The effect of a cancer diagnosis on disability status

6531

Background: Although cancer and cancer treatments may lead to an inability to work, working-age adults eligible for Medicare benefits on the basis of disability face a 29-month waiting period between initial application due to disability and enrollment in the program. In this study we evaluated patterns of Medicare enrollment for working-age adults with cancer and determined factors predicting enrollment. Methods: The Surveillance, Epidemiology, and End Results (SEER) and SEER-Medicare data were used for this retrospective cohort analysis. We included patients age 21 to 59 diagnosed with lung, prostate, colorectal, and breast cancer (female) cases from 1992 through 2002. Patients were followed until 2005 or death. We constructed line plots of time from cancer diagnosis to enrollment in Medicare due to disability, anticipating a spike in enrollment around 29 months post-diagnosis. We compared demographic and tumor characteristics in the disabled to the all similarly aged patients included in SEER. We used logistic regression to determine factors associated with enrollment in Medicare due to disability 29 to 35 months post-diagnosis including demographic characteristics, stage at diagnosis, and type of surgical treatment. Results: We identified 359,049 working-age adults who were diagnosed with prostate, lung, colorectal, or female breast cancer. Within 5 years of diagnosis, 4.4% had enrolled in Medicare due to disability, most between 29 and 31 months post-diagnosis (the earliest time period of eligibility on the basis of cancer diagnosis). Later stage at diagnosis, lack of surgical treatment, aggressive surgical treatment, unmarried marital status, Hispanic or African American race/ethnicity, older age, and male gender were associated with statistically significantly higher odds of enrollment in Medicare due to disability. Conclusions: A significant number of working-age cancer patients become eligible for enrollment in Medicare due to disability. Most become eligible between 29 and 31 months after diagnosis indicating that cancer and/or treatment had a substantial permanent impact on ability to work from the time of diagnosis. Federal policy offering Medicare benefits only 29 months after application should be reevaluated.

No significant financial relationships to disclose.

Recommended healthcare among elderly cancer survivors

6045

Background: Earle and colleagues (2003, 2004) have published conflicting information regarding recommended services among cancer survivors: breast cancer survivors had higher rates than persons without cancer (2003); and colorectal cancer survivors had lower rates (2004). We examined the use of preventive services and recommended diabetes care in 1999–2002 among elderly Medicare beneficiaries who were long-term survivors of 5 different types of cancer: bladder, breast, colorectal, prostate and uterine. Methods: Retrospective cohort analysis using the linked SEER/Medicare database of beneficiaries living in the SEER areas of the NCI who survived 5 years after bladder, breast, colorectal, prostate or uterine cancer diagnosis and a 5% random sample of beneficiaries with no cancer history residing these areas. We compared the rates of influenza vaccination and breast cancer screening, as well as diabetes care services: hemoglobin A1c (HbA1c) testing, eye examination, and lipid testing. Crude and multivariate adjusted rates were calculated and compared. Results: In 1999 through 2002, depending on the cancer type and year, cancer survivors were between 20 and 50% more likely to receive influenza vaccine or mammograms than persons who never had cancer (women with breast cancer excluded). Among those cancer survivors with diabetes, the rates of annual HbA1c testing or eye examination were 1 to 16% greater in all years than among those without cancer, p < 0.05, when adjusted for age-group, gender (if needed), and race. Differences in the serum lipid level determination rates were even smaller or not significant (p ≥ 0.05) between the cancer survivors and controls. Interestingly, depending on the cancer type, the rates of influenza vaccination and mammography were up to 30% higher among cancer survivors with diabetes than in survivors who did not have diabetes. Multivariate models that included other sociodemographic variables, comorbities and other relevant covariates confirmed these findings. Conclusions: Elderly persons who have survived cancer were generally more likely to receive preventive and other recommended services compared with those without cancer. The presence of another chronic disease such as diabetes, may enhance the use of preventive services.

No significant financial relationships to disclose.

Hospice use in Medicare managed care and fee-for-service systems

OBJECTIVE

To examine whether patterns of hospice use by older Medicare beneficiaries are consistent with the differing financial incentives in Medicare managed care (MC) and fee-for-service (FFS) settings. Specifically, are use patterns consistent with incentives that might encourage hospice use for MC enrollees and discourage hospice use for FFS enrollees?

STUDY DESIGN

One-year study of hospice use by Medicare beneficiaries dying in 1996.

PATIENTS AND METHODS

Medicare enrollment and hospice administrative data were used to examine hospice use before death for all elderly individuals residing in 100 US counties with high MC enrollment in 1996. Age-, sex-, and race-adjusted rate of hospice use and length of stay in hospice are compared between FFS and MC enrollees across and within (when possible) the 100 counties.

RESULTS

Rates of hospice use were significantly higher for MC enrollees than for FFS enrollees (26.6 vs 17.0 per 100 deaths; P < .001). These differences persisted within age, sex, and race groups but were not related to area MC enrollment rate or the amount of money paid to managed care organizations. Age-, sex-, and race-adjusted differences were observed in 94 of 100 counties. Length of stay in hospice was marginally longer for MC enrollees than for FFS enrollees (median, 24 vs 21 days; P < .0001).

CONCLUSIONS

System of care is an important determinant of hospice use in the elderly Medicare population.

Identifying persons with diabetes using Medicare claims data

The objective of this study was to develop and validate a method for identifying Medicare beneficiaries with diabetes by using Medicare claims data. We used self-reports of diabetes status from participants in the Medicare Current Beneficiary Survey to determine disease status, and then we examined these participants' Medicare claims. Using self-reported diabetes status as the "gold standard," we determined the sensitivity, specificity, and reliability of claims data in identifying beneficiaries with diabetes. We found that to construct a method that is adequately sensitive (> or = 70%), highly specific (> or = 97.5%), and reliable (kappa > or = 0.80), researchers must combine information from different types of Medicare claims files, use 2 years of data to identify cases, and require at least 2 diagnoses of diabetes among claims involving ambulatory care. Since these criteria are met by more than one method, the choice of method should be governed by the goals of the research as well as more practical concerns.

Monitoring the health status and impact of treatment on Americans: the Medicare Beneficiary Health Status Registry

OBJECTIVE

A major new survey program, the Medicare Beneficiary Health Status Registry (MBHSR), has been proposed to improve the monitoring of the health status of Medicare beneficiaries. The MBHSR would collect data by mail with telephone follow up of nonrespondents to permit economical assessment of a total Registry of approximately 200,000 Medicare beneficiaries, approximately 54,000 of whom would be surveyed in any given year. (Surveys would be conducted of samples of new enrollees who would be reinterviewed every five years.)

METHOD

To assess the feasibility of that approach, a field test was conducted with a probability sample (n = 1,922) that comprised approximately equal numbers of new Medicare enrollees (aged, 65) and current beneficiaries (age range, 76-80). The field test was designed to assess the quality of the data that this design would produce.

FINDINGS

Results indicate that the proposed design of the MBHSR could achieve response rates of approximately 80% among both age cohorts using a survey instrument that took 30 minutes to complete. Internal reliability of Activities of Daily Living, Instrumental Activities of Daily Living, Mobility, Mental Health Index, General Health, and Prostate Symptomatology scales ranged from 0.77 to 0.93. When measurements were repeated approximately 30 days after the initial survey, moderate to high levels of cross temporal correlation (range, 0.64-0.96) were found for most indexes, with the exception of prostate symptomatology. In addition, an earlier comparison of survey responses in the MBHSR field test to Medicare payment records indicated that the MBHSR field test obtained highly accurate reports of most of the major surgeries that were recorded in Medicare claims files.

CONCLUSION

The design proposed for the MBHSR is feasible. If implemented, it should produce acceptably high rates of response and data quality.

The quality of health data obtained in a new survey of elderly Americans: a validation study of the proposed Medicare Beneficiary Health Status Registry (MBHSR)

The Medicare Beneficiary Health Status Registry (MBHSR) is a proposed new survey program that would collect health status indicators annually from large probability samples of Medicine beneficiaries. For reasons of economy, the MBHSR would use mail survey procedures with telephone follow-up of nonrespondents. Because of concerns about response rates and the validity and reliability of the data obtained by such methods, a large-scale (N = 1,922) field test was conducted. The field test assessed the validity of MBHSR survey reports of past medical treatment and conditions by comparing those reports with Medicare claims data. It assessed the (internal) reliability of MBHSR survey responses by comparing responses with logically related survey questions from the MBHSR. Analyses indicate that the MBHSR survey procedures using a combination of mail data collection with telephone follow-up of nonrespondents produced relatively high levels of sensitivity and specificity in identifying medical treatments and procedures previously recorded in Medicare claims data. In addition, the MBHSR Field Test obtained, in general, relatively high levels of internal consistency in survey reports.

Use of eye care services among the 1991 Medicare population

PURPOSE

To determine the use of eye care services by type of provider (ophthalmologist, optometrist, and non-ophthalmologist physician) in the Medicare population.

METHODS

As a basis for characterizing eye conditions and ophthalmic services among a population 65 years of age and older, 1991 claims from a representative 5% sample of Medicare beneficiaries were analyzed using a previously described classification scheme. Analysis was specifically conducted by type of provider as well as by the service provided.

RESULTS

Almost one half of the approximately 30 million Medicare beneficiaries 65 years of age or older received eye care services in 1991, resulting in more than 35,000,000 visits (claims). Ophthalmologists provided services to 71% of this eye care population, and optometrists to 22%; 36% of this population received ophthalmic-related services from other providers, and 14% from only other providers (commonly for eye lid dermatitis and tumors). Cataract was the most common condition, accounting for 41% of visits to ophthalmologists (and 1.2 million cases of surgery), glaucoma accounted for 19% of visits, and retinal diseases for 14%. The visit percentages for optometrists are 58%, 8%, and 11%, respectively. Ophthalmic examination and evaluation accounted for 63% of the 28,000,000 paid ophthalmologists' procedures, and 58% of the 5,500,000 optometrists' procedures.

CONCLUSION

Optometrists and physicians other than ophthalmologists were the sole providers of ophthalmic-related services to a large percentage of beneficiaries who received eye care in 1991. Within the universe of service provided by ophthalmologists, the majority of all care consisted of evaluation and management services as opposed to surgical procedure-based care.

The use and costs of physician services for ophthalmic surgical procedures in 1988 and 1991

BACKGROUND AND OBJECTIVE

To examine the change in volume and costs of physician services for ophthalmic surgical procedures associated with physician fee cuts.

MATERIALS AND METHODS

The authors analyzed the physician claims (Part B) data for a 5% random sample of the Medicare population. Number, rate, average allowed charge, and total cost of physician services for ophthalmic surgical procedures were compared for 1988 and 1991.

RESULTS

An estimated 3.1 million (98 per 1000) ophthalmic surgical procedures were performed on Medicare beneficiaries in 1991, compared with 2.3 million (76 per 1000) in 1988. There was a 35% increase in number and a 28% increase in rate. The average allowed charge for these services decreased by 26% ($1155 vs $852 per procedure), with an overall cost of $2.6 billion in both years.

CONCLUSION

A reduction in fee for physician services for ophthalmic surgical procedures from 1988 to 1991 was associated with an increase in the volume of the services. The overall costs of physician services for ophthalmic surgical procedures remained consistent between the two years.

Use of Medicare data to identify incident breast cancer cases

Surveillance, Epidemiology and End Results (SEER) data from the National Cancer Institute (NCI) provide reliable information about cancer incidence. However, because SEER data are geographically limited and have a 2-year time lag, we evaluated whether Medicare data could provide timely information on cancer incidence. Comparing Medicare women hospitalized for breast cancer with women reported to SEER, Medicare data had high specificity (96.6 percent), yet low sensitivity (59.4 percent). We conclude that Medicare hospitalization data can identify incident cases for cancers that usually require inpatient hospitalization. For cancers that often only receive outpatient treatment, such as breast cancer, additional Medicare data, such as physician bills, are needed to understand the entirety of treatment practices.

Is there any connection between a second pneumonia shot and hospitalization among Medicare beneficiaries?

To learn whether the risk of revaccination in adults should limit its use, the authors investigated whether adverse events requiring hospitalization occurred in a group of Medicare enrollees revaccinated with pneumococcal polysaccharide vaccine. A prospective cohort analysis and case study of revaccinated people involved five percent of all elderly Medicare enrollees from 1985 through 1988, consisting of 66,256 people receiving one dose of vaccine and 1,099 receiving two doses. Comparison was made of the hospitalization rate within 30 days after revaccination and rates of singly vaccinated persons using discharge diagnosis for all those hospitalized during the 30 days after revaccination. No significant difference was found between the hospitalization rate of the revaccinated cohort and comparison group. No adverse reactions attributable to pneumococcal polysaccharide vaccine causing hospitalization were identified among 39 revaccinated persons who were hospitalized within 30 days of revaccination. Revaccination of elderly Medicare beneficiaries does not cause events serious enough to require hospitalization. Vaccination of persons according to the Public Health Service Immunization Practice Advisory Committee guidelines is recommended when the prior immunization status is unknown.

The burden and outcomes associated with dehydration among US elderly, 1991

OBJECTIVES

Dehydration has been underappreciated as a cause of hospitalization and increased hospital-associated mortality in older people. This study used national data to analyze the burden and outcomes following hospitalizations with dehydration in the elderly.

METHODS

Data from 1991 Medicare files were used to calculate rates of hospitalization with dehydration, to examine demographic characteristics and concomitant diagnoses associated with dehydration, and to analyze the contribution of dehydration to mortality.

RESULTS

In 1991, 6.7% (731,695) of Medicare hospitalizations had dehydration listed as one of the five reported diagnoses, a rate of 236.2/10,000 elderly Medicare beneficiaries. In 1991, Medicare reimbursed over $446 million for hospitalizations with dehydration as the principal diagnosis. Older people, men, and Blacks had elevated risks for hospitalization with dehydration. Acute infections, such as pneumonia and urinary tract infections, were frequent concomitant diagnoses. About 50% of elderly Medicare beneficiaries hospitalized with dehydration died within a year of admission.

CONCLUSIONS

Hospitalization of elderly people with dehydration is a serious and costly medical problem. Attention should be focused on understanding predisposing factors and devising strategies for prevention.

Hospitalizations with adverse events caused by digitalis therapy among elderly Medicare beneficiaries

BACKGROUND

Digitalis products are among the agents most frequently prescribed to the elderly, yet previous studies have not provided age-, race-, and sex-specific rates of utilization of digitalis by this population. Estimates of the rate of hospitalization with an adverse reaction from digitalis therapy have varied considerably between systems relying on passive reports and those using active surveillance.

METHODS

Medicare data from 1985 through 1991 and data from the 1987 National Medical Expenditure Survey were used to determine population-based estimates of the use of digitalis in elderly beneficiaries by age group, sex, and race. Hospitalization rates with an adverse event caused by digitalis therapy were calculated for those persons estimated to be using digitalis. Medicare data were used to identify the frequency of selected comorbidities among persons with an adverse event caused by digitalis therapy as well as the frequency of clinical manifestations associated with digitalis intoxication.

RESULTS

Over 3 million Medicare beneficiaries were estimated to be using digitalis in 1987. A total of 202,011 hospitalizations with a coded adverse event caused by digitalis therapy were reported during the 7-year study period. Of persons estimated to be using digitalis, 8.53 per 1000 were hospitalized annually with an adverse event caused by digitalis therapy. Women, individuals with increasing age, and persons of black race, especially those with impaired renal function, were significantly (P < .05) more likely to experience hospitalization with an adverse event caused by digitalis therapy.

CONCLUSION

This information may help identify categories of elderly patients who require more frequent monitoring to prevent adverse effects of digitalis therapy. Changes in the format of the hospital bill to include more diagnoses along with increased mandatory reporting of adverse drug events will improve the sensitivity of Medicare data for surveillance of adverse drug events.

Measuring the incidence of cancer in elderly Americans using Medicare claims data

BACKGROUND

The Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute is the most frequently used and best estimate of the incidence of cancer in the United States. Although synthetic estimates based on the SEER information can be used to plan cancer prevention and intervention programs, the evaluation of these action programs and the monitoring of cancer incidence in states or other geographic areas requires information on the population for whom the program is directed.

METHODS

The age-adjusted incidence of six cancers among persons 65 years of age and older for 1986-1987 living in the five states participating in the SEER program was compared with the incidence derived from hospitalization records contained in the Health Care Financing Administration's (HCFA) administrative data files. Age-adjusted incidence rates for 1990 developed from HCFA data for persons living in the nine SEER program areas were contrasted with the incidence rates for persons living in the rest of the United States and were developed for each of the 50 states and the District of Columbia.

RESULTS

The comparison of the SEER and HCFA overall age-adjusted cancer incidence rates in the elderly for 1986-1987 showed that for four of the six cancers (breast, colon, lung, and corpus uteri) the rates differed by 5% or less. The HCFA derived rates were 6.37% and 7.65% greater than the SEER rates for prostate and esophagus cancer, respectively. The incidence of cancer between 1986 and 1990 was neither uniformly higher nor lower among elderly SEER program area residents compared with residents of the rest of the country. Incidence rates varied greatly among states for each of the cancers.

CONCLUSIONS

HCFA administrative data can be used by states or other geographic units to monitor the incidence of cancer in the elderly as well as to plan and evaluate cancer prevention and intervention programs.

Continuing differences in the rates of percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery between elderly black and white Medicare beneficiaries

Rates of hospitalization among black and white male and female Medicare beneficiaries, 65 years of age and older, for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery and 30-day postadmission mortality rates were compared for the years 1986 through 1990. The age-adjusted rates of hospitalization for both procedures increased, and the 30-day postadmission mortality rates decreased in all four race-sex groups. The greatest increase in the procedure rates were seen among white males. Using two estimates of the prevalence of ischemic heart disease in the elderly to adjust for the need for these cardiac procedures, the 1990 rates of PTCA in white beneficiaries were between 1.55 and 1.99 times higher than the rates among black beneficiaries, and the rates of CABG surgery were between 1.68 and 2.16 times higher. These differences in revascularization rates raise questions about whether there is equal access to certain treatments in the two race groups.

Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries

This study analyzes administrative data from the Medicare program to compare differences by race in the use of 17 major procedures performed in the hospital. In both 1986 and 1992, black beneficiaries were less likely than white beneficiaries to have received these procedures while hospitalized. The largest differences were seen for "referral-sensitive surgeries" such as percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, total knee replacement, and total hip replacement. These differences by race suggest that there are barriers to these services. In contrast, black beneficiaries were found to have substantially higher rates than white beneficiaries in the use of four procedures performed in the hospital: amputation of part of the lower limb, surgical debridement, arteriovenostomy, and bilateral orchiectomy. The types of procedures for which black beneficiaries have higher rates raise questions about whether there is a need for more comprehensive and continuous ambulatory care for the underlying health conditions associated with these procedures.

The impact and cost of influenza in the elderly

BACKGROUND

Traditional methods of measuring the impact and cost of influenza virus have focused on epidemic years and morbidity and mortality due to pneumonia and influenza.

METHODS

Annualized age-sex-race adjusted rates of hospitalization for pneumonia and influenza and other diagnoses among elderly Medicare beneficiaries during the epidemic influenza season of 1989 to 1990 and the nonepidemic season of 1990 to 1991 were compared with an interim period in 1990 without influenza virus circulation.

RESULTS

The rates of hospitalization for pneumonia and influenza, acute bronchitis, chronic respiratory disease, and congestive heart failure were significantly greater during each influenza period compared with the interim period. The highest rates were found in the epidemic season of 1989 to 1990. The amount reimbursed by Medicare to hospitals to 1990. The amount reimbursed by Medicare to hospitals for the treatment of excess hospitalizations during periods of influenza activity was more than $1 billion in 1989 to 1990 and almost $750 million in 1990 to 1991.

CONCLUSIONS

Measures of the impact and cost of influenza in elderly Americans should include all of the diagnoses listed above and should recognize that the impact of influenza virus is significant even in nonepidemic years. There are great opportunities for cost savings if effective control programs are implemented.

Appendectomy incidental to cholecystectomy among elderly Medicare beneficiaries

To assess the risks of adverse outcomes after appendectomy incidental to cholecystectomy among elderly Medicare beneficiaries, 8,936 persons undergoing cholecystectomy with incidental appendectomy and 44,461 persons undergoing cholecystectomy without incidental appendectomy were studied. Controlling for age, race, gender and co-morbidity status, the risk for wound infection in persons with incidental appendectomy was 83 percent higher than in persons without incidental appendectomy (95 percent confidence interval, 1.53 to 2.18). The risks for having other adverse outcomes, including other infections, extensive intrahospital complications and mortality rate at 30 days, were also higher for the former group, although these differences were not statistically significant. In addition, the demographic characteristics and health status of persons undergoing cholecystectomy with incidental appendectomy with persons undergoing cholecystectomy only were compared. Males, persons of younger ages, of white race or with no co-morbid conditions, were significantly more likely to undergo cholecystectomy with incidental appendectomy. Variables to control for differences in the demographic characteristics and health status between persons receiving and not receiving incidental appendectomy were included in the regression models for adverse outcomes. However, these models may not completely control for differences between the two groups. As a result, the actual relationship between incidental appendectomy and adverse outcomes may be underestimated. The preventive effect of incidental appendectomy on morbidity and mortality rates from future instances of appendicitis was assessed by determining the remaining lifetime risk for acute appendicitis. For persons 65 to 69 years of age, 115 incidental appendectomies would be required to prevent one future instance of appendicitis and 4,472 incidental appendectomies would be needed to prevent a single future death from acute appendicitis. Because incidental appendectomy increases the risk for wound infection among persons undergoing cholecystectomy and because the lifetime risk for acute appendicitis is relatively low for persons of this age group, surgeons should carefully consider the risks and benefits of incidental appendectomy in the elderly.

Accuracy of coding in Medicare part B claims. Cataract as a case study

We studied the accuracy of Medicare part B coding for cataract extraction to provide validation for research involving Medicare data. Hospital and physician office records associated with a sample of 802 paid claims for cataract surgery were reviewed. The sample was randomly selected from 118,420 Medicare part B claims for cataract surgery submitted by physicians in an 11-state sample during the first quarter of 1988. Medical records were successfully obtained for 796 cataract surgery episodes (99.2%), of which 794 (99.7%) indicated that cataract extraction had been performed. In the remaining two cases, cataract surgery was attempted but aborted. In 24 (3%) of the 794 cases, the surgical approach (intracapsular or extracapsular) indicated in the operative note differed from the coded on the physician's bill. In all cases in which the operative note indicated a secondary procedure performed at the time of surgery, the billing information was in agreement. We conclude that, at least in the case of cataract surgery, the Medicare part B database is 99% accurate (95% confidence interval, +/- 0.6%) for cataract surgery having occurred and 96% accurate (95% confidence interval, +/- 1.4%) in terms of surgical approach.

Determination of lung cancer incidence in the elderly using Medicare claims data

The Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute provides data for making national estimates of lung cancer incidence and for monitoring secular trends. The authors compared the number of cases of lung cancer and the incidence rates among elderly residents of the five states included in the SEER program in 1986-1987 with the number of incident cases identified and the rates calculated using hospitalization and enrollment data on elderly Medicare beneficiaries maintained by the Health Care Financing Administration (HCFA) for the same years. The SEER program state registries identified 5.9% more cases than did HCFA (p < 0.01). However, the overall rates were similar (274.2/100,000 population for SEER and 264.7/100,000 population for HCFA), as were the majority of the rates for the different demographic subgroups examined. Age-adjusted lung cancer incidence rates for 1986 through 1990 among elderly Medicare beneficiaries residing outside of all nine SEER areas were 8-13 percent higher than the rates calculated for SEER-area residents. This observation is supported by the existence of similar differences in the age-adjusted lung cancer mortality rates for 1979 through 1988 in the same populations. Because the SEER areas may not be representative of the entire nation for lung cancer incidence and HCFA data cover the entire country, the authors recommend using HCFA information to complement the SEER data system.

National outcomes of cataract extraction. III. Corneal edema and transplant following inpatient surgery

We analyzed the likelihood of rehospitalization for corneal edema or corneal transplantation in all 338,141 Medicare beneficiaries older than 65 years who were admitted to US hospitals for cataract extraction in 1984. The rate of rehospitalization for corneal edema or transplant within 4 years of intracapsular cataract extraction was 1.4%, almost twice the rate associated with extracapsular extraction (0.63%) or phacoemulsification (0.62%; P less than .0001). No significant difference in the rate of corneal transplantation was detected between those undergoing extracapsular cataract extraction and those undergoing phacoemulsification. Among patients who had intracapsular cataract extraction, those who underwent concurrent intraocular lens implantation surgery had a higher rate of rehospitalization for corneal edema or transplantation than those who did not (1.11% vs 0.86%; P = .0003). However, this difference is only manifest starting at about 3 years after surgery. Among patients who underwent extracapsular cataract extraction and phacoemulsification, however, those who underwent intraocular lens implantation during surgery had a lower rate of corneal edema or transplantation than those who did not (0.47% vs 0.74%; P less than .0001). This difference was seen almost immediately after surgery. Cataract surgery accompanied by anterior vitrectomy was associated with a threefold increase in the 4-year rate of corneal edema or transplantation compared with cataract surgery alone (2.42% vs 0.87%; P less than .0001).

Undertreatment of glaucoma among black Americans

BACKGROUND

Cross-sectional studies and those using national data sets estimate that glaucoma-related blindness is between six and eight times more common among black Americans than among whites. Community-based studies have found that glaucoma is four to six times more prevalent among blacks. It is not known why blacks with glaucoma are more likely to become blind than whites with glaucoma.

METHODS

To investigate the possibility that undertreatment of glaucoma is an important factor contributing to this higher rate of blindness, we studied the population-based rates of incisional and laser surgery for open-angle glaucoma among blacks and whites in a 5 percent random sample of Medicare claims for 1986 through 1988.

RESULTS

For all U.S. census divisions combined, the rate of surgery for glaucoma among black Medicare beneficiaries was 2.2 times higher than the rate among white beneficiaries (95 percent confidence interval, 2.1 to 2.3). We calculated an expected rate of treatment among blacks on the basis of the rate of treatment among whites and the assumption that glaucoma is four times more prevalent among blacks--a conservative estimate. The observed rate of glaucoma surgery among blacks was 45 percent lower than the expected rate we calculated, which may in part account for the excess rate of blindness among blacks. The magnitude of this difference in treatment rates varied from 29 percent in the Middle Atlantic states to 50 percent in the South Atlantic states.

CONCLUSIONS

Older black Americans are not receiving potentially sight-saving care for open-angle glaucoma at the same rate as older white Americans.

National outcomes of cataract extraction. Endophthalmitis following inpatient surgery

We analyzed the likelihood of rehospitalization for endophthalmitis in 338,141 Medicare beneficiaries over age 65 years who were admitted to US hospitals for cataract extraction in 1984. This cohort represents approximately one half of all persons who underwent cataract extraction under the Medicare program in 1984. Extracapsular extraction was performed in 195,587 (58%) of cases, intracapsular cataract extraction in 99,971 (30%), and phacoemulsification in 28,474 (8%). The risk of rehospitalization for endophthalmitis in the year following surgery was 0.17% for intracapsular cataract extraction compared with 0.12% for extracapsular extraction or phacoemulsification (P less than .002). The risk of endophthalmitis at 1 month was higher for intracapsular cataract extraction than for extracapsular extraction or phacoemulsification (0.11% vs 0.085%), although the difference did not reach statistical significance. Cataract surgery accompanied by anterior vitrectomy increased the 1-month risk of rehospitalization for endophthalmitis to 0.41%, more than a four-fold increase over that for cataract surgery alone (0.09%; P less than .05). The rates of endophthalmitis at 1 year were 0.58% and 0.13%, respectively, for cataract surgery with anterior vitrectomy and cataract surgery alone (P less than .0001). No significant differences in the rate of rehospitalization for endophthalmitis were observed based on the use of an intraocular lens, age, or race. Endophthalmitis within 1 year of surgery was 1.2 times more frequent in men than in women (0.16% vs 0.13%; P = .03). Overall, the likelihood of postoperative endophthalmitis from a national sample is consistent with case series previously reported.

National outcomes of cataract extraction. I. Retinal detachment after inpatient surgery

Rehospitalization for retinal detachment (RD) was studied in 338,141 Medicare beneficiaries older than 65 years of age who were undergoing inpatient cataract extraction in 1984. Extracapsular cataract extraction (ECCE) was performed in 60% of patients, intracapsular cataract extraction (ICCE) in 31%, and phacoemulsification in 9%. The risk of rehospitalization for RD within 4 years of ICCE was 1.55% over 1.5 times the risk associated with ECCE (0.9%). The risk of RD after phacoemulsification was 1.17%. Cataract surgery accompanied by anterior vitrectomy was associated with a 5.0%, likelihood of RD at 4 years, which is 4.5 times greater than that for cataract surgery alone (1.12%). White patients were 1.7 times more likely to be rehospitalized for RD than were black patients (1.15% versus 0.67%; P less than 0.001). In both races, younger patients were more likely to be rehospitalized for RD than were older patients (P less than 0.001). While the increased rate of RD after ICCE versus ECCE confirms previously held clinical beliefs, the increase in the risk following phacoemulsification (P less than 0.0001) has not been reported previously.

Mucosal immunity induced by enhance-potency inactivated and oral polio vaccines

Oral polio vaccine (OPV) is recommended for routine immunization in the United States in part because of its ability to induce intestinal and pharyngeal immunity to reinfection. Mucosal immunity produced by OPV and enhanced-potency inactivated polio vaccine (E-IPV) was compared by challenging vaccines with type 1 OPV. Fewer OPV (25%) than E-IPV (63%) vaccinees excreted OPV virus in stool after challenge. The mean stool virus titer was higher and the duration of shedding longer among E-IPV excreters. Only one E-IPV and three OPV vaccinees shed virus in the pharynx after challenge. Prechallenge serum neutralizing antibody levels were not statistically different among E-IPV vaccinees who did and did not shed virus; these levels were much higher than those of OPV vaccinees. Poliovirus-specific IgA levels in stool did not correlate with viral excretion. E-IPV was less effective than OPV in preventing and limiting intestinal infection, even though it induced higher postvaccination serum antibody levels.

Comparative evaluation of immunization with live attenuated and enhanced-potency inactivated trivalent poliovirus vaccines in childhood: systemic and local immune responses

Serum neutralizing, nasopharyngeal neutralizing, and IgA antibodies were determined in 123 infants immunized with one of four schedules containing live oral vaccine (OPV), inactivated vaccine (IPV), or combinations of the two trivalent poliovirus vaccines: OPV-OPV-OPV, IPV-IPV-IPV, IPV-OPV-OPV, or IPV-IPV-OPV. Nearly 100% of individuals formed serum neutralizing antibodies. The highest geometric mean titer (GMT) of antibody to polioviruses 1, 2, and 3 occurred in groups IPV-IPV-OPV, IPV-OPV-OPV, and IPV-IPV-IPV, respectively. Local neutralizing and IgA antibody responses were detected in 41%-88% and 75%-100%, respectively. Peak GMT of nasopharyngeal antibodies differed minimally between immunization groups. The data suggest that incorporation of at least one dose of IPV at the start of the immunization schedule tends to increase systemic as well as local antibody production.

The humoral immune response to type 1 oral poliovirus vaccine in children previously immunized with enhanced potency inactivated poliovirus vaccine or live oral poliovirus vaccine

Sixty-one children who had previously received three doses of enhanced potency inactivated poliovirus vaccine (epIPV) at 2, 4, and 18 months of age and 56 children who had previously received oral poliovirus vaccine (OPV) according to the same schedule were challenged with a single dose of monovalent, type 1 oral poliovirus vaccine (OPV1) between 19 and 52 months of age. Before the OPV1 challenge, the previously epIPV-immunized recipients had a geometric mean poliovirus type 1 microneutralization antibody titer (geometric mean titer [GMT]) of 11.1 IU, which was significantly higher than the prechallenge GMT of 2.2 IU among the children who had previously received OPV. Three weeks after the OPV1 challenge, the GMTs for the epIPV-immunized recipients and the OPV-immunized recipients were 35.3 IU and 5.1 IU, respectively. For the epIPV-immunized recipients, both the prechallenge GMT and the postchallenge GMT were dependent on the D antigen content of the vaccine that they had previously received. A fourfold or greater rise in poliovirus type 1 antibody occurred after the OPV1 challenge in 50.9% of the epIPV-immunized children and in 28.6% of the OPV-immunized children; this difference was statistically significant. For both groups, antibody boosts were inversely correlated with the pre-challenge serum antibody titer. However, the epIPV-immunized children consistently were more likely to boost than the OPV-immunized children at equivalent levels of prechallenge antibody. This experience indicated that OPV1 administration effectively raises the level of serum antibody in children previously immunized with three doses of epIPV, especially in children with lower levels of preexisting antibody. This booster response was superior to the booster response of children who received three doses of OPV.

Trends and patterns in place of death for Medicare enrollees

Two changes in the Medicare program in 1983 may have affected where aged persons die--the change from retrospective hospital reimbursement to the prospective payment system and passage of the Medicare hospice benefit. Patterns and trends in where people die--hospitals, other institutions such as nursing homes, decedents' homes, and other places--for persons 65 years of age or over from 1980 through 1986 are examined. The proportion of deaths in hospitals declined somewhat after implementation of prospective payment. The hospice benefit may have caused the shift among cancer patients away from hospital deaths toward deaths at home.

Serologic response to oral polio vaccine and enhanced-potency inactivated polio vaccines

In a randomized, controlled trial carried out from November 1980 to July 1983 involving 1,114 infants in Baltimore City and in Baltimore and Prince George's counties, Maryland, the serologic response to three doses of two enhanced-potency inactivated polio vaccines was compared with the response to three doses of oral polio vaccine. The mean ages at vaccination were 2.2, 4.7, and 19.9 months, respectively, for the three doses. Seroconversion after the first dose varied from 35% to 84%, and it was higher after oral polio vaccine than after either of the enhanced-potency inactivated polio vaccines for polioviruses types 2 and 3. Approximately two and one-half and 16 months after the second dose, almost all inactivated polio vaccine recipients had antibodies against all three virus types (98-100%). Fewer oral polio vaccine recipients had detectable antibodies to type 1 (89-92%) and to type 3 (96%). After three doses of vaccine, all children had antibodies against types 2 and 3. Approximately 1% of the inactivated polio vaccine recipients and 3% of the oral polio vaccine recipients lacked antibody to type 1. One or two doses of oral polio vaccine stimulated higher reciprocal geometric mean antibody titers against type 2 poliovirus than did the inactivated polio vaccine. For the other two types, the results were mixed. The third dose of inactivated polio vaccine produced significant increases in the reciprocal geometric mean titers against each of the three poliovirus types and resulted in significantly higher reciprocal geometric mean titers after three doses of vaccine for recipients of inactivated polio vaccine than for recipients of oral polio vaccine.

Physician knowledge, attitudes, and behavior related to reporting adverse drug events

Voluntary physician reporting of adverse drug events (ADEs) in their patients remains the single most important source of information on serious and rare ADEs. Yet, substantial underreporting exists and the factors producing it are unclear. We surveyed 3000 randomly chosen physicians by mailed questionnaire to determine their knowledge about the reporting system, attitudes toward reporting, and their past behavior in reporting the ADEs they had detected. Responses numbered 1121. Only 57% were aware of the Food and Drug Administration's reporting system. While 418 physicians had detected an ADE in their practices during the previous year, only 21 physicians reported these events directly to the Food and Drug Administration. The physicians appear to appreciate the safety issues involved in prescription drug use and view reporting as a professional obligation; however, the current reporting system is considered inconvenient.

Rationale for the sequential use of inactivated poliovirus vaccine and live attenuated poliovirus vaccine for routine poliomyelitis immunization in the United States

Despite the concerns mentioned in the last section, there are many reasons to believe that a polio immunization schedule that incorporates sequential doses of inactivated poliovirus vaccine and live attenuated poliovirus vaccine would provide both humoral and intestinal immunity to the fully immunized person that is at least as good, if not better, than the immunity achieved by the use of IPV or OPV alone. A substantial degree of protection should also extend to partially immunized and unimmunized preschool aged children in the community. Furthermore most of the cases of OPV-associated paralytic poliomyelitis could be prevented. Because the reasons for these beliefs are based on data from small studies and on inferences from related research, specific recommendations for a change from current polio immunization policy must depend on additional clinical research. Well-designed trials comparing several different options for sequencing both inactivated and live vaccines are needed, and these studies should focus carefully on both humoral and intestinal immunity conferred by the various vaccine schedules.

A comparison of the serologic responses to oral and injectable trivalent poliovirus vaccines

United States children two months of age were randomly assigned to two groups that received either the commercially available oral trivalent poliovirus vaccine ( OPV ) or an injectable (inactivated) trivalent poliovirus vaccine (IPV) with a confirmed minimum D-antigen content of 27, 3.5, and 29 units for poliovirus types 1, 2, and 3, respectively. Vaccine was given at two, four, and 18 months of age. Sera obtained from 439 children at two, four, and six months of age and from 85 children at 18 and 20 months of age were examined for neutralizing antibodies. The percentage of children with detectable antibodies and the reciprocal geometric mean titers were similar for both groups at two months of age for antibodies to all three poliovirus types. At 20 months of age, all children but one had detectable antibodies to all three poliovirus types. Significantly higher geometric mean titers against types 2 and 3 were noted at 20 months of age for the IPV group.

The epidemiology and control of measles in Yaoundé, Cameroun, 1968-1975

Surveillance data on measles in Yaoundé during the 8 years from 1968-1975 have been reviewed. Measles epidemics occurred in every year except 1969-1970, the period of the attach phase of the Smallpox Eradication and Measles Control Programme. Subsequent biennial mass measles immunisation campaigns and maintenance measles immunisation at the child health centre failed to interrupt epidemic transmission. 70-80% of cases were under 24 months of age. Annual outbreaks occurred during the first half of each year, but smaller numbers of cases continued throughout the year. The outbreaks came to an end despite 32-41% of 6 through 36 month old children remaining susceptible. The seasonality of measles was not simply related to the annual rainfall pattern. Rather it is hypothesised that measles seasonality depends on the movement of young children with their mothers during the annual agricultural cycles. Measles immunisation programmes must be adapted to local epidemiological and cultural conditions in order to interrupt transmission.

Simultaneous administration of live attenuated measles vaccine with DTP vaccine

Live attenuated measles vaccine was administered to Cameroonian children 12 to 39 months of age alone or with either diphtheria-tetanus toxoids or diphtheria and tetanus toxoids and pertussis (DTP) vaccine. Among children who were initially seronegative for measles hemagglutination inhibition antibodies, seroconversion rates and postvaccination geometric mean titers were similar in all groups. Pertussis antigen in the DTP vaccine was judged to be potent by laboratory potency testing and serologic response in recipients of the vaccine. Thus, the two vaccines may be administered simultaneously without compromising their immunogenicity. These results allow greater flexibility in planning individual or mass immunization schedules.

Evaluation of a mass measles immunization campaign in Yaoundé, Cameroun

A mass measles immunization campaign carried out in Yaoundé, Cameroun, has been evaluated. Sixty per cent of the children were immune to measles at the time of the campaign. Only 51% of the susceptible children received vaccine. This was caused by a lack of attendance at the vaccination centres and errors in the selection of children given vaccine. The vaccine administered was relatively ineffective: 40% seroconversion. Difficulties which probably contributed to the low seroconversion rate included sub-optimal vaccine titre, inadequate doses of vaccine, and the relatively long time of vaccine utilization under tropical temperatures. Overall, 83% of the vaccine given to the vaccinating team was wasted. Future immunization campaigns can be improved through better screening of the children, improved handling of the vaccine, the use of marker vaccines, and improved health education.