS: Patients aged ≥ 18 years with RA and 24 months continuous enrollment between January 2007 and December 2015 who newly initiated a TNFi in IQVIA™ Health Plan Claims Data were included in our study. Opioid utilization at baseline and during follow-up were identified and compared. RESULTS: Of 2330 patients with RA that were included in the study, 38.8% of patients used opioids in both baseline and follow-up periods. From pre-index to post-index, the proportion of patients receiving any opioid decreased from 54.0 to 51.0%. In addition, the proportion of those who received ≥ 50 mg median daily MED decreased from 12.6 to 10.6% during pre-post periods. CONCLUSIONS: This real-world study of commercially insured patients with RA suggests that opioid use among these patients is prevalent. There was a small decrease in overall opioid utilization after TNFi initiation.