Vaccine Effectiveness Against Influenza A-Associated Hospitalization, Organ Failure, and Death: United States, 2022-2023

BACKGROUND

Influenza circulation during the 2022-2023 season in the United States largely returned to pre-coronavirus disease 2019 (COVID-19)-pandemic patterns and levels. Influenza A(H3N2) viruses were detected most frequently this season, predominately clade 3C.2a1b.2a, a close antigenic match to the vaccine strain.

METHODS

To understand effectiveness of the 2022-2023 influenza vaccine against influenza-associated hospitalization, organ failure, and death, a multicenter sentinel surveillance network in the United States prospectively enrolled adults hospitalized with acute respiratory illness between 1 October 2022, and 28 February 2023. Using the test-negative design, vaccine effectiveness (VE) estimates against influenza-associated hospitalization, organ failures, and death were measured by comparing the odds of current-season influenza vaccination in influenza-positive case-patients and influenza-negative, SARS-CoV-2-negative control-patients.

RESULTS

A total of 3707 patients, including 714 influenza cases (33% vaccinated) and 2993 influenza- and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-negative controls (49% vaccinated) were analyzed. VE against influenza-associated hospitalization was 37% (95% confidence interval [CI]: 27%-46%) and varied by age (18-64 years: 47% [30%-60%]; ≥65 years: 28% [10%-43%]), and virus (A[H3N2]: 29% [6%-46%], A[H1N1]: 47% [23%-64%]). VE against more severe influenza-associated outcomes included: 41% (29%-50%) against influenza with hypoxemia treated with supplemental oxygen; 65% (56%-72%) against influenza with respiratory, cardiovascular, or renal failure treated with organ support; and 66% (40%-81%) against influenza with respiratory failure treated with invasive mechanical ventilation.

CONCLUSIONS

During an early 2022-2023 influenza season with a well-matched influenza vaccine, vaccination was associated with reduced risk of influenza-associated hospitalization and organ failure.

The Impact of Environmental Benzene, Toluene, Ethylbenzene, and Xylene Exposure on Blood-Based DNA Methylation Profiles in Pregnant African American Women from Detroit

African American women in the United States have a high risk of adverse pregnancy outcomes. DNA methylation is a potential mechanism by which exposure to BTEX (benzene, toluene, ethylbenzene, and xylenes) may cause adverse pregnancy outcomes. Data are from the Maternal Stress Study, which recruited African American women in the second trimester of pregnancy from February 2009 to June 2010. DNA methylation was measured in archived DNA from venous blood collected in the second trimester. Trimester-specific exposure to airshed BTEX was estimated using maternal self-reported addresses and geospatial models of ambient air pollution developed as part of the Geospatial Determinants of Health Outcomes Consortium. Among the 64 women with exposure and outcome data available, 46 differentially methylated regions (DMRs) were associated with BTEX exposure (FDR adjusted p-value < 0.05) using a DMR-based epigenome-wide association study approach. Overall, 89% of DMRs consistently exhibited hypomethylation with increasing BTEX exposure. Biological pathway analysis identified 11 enriched pathways, with the top 3 involving gamma-aminobutyric acid receptor signaling, oxytocin in brain signaling, and the gustation pathway. These findings highlight the potential impact of BTEX on DNA methylation in pregnant women.

Development and validation of algorithms for identifying lines of therapy in multiple myeloma using real-world data

Aim: To validate algorithms based on electronic health data to identify composition of lines of therapy (LOT) in multiple myeloma (MM). Materials & methods: This study used available electronic health data for selected adults within Henry Ford Health (Michigan, USA) newly diagnosed with MM in 2006-2017. Algorithm performance in this population was verified via chart review. As with prior oncology studies, good performance was defined as positive predictive value (PPV) ≥75%. Results: Accuracy for identifying LOT1 (N = 133) was 85.0%. For the most frequent regimens, accuracy was 92.5-97.7%, PPV 80.6-93.8%, sensitivity 88.2-89.3% and specificity 94.3-99.1%. Algorithm performance decreased in subsequent LOTs, with decreasing sample sizes. Only 19.5% of patients received maintenance therapy during LOT1. Accuracy for identifying maintenance therapy was 85.7%; PPV for the most common maintenance therapy was 73.3%. Conclusion: Algorithms performed well in identifying LOT1 - especially more commonly used regimens - and slightly less well in identifying maintenance therapy therein.

Impact of Electronic Chronic Pain Questions on patient-reported outcomes and healthcare utilization, and attitudes toward eCPQ use among patients and physicians: prospective pragmatic study in a US general practice setting

Objective

The Electronic Chronic Pain Questions (eCPQ) has been developed to help healthcare providers systematically capture chronic pain data. This study evaluated the impact of using the eCPQ on patient-reported outcomes (PROs) and healthcare resource utilization (HCRU) in a primary care setting, and patient and physician perceptions regarding use of, and satisfaction with, the eCPQ.

Methods

This was a prospective pragmatic study conducted at the Internal Medicine clinic within the Henry Ford Health (HFH) Detroit campus between June 2017 and April 2020. Patients (aged ≥18 years) attending the clinic for chronic pain were allocated to an Intervention Group to complete the eCPQ in addition to regular care, or a control group to receive regular care only. The Patient Health Questionnaire-2 and a Patient Global Assessment were assessed at baseline, 6-months, and 12-months study visits. HCRU data were extracted from the HFH database. Telephone qualitative interviews were conducted with randomly selected patients and physicians who used the eCPQ.

Results

Two hundred patients were enrolled, 79 in each treatment group completed all 3 study visits. No significant differences (p > 0.05) were found in PROs and HCRU between the 2 groups. In qualitative interviews, physicians and patients reported the eCPQ as useful, and using the eCPQ improved patient-clinician interactions.

Conclusion

Adding the eCPQ to regular care for patients with chronic pain did not significantly impact the PROs assessed in this study. However, qualitative interviews suggested that the eCPQ was a well-accepted and potentially useful tool from a patient and physician perspective. By using the eCPQ, patients were better prepared when they attended a primary care visit for their chronic pain and the quality of patient-physician communication was increased.

HALF OF OLDER ADULTS HOSPITALIZED WITH COVID-19 EXPERIENCE SYMPTOMS ONE YEAR LATER

Older adults hospitalized with severe COVID-19 are at higher risk of experiencing serious in-hospital outcomes and long-term health consequences following discharge. Declines in health and functional ability post-hospitalization are important infection-related outcomes. This study’s aim was to examine functional recovery one year following COVID-19 hospitalization. Twenty-one adults ≥60 years of age hospitalized with confirmed COVID-19 infection between 3/2020–5/2020 in Southeast Michigan completed a survey 9–15 months post-discharge including items from the Fried Frailty score, Short Form 36 Physical Assessment, PROMIS Dyspnea Scale, and the World Health Organization Disability Assessment Schedule. Mean age at hospital admission was 69 (standard deviation 7). Half of participants (52%) indicated they had too little energy to do the things they wanted to do, 52% (n=11) indicated moderate to severe shortness of breath when walking up two flights of stairs, and 43% (n=9) indicated they were limited a lot in walking several blocks. Additionally, 57% (n=12) indicated they were severely or extremely emotionally affected by their health due to their COVID-19 infection. Results were similar in only those ≥70 years (n=7). Our survey indicates that half of patients hospitalized with severe COVID-19 from the first infection wave in Southeast Michigan are significantly affected up to a year or more after their initial infection, and may benefit from long-term outpatient care. More research is needed to inform development of effective treatments for the long-term emotional and physical impacts of severe COVID-19.

Vaccine-associated attenuation of subjective severity among outpatients with influenza

Influenza vaccines can mitigate illness severity, including reduced risk of ICU admission and death, in people with breakthrough infection. Less is known about vaccine attenuation of mild/moderate influenza illness. We compared subjective severity scores in vaccinated and unvaccinated persons with medically attended illness and laboratory-confirmed influenza. Participants were prospectively recruited when presenting for care at five US sites over nine seasons. Participants aged ≥ 16 years completed the EQ-5D-5L visual analog scale (VAS) at enrollment. After controlling for potential confounders in a multivariable model, including age and general health status, VAS scores were significantly higher among 2,830 vaccinated participants compared with 3,459 unvaccinated participants, indicating vaccinated participants felt better at the time of presentation for care. No differences in VAS scores were observed by the type of vaccine received among persons aged ≥ 65 years. Our findings suggest vaccine-associated attenuation of milder influenza illness is possible.

Epidemiology and outcomes in patients with anemia of CKD not on dialysis from a large US healthcare system database: a retrospective observational study

Background

Optimal management of anemia of chronic kidney disease (CKD) remains controversial. This retrospective study aimed to describe the epidemiology and selected clinical outcomes of anemia in patients with CKD in the US.

Methods

Data were extracted from Henry Ford Health System databases. Adults with stages 3a–5 CKD not on dialysis (estimated glomerular filtration rate < 60 mL/min/1.73m²) between January 1, 2013 and December 31, 2017 were identified. Patients on renal replacement therapy or with active cancer or bleeding were excluded. Patients were followed for ≥12 months until December 31, 2018. Outcomes included incidence rates per 100 person-years (PY) of anemia (hemoglobin < 10 g/dL), renal and major adverse cardiovascular events, and of bleeding and hospitalization outcomes. Adjusted Cox proportional hazards models identified factors associated with outcomes after 1 and 5 years.

Results

Among the study cohort (N = 50,701), prevalence of anemia at baseline was 23.0%. Treatments used by these patients included erythropoiesis-stimulating agents (4.1%), iron replacement (24.2%), and red blood cell transfusions (11.0%). Anemia incidence rates per 100 PY in patients without baseline anemia were 7.4 and 9.7 after 1 and 5 years, respectively. Baseline anemia was associated with increased risk of renal and major cardiovascular events, hospitalizations (all-cause and for bleeding), and transfusion requirements. Increasing CKD stage was associated with increased risk of incident anemia, renal and major adverse cardiovascular events, and hospitalizations.

Conclusions

Anemia was a prevalent condition associated with adverse renal, cardiovascular, and bleeding/hospitalization outcomes in US patients with CKD. Anemia treatment was infrequent.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02778-8.

Real-world impact of fremanezumab on migraine symptoms and resource utilization in the United States

Background

Fremanezumab, a fully humanized monoclonal antibody (IgG2Δa) that selectively targets calcitonin gene-related peptide (CGRP), is approved for migraine prevention in adults. Real-world data on the effectiveness of fremanezumab are limited. This retrospective, observational cohort study assessed patient-reported migraine symptoms, health care resource utilization (HCRU), and direct medical costs before and after fremanezumab treatment initiation.

Methods

Data were extracted from September 2018 through June 2020 from the Midwest component of EMRClaims+®, an integrated health services database containing > 20 million medical records from national commercial insurance claims, Medicare claims, and regional electronic medical records. Patients included in the cohort analysis were aged ≥ 18 years and were administered fremanezumab, with enrollment or treatment history for ≥ 6 months prior (pre-index) to initiating fremanezumab (index date) and ≥ 1 month after the index date (post-index), and without pregnancy or pregnancy-related encounters during the study period. Patient-reported headache frequency, migraine pain intensity (MPI), composite migraine symptoms, and HCRU were assessed pre-index and ≥ 1 month after fremanezumab initiation. Wilcoxon signed-rank tests were used to compare means of migraine symptoms and outcomes and HCRU before and after fremanezumab initiation.

Results

Overall, 172 patients were eligible for analysis. Of patients who self-reported (n = 129), 83.7% reported improvement in headache frequency or symptoms after fremanezumab treatment. Specifically, headache frequency decreased by 63% after fremanezumab initiation: mean (standard deviation) headache frequency was 22.24 (9.29) days per month pre-index versus 8.24 (7.42) days per month post-index (P < 0.0001). Mean MPI also decreased by 18% after fremanezumab initiation: MPI was 5.47 (3.19) pre-index versus 4.51 (3.34) post-index (P = 0.014). Mean emergency room (ER) visits per month decreased from 0.72 to 0.54 (P = 0.003), and mean outpatient visits per month decreased from 1.04 to 0.81 (P < 0.001). Mean hospitalizations per month decreased, but the results did not reach statistical significance (P = 0.095). Hospitalization and ER costs decreased, while outpatient costs increased, from pre-index to post-index, but differences were not statistically significant (P ≥ 0.232).

Conclusions

Significant reductions in headache frequency, MPI, and HCRU were observed after fremanezumab initiation in patients with migraine in a US real-world setting.

Agreement between state registry, health record, and self-report of influenza vaccination

BACKGROUND

Documentation of influenza vaccination, including the specific product received, is critical to estimate annual vaccine effectiveness (VE).

METHODS

We assessed performance of the Michigan Care Improvement Registry (MCIR) in defining influenza vaccination status relative to documentation by provider records or self-report among subjects enrolled in a study of influenza VE from 2011 through 2019.

RESULTS

The specificity and positive predictive value of MCIR were high; however, >10% of vaccinations were identified only by other sources each season. The proportion of records captured by MCIR increased from a low of 67% in 2013-2014 to a high of 89% in 2018-2019, largely driven by increased capture of vaccination among adults.

CONCLUSIONS

State vaccine registries, such as MCIR, are important tools for documenting influenza vaccination, including the specific product received. However, incomplete capture suggests that documentation from other sources and self-report should be used in combination with registries to reduce misclassification.

Ambient BTEX exposure and mid-pregnancy inflammatory biomarkers in pregnant African American women

Air pollution is associated with preterm birth (PTB), potentially via inflammation. We recently showed the mixture benzene, toluene, ethylbenzene, and xylene (BTEX) is associated with PTB. We examined if ambient BTEX exposure is associated with mid-pregnancy inflammation in a sample of 140 African-American women residing in Detroit, Michigan. The Geospatial Determinants of Health Outcomes Consortium study collected outdoor air pollution measurements in Detroit; these data were coupled with Michigan Air Sampling Network measurements to develop monthly BTEX concentration estimates at a spatial density of 300 m². First trimester and mid-pregnancy BTEX exposure estimates were assigned to maternal address. Mid-pregnancy (mean 21.3 ± 3.7 weeks gestation) inflammatory biomarkers (high-sensitivity C-reactive protein, interleukin [IL]-6, IL-10, IL-1β, and tumor necrosis factor-α) were measured with enzyme immunoassays. After covariate adjustment, for every 1-unit increase in first trimester BTEX, there was an expected mean increase in log-transformed IL-1β of 0.05 ± 0.02 units (P = 0.014) and an expected mean increase in log-transformed tumor necrosis factor-α of 0.07 ± 0.02 units (P = 0.006). Similarly, for every 1-unit increase in mid-pregnancy BTEX, there was a mean increase in log IL-1β of 0.06 ± 0.03 units (P = 0.027). There was no association of either first trimester or mid-pregnancy BTEX with high-sensitivity C-reactive protein, IL-10, or IL-6 (all P > 0.05). Ambient BTEX exposure is associated with inflammation in mid-pregnancy in African-American women. Future studies examining if inflammation mediates associations between BTEX exposure and PTB are needed.

Clinical Outcomes and Healthcare Resource Utilization in a Real-World Population Reflecting the DAPA-CKD Trial Participants

INTRODUCTION

The DAPA-CKD trial assessed dapagliflozin in patients with chronic kidney disease (CKD) with or without type 2 diabetes (T2D). To aid interpretation of results, renal and cardiovascular outcomes plus healthcare resource utilization (HCRU) and costs were assessed in a real-world population similar to that of DAPA-CKD.

METHODS

Henry Ford Health System (2006-2016) data were used to identify patients with CKD stages 2-4 [estimated glomerular filtration rate (eGFR) 25-75 ml/min/1.73 m2 at index and urine albumin-to-creatinine ratio (UACR) 0-5000 mg/g; n = 22,251]. Included patients had confirmatory eGFR ≥ 90 days post-index and no kidney transplant or progression to end-stage kidney disease during 12 months pre-index. The final population (n = 6557) was stratified by UACR (0-29, 30-199 and 200-5000 mg/g; the last comprising the DAPA-CKD-like cohort). Patients were followed for 5 years post-index.

RESULTS

Adverse clinical outcomes incidence increased with UACR and was highest for the DAPA-CKD-like cohort (UACR 200-5000 mg/g) versus lower UACR categories (0-29 mg/g and 30-199 mg/g): renal composite outcome (progression to CKD stage 5, dialysis, transplant, ≥ 50% sustained eGFR decline): 26.0% versus 2.2% and 5.8%; heart failure (HF): 36.1% versus 13.9% and 24.6%; myocardial infarction: 11.3% versus 4.7% and 7.4%; stroke: 8.9% versus 4.0% and 5.7%; and mortality: 18.5% versus 6.0% and 11.7%, respectively. Within the DAPA-CKD-like cohort, patients with versus without T2D or HF had a higher frequency of adverse outcomes. The DAPA-CKD-like cohort also had significantly higher annualized per-patient healthcare costs ($39,222/year versus $19,547/year), hospital admission rate (0.55/year versus 0.20/year) and outpatient specialist visit rate (7.55/year versus 6.74/year) versus the lowest UACR category.

CONCLUSION

The significant adverse renal and cardiovascular outcomes observed, particularly in the DAPA-CKD-like cohort, represent a substantial burden resulting in increased mortality, HCRU and costs, demonstrating the need for additional treatment options.

Assessment of vitamin B12 deficiency and B12 screening trends for patients on metformin: a retrospective cohort case review

Objectives

Our study investigated the use of vitamin B₁₂ testing in a large cohort of patients on metformin and assesses appropriateness and benefits of screening recommendations for vitamin B₁₂ deficiency.

Design

This retrospective cohort study included insured adult patients who had more than 1 year of metformin use between 1 January 2010 and 1 October 2016 and who filled at least two consecutive prescriptions of metformin to establish compliance. The comparison group was not exposed to metformin. Primary outcome was incidence of B₁₂ deficiency diagnosed in patients on metformin. Secondary outcome was occurrence of B₁₂ testing in the patient population on metformin. Records dated through 31 December 2018 were analysed.

Setting

Large hospital system consisting of inpatient and outpatient data base.

Participants

A diverse, adult, insured population of patients who had more than 1 year of metformin use between 1 January 2010 and 1 October 2016 and who filled at least two consecutive prescriptions of metformin.

Results

Of 13 489 patients on metformin, 6051 (44.9%) were tested for vitamin B₁₂ deficiency, of which 202 (3.3%) tested positive (vs 2.2% of comparisons). Average time to test was 990 days. Average time to test positive for deficiency was 1926 days. Factors associated with testing were linked to sex (female, 47.8%), older age (62.79% in patients over 80 years old), race (48.98% white) and causes of malabsorption (7.11%). Multivariable logistic regression showed older age as the only factor associated with vitamin B₁₂ deficiency, whereas African-American ethnicity approached significance as a protective factor.

Conclusions

Based on our study’s findings of vitamin B₁₂ deficiency in patients on metformin who are greater than 65 years old and have been using it for over 5 years, we recommend that physicians consider screening in these populations.

African Americans Demonstrate Significantly Lower Serum Alanine Aminotransferase Compared to Non-African Americans

BACKGROUND AND AIMS

Normal ranges of serum alanine aminotransferase (ALT) may vary by race. However, results from research studies are contradictory, and many of these studies have included only small numbers of African Americans. We investigated ALT values in patients without evidence of liver disease to determine whether normal ranges differ across race groups. We also evaluated whether a race- and sex-dependent upper limit of normal (ULN) would improve the ability of ALT to predict liver disease compared to the sex-dependent ULN currently in use.

METHODS

We identified ICD9 codes for liver conditions and diabetes in medical records from a sample of 6719 patients. Analysis of variance (ANOVA) was used to assess differences in ALT log-transformed distributions by race. Logistic regression was used to evaluate whether the addition of race to the current sex-dependent ULN improves the ability of ALT to predict liver disease (assessed by area under the receiver operating characteristic curve (AUROC)).

RESULTS

Among 1200 patients with BMI 18.5 < 25 and no evidence of liver disease or type 2 diabetes in their medical record, African Americans demonstrated significantly lower ALT (23.47 IU/L; 95% CL 22.87-24.10) than a combined group of Asian American/White/Other patients (25.71 IU/L; 95% CL 24.69-26.77). This difference remained across BMI categories. The race- and sex-dependent model demonstrated significantly better predictive ability than the sex-dependent model (AUROC = 66.6% versus 59.6%, respectively; p < 0.0001).

CONCLUSIONS

In a large, racially diverse sample, African Americans demonstrated significantly lower ALT compared to non-African Americans; this difference remained as BMI increased. The establishment of race-specific normal ranges for ALT could contribute to better screening and care for African American patients.

Prenatal airshed pollutants and preterm birth in an observational birth cohort study in Detroit, Michigan, USA

Detroit, Michigan, currently has the highest preterm birth (PTB) rate of large cities in the United States. Disproportionate exposure to ambient air pollutants, including particulate matter ≤2.5 μm (PM_2.5), PM ≤ 10 μm (PM₁₀), nitrogen dioxide (NO₂) and benzene, toluene, ethylbenzene, and xylenes (BTEX) may contribute to PTB. Our objective was to examine the association of airshed pollutants with PTB in Detroit, MI. The Geospatial Determinants of Health Outcomes Consortium (GeoDHOC) study collected air pollution measurements at 68 sites in Detroit in September 2008 and June 2009. GeoDHOC data were coupled with 2008-2010 Michigan Air Sampling Network measurements in Detroit to develop monthly ambient air pollution estimates at a spatial density of 300 m². Using delivery records from two urban hospitals, we established a retrospective birth cohort of births by Detroit women occurring from June 2008 to May 2010. Estimates of air pollutant exposure throughout pregnancy were assigned to maternal address at delivery. Our analytic sample size included 7961 births; 891 (11.2%) were PTB. After covariate adjustment, PM₁₀ (P = 0.003) and BTEX (P < 0.001), but not PM_2.5 (P = 0.376) or NO₂ (P = 0.582), were statistically significantly associated with PTB. In adjusted models, for every 5-unit increase in PM₁₀ there was a 1.21 times higher odds of PTB (95% CI 1.07, 1.38) and for every 5-unit increase in BTEX there was a 1.54 times higher odds of PTB (95% CI 1.25, 1.89). Consistent with previous studies, higher PM₁₀ was associated with PTB. We also found novel evidence that higher airshed BTEX is associated with PTB. Future studies confirming these associations and examining direct measures of exposure are needed.

Risk of chemotherapy-induced febrile neutropenia in patients with metastatic cancer not receiving granulocyte colony-stimulating factor prophylaxis in US clinical practice

Objectives

To evaluate the use of granulocyte colony-stimulating factor (G-CSF) prophylaxis in US patients with selected metastatic cancers and chemotherapy-induced febrile neutropenia (FN) incidence and associated outcomes among the subgroup who did not receive prophylaxis.

Methods

This retrospective cohort study was conducted at four US health systems and included adults with metastatic cancer (breast, colorectal, lung, non-Hodgkin lymphoma [NHL]) who received myelosuppressive chemotherapy (2009–2017). Patients were stratified by FN risk level based on risk factors and chemotherapy (low/unclassified risk, intermediate risk without any risk factors, intermediate risk with ≥ 1 risk factor [IR + 1], high risk [HR]). G-CSF use was evaluated among all patients stratified by FN risk, and FN/FN-related outcomes were evaluated among patients who did not receive first-cycle G-CSF prophylaxis.

Results

Among 1457 metastatic cancer patients, 20.5% and 28.1% were classified as HR and IR + 1, respectively. First-cycle G-CSF prophylaxis use was 48.5% among HR patients and 13.9% among IR + 1 patients. In the subgroup not receiving first-cycle G-CSF prophylaxis, FN incidence in cycle 1 was 7.8% for HR patients and 4.8% for IR + 1 patients; during the course, corresponding values were 16.9% and 15.9%. Most (> 90%) FN episodes required hospitalization, and mortality risk ranged from 7.1 to 26.9% across subgroups.

Conclusion

In this retrospective study, the majority of metastatic cancer chemotherapy patients for whom G-CSF prophylaxis is recommended did not receive it; FN incidence in this subgroup was notably high. Patients with elevated FN risk should be carefully identified and managed to ensure appropriate use of supportive care.

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05715-3) contains supplementary material, which is available to authorized users.

Add-on tiotropium versus step-up inhaled corticosteroid plus long-acting beta-2-agonist in real-world patients with asthma

Background: A step-up approach (increasing inhaled corticosteroid [ICS] dose and/or add-on treatment) is recommended for asthma that is uncontrolled despite ICS plus long-acting beta-2-agonist (LABA) combination treatment. Understanding the impact of different treatment options on health outcomes can help guide treatment decision-making. Objective: To compare the effectiveness of add-on tiotropium 1.25 µg (two puffs once daily) versus an increased ICS plus LABA dose in a real-world cohort of patients with asthma initiated on ICS plus LABA. Methods: De-identified data from patients ages ≥12 years and with asthma who were initiated on ICS plus LABA, and then had tiotropium added (Tio group; index date) or an ICS plus LABA dose increased (inc-ICS group; index date) were collected from two medical and pharmacy claims data bases (2014-2018). To account for population/group differences, propensity score matching was performed. The primary end point was the exacerbation risk after the index date. Secondary end points included exacerbation rates 6 and 12 months postindex, health-care resource utilization, costs, and short-acting beta-2-agonist (SABA) refills 12 months postindex. Results: Overall, 7857 patients (Tio group, 2619; inc-ICS group, 5238) were included. The exacerbation risk was 35% lower in the Tio group than in the inc-ICS group (hazard ratio 0.65 [95% confidence interval, 0.43-0.99]; p = 0.044). Exacerbation rates in the Tio group also were significantly lower within 6 and 12 months postindex (64% and 73%, respectively). All-cause and asthma-related emergency department (ED) visits were 47% and 74% lower, respectively (p < 0.0001 for both), and all-cause and asthma-related hospitalizations were 48% (p < 0.01) and 76% (p < 0.001) lower, respectively, in the Tio group. Also, significantly fewer patients in the Tio group versus the inc-ICS group required SABA refills (56% versus 67%, p < 0.0001). Conclusion: Add-on tiotropium significantly decreased the risk and rate of exacerbations, decreased all-cause and asthma-related ED visits and hospitalizations, and reduced SABA refills compared with increasing the ICS plus LABA dose. The findings supported the use of add-on tiotropium for patients with uncontrolled asthma taking ICS plus LABA.

Impact of opioid use on patients undergoing screening colonoscopy according to the quality of bowel preparation

Aims

Constipation associated with opioid therapy for chronic pain may negatively impact colonoscopy success. This retrospective, observational study using administrative data and electronic medical records evaluated the impact of opioid use on colonoscopy outcomes.

Methods and Results

Procedural codes were used to identify patients who had a screening colonoscopy at two Henry Ford Health System centers (January 2015–December 2016). All patients had completed a standard uniform bowel preparation protocol. Medication orders and filled prescriptions were used to identify patients with a history of opioid use during the 28 days preprocedure (exposed) and a matched random sample of presumptive opioid nonusers (unexposed). Electronic medical records were reviewed for colonoscopy procedure data and outcomes.

The exposed and unexposed groups included 964 and 1054 patients, respectively. Inadequate bowel preparation was significantly more common in the exposed versus unexposed group (18.5% vs 12.7%; P < 0.001). In the exposed and unexposed groups, 97.1 and 98.0% of colonoscopy procedures were completed, respectively (P = nonsignificant). Total procedure time was slightly increased for the exposed versus unexposed group (23.8 vs 22.5 min; P = 0.039). Polyp identification and cancer diagnosis were similar between groups. Prolonged sedation occurred in three patients in the exposed group and none in the unexposed group. Procedural complications were rare, but the incidence was significantly greater in the exposed versus unexposed group (1.3% vs 0.2%; P < 0.01).

Conclusions

Opioid exposure was associated with significant reductions in the quality of preprocedure bowel preparation and an increased risk of complications in patients undergoing colonoscopy.

P0696CHARACTERIZATION OF A DAPA-CKD-LIKE POPULATION USING A CONTEMPORARY US HEALTHCARE SYSTEM: COHORT CHARACTERISTICS AND CLINICAL OUTCOMES

Background and Aims

The Sodium Glucose Co-Transporter 2 inhibitor (SGLT-2i) class of drugs have demonstrated significant cardiorenal benefits in patients with type 2 diabetes (T2D), including reducing the composite renal outcome of significant eGFR decline, End Stage Kidney Disease (ESKD) or renal death in patients with T2D and preserved renal function and also in patients with overt Diabetic Kidney Disease. In addition, SGLT-2i have proven to have beneficial effects on cardiovascular (CV) outcomes in patients with heart failure with reduced ejection fraction (HFrEF) independent of glycaemic status. The DAPA-CKD Trial (A study to evaluate the effect of dapagliflozin on renal outcomes and CV mortality in patients with CKD) is the first SGLT-2i renal outcome trial to test the efficacy and safety of an SGLT-2i, dapagliflozin, in patients with diagnosed CKD with and without T2D.

In order to appropriately evaluate the future results and aid clinical interpretation of the DAPA-CKD trial, the present study assessed the renal and CV outcomes of a “DAPA-CKD-like population” (eGFR 25-75ml/min/1.73m2 and UACR 200-5000mg/g) in a contemporary US real healthcare system.

Method

Administrative data from the Henry Ford Health System was used to identify persons with CKD stages 2 through 4 between 2006 and 2016 based on eGFR lab reading (n=38,376). Exclusions included no confirmatory eGFR &gt; 90 days from index date, death within 30 days, history of renal transplant, and evidence of renal replacement therapy, or progression to CKD stage 5 during the baseline period (6 months pre or post index date). Within that cohort, 17,742 had eGFR (25-75ml/min/1.73m2) and 9,177 had a UACR (0-5000 mg/g) within 12 months of index date. Additional exclusions included type 1 diabetes (n=2,546), lupus nephritis (n=1) and polycystic kidney disease (n=20). Patients were followed through December 31st, 2018.

Results

Of the 6,557 patients that met the eligibility criteria and were included in the study cohort, the mean age was 62.9 years and 46.2% were male. The population was stratified by UACR (0-&lt;30, 30–199, 200–5,000mg/g). Across all outcomes assessed, the clinical outcomes were highest in the DAPA-CKD-like cohort (UACR 200-5000mg/g) (HF 36.1%; MI 11.3%, Stroke 8.9%; ESKD 18.6%; Mortality 18.5%; see Figure 1). The greatest increase was observed for renal outcomes particularly ESKD, increasing from 0.9% (UACR 0-&lt;30mg/g) to 3.4% (UACR 30-199mg/g) to 18.6% (UACR 200-5000mg/g).

Conclusion

In a contemporary US healthcare system, there remains significant adverse renal, CV and mortality outcomes among patients fitting the DAPA-CKD study inclusion criteria. These results highlight the unmet need existing for additional therapies to delay disease progression and improve patient outcomes and survival in this population.

P0788HEALTHCARE RESOURCE UTILIZATION AND COSTS IN A DAPA-CKD-LIKE POPULATION USING A CONTEMPORARY US HEALTHCARE COHORT

Background and Aims

Recent studies have shown an association between Sodium Glucose Co-Transporter 2 inhibitor (SGLT-2i) class of drugs and lower healthcare costs compared with other glucose lowering therapy, in type 2 diabetes (T2D) patients mainly as a result of reduced rates of cardiovascular and other T2D-associated outcomes. The DAPA-CKD Trial (A study to evaluate the effect of dapagliflozin on renal outcomes and CV mortality in patients with CKD) is the first SGLT-2i renal outcomes trial to test the efficacy and safety of an SGLT-2i, dapagliflozin, in patients with CKD with and without T2D. The objective of this study is to assess the healthcare resource utilization and cost in a “DAPA-CKD-like population” (eGFR 25-75ml/min/1.73m2 and UACR 200-5000mg/g) using a contemporary US healthcare system.

Method

Data from the Henry Ford Health System (HFHS) were used to identify persons with CKD stages 2 through 4 between 2006 and 2016 (based on eGFR labs) and patients were followed through 2018. Persons with no confirmatory eGFR &gt; 90 days from index date, death within 30 days, history of renal transplant, and evidence of renal replacement therapy, or progression to CKD stage 5 during the baseline period (6 months pre or post index date) were excluded.

Inpatient admissions, inpatient days, emergency department encounters, and ambulatory care encounters with primary care, specialty care and overall were assessed. Cumulative utilization was evaluated for all patients and evaluation based on the follow-up time. Patients were censored on date of death, last contact with the Health System or at December 31st, 2018. The utilization rates are the total observed utilization divided by follow-up time and reported as an annual rate. Billing records for all care with HFHS were used to estimate costs.

Results

6,557 patients (mean age 62.9 years, 46.2% male) met the eligibility criteria and are included in the study cohort. The population was stratified by UACR (0-&lt;30, 30–199, 200–5,000mg/g). The DAPA-CKD-like population (200-5000mg/g) was associated with significantly higher annualized per-patient healthcare costs, $39,222/yr (UACR 200-5000mg/g) vs. $19,547/yr (UACR &lt;30mg/g). This increased healthcare utilization was predominantly driven by increased acute care, including hospital admissions, inpatient days and emergency department visits. Persons in the highest UACR category were almost three times more likely to have a hospital admission compared to the lowest UACR (rates 0.55/year vs. 0.20/year, respectively; see Figure below). Persons in the lowest UACR category had more primary care visits per year compared with those with highest UACR (5.81 vs 5.21). In contrast, the highest number of outpatient specialist visits per year was reported for the DAPA-CKD-like population (7.55 vs. 6.74).

Conclusion

This analysis of a contemporary US healthcare system demonstrated that there exists a high disease burden in the DAPA-CKD-like population as seen by the substantial increase in healthcare resource utilization and costs compared to other cohorts of patients with a lower UACR. These results highlight the need for innovative therapies to improve patient outcomes in this population.

Tight versus standard blood pressure control on the incidence of myocardial infarction and stroke: an observational retrospective cohort study in the general ambulatory setting

Background

The 2017 American College of Cardiology and American Heart Association guideline defined hypertension as blood pressure (BP) ≥ 130/80 mmHg compared to the traditional definition of ≥140/90 mmHg. This change raised much controversy. We conducted this study to compare the impact of tight (TBPC) versus standard BP control (SBPC) on the incidence of myocardial infarction (MI) and stroke.

Methods

We retrospectively identified all hypertensive patients in an ambulatory setting based on the diagnostic code for 1 year at our institution who were classified by the range of BP across 3 years into 2 groups of TBPC (< 130 mmHg) and SBPC (130–139 mmHg). We compared the incidence of new MI and stroke between the 2 groups across a 2-year follow-up. Multivariate analysis was done to identify independent predictors for the incidence of new MI and stroke.

Results

Of 5640 study patients, the TBPC group showed significantly less incidence of stroke compared to the SBPC group (1.5% vs. 2.7%, P < 0.010). No differences were found in MI incidence between the 2 groups (0.6% vs. 0.8%, P = 0.476). Multivariate analysis showed that increased age independently increased the incidence of both MI (OR 1.518, 95% CI 1.038–2.219) and stroke (OR 1.876, 95% CI 1.474–2.387), and TBPC independently decreased the incidence of stroke (OR 0.583, 95% CI 0.374–0.910) but not of MI.

Conclusions

Our observational study suggests that TBPC may be beneficial in less stroke incidence compared to SBPC but it didn’t seem to affect the incidence of MI. Our study is limited by its retrospective design with potential confounders.

Effect of clinically significant thresholds of eosinophil elevation on health care resource use in asthma

BACKGROUND

Blood eosinophil counts correlate with exacerbations, but there is a lack of consensus on a clinically relevant definition of eosinophil count elevation.

OBJECTIVE

To analyze health care resource use among patients with elevated blood eosinophil counts defined at 150 cells/μL or greater and 300 cells/μL or greater.

METHODS

Data on patients who received a diagnosis of asthma between 2007 and 2016 were extracted from EMRClaims + database. Patients were defined as having elevated eosinophil counts if any test result during 3 months before follow-up found blood eosinophil count of 150 cells/μL or more or 300 cells/μL or more. Hospitalizations, emergency department visits, outpatient visits, and associated costs were compared. With logistic regression, likelihood of hospitalization was assessed in the presence of eosinophil elevation.

RESULTS

Among 3687 patients who met the study criteria, 1152 received a test within 3 months before the follow-up period, of whom 644 (56%) had elevated eosinophil counts of 150 cells/μL or greater and 322 (29%) had eosinophil counts of 300 cells/μL or greater. Overall, the mean (SD) number of hospitalizations for patients with elevated eosinophil counts vs the comparator was significantly greater (0.29 [0.92] vs 0.17 [0.57], P < .001 at ≥150 cells/μL and 0.30 [0.95] vs 0.18 [0.61] at ≥300 cells/μL, P = .001). The total mean cost was significantly greater for patients with elevated eosinophil counts (at ≥150 cells/μL: $10,262 vs $7149, P < .001 and at ≥300 cells/μL: $9966 vs $7468, P = .003).

CONCLUSION

Patients with asthma incurred greater health care resource use when their blood eosinophil counts were elevated at 150 cells/μL or greater and 300 cells/μL or greater as measured within 3 months of follow-up.

Abstract P2-08-24: Risk of chemotherapy-induced febrile neutropenia (FN) in patients with metastatic cancer of the breast or other sites not receiving colony-stimulating factor prophylaxis (CSF) in US clinical practice

Background: Clinical practice guidelines recommend CSF prophylaxis for patients receiving chemotherapy regimens with a high risk of FN (&gt;20%), and consideration of CSF prophylaxis for those receiving intermediate-risk regimens (10-20%) who have ≥1 risk factor for FN. The objective of this study was to estimate the use of CSF prophylaxis among patients with metastatic cancer, and the risk of FN among eligible patients not receiving it.

Methods: This retrospective study was conducted at four US health systems—Geisinger Health System (PA), Henry Ford Health System (MI), Kaiser Permanente Northwest (OR, WA), and Reliant Medical Group (MA). Study population comprised patients who received chemotherapy for metastatic solid tumors (breast, colon/rectum, lung) or non-Hodgkin’s lymphoma (NHL) from 2009-2017. For each eligible patient, data on chemotherapy course, cycles, and regimens, as well as the use of supportive care (CSF, antimicrobials) and FN episodes during the course, were collected via a standardized case report form using electronic data warehouses, cancer registries, and medical charts. Analyses were non-comparative and descriptive only.

Results: Study population totaled 1,457 patients (26% breast; 25% colon/rectum; 43% lung; 6% NHL). Nearly half of all patients received a chemotherapy regimen classified as either high-risk for FN (21%), or intermediate-risk for FN and had ≥1 FN risk factor (28%). Among patients receiving high-risk regimens, 51% did not receive primary prophylaxis with CSF (PP-CSF), and among those receiving an intermediate-risk regimen with ≥1 risk factor, 86% did not receive PP-CSF; among all remaining patients, 89% did not receive PP-CSF. Across these three subgroups of patients who did not receive PP-CSF (ie, high-risk regimen, intermediate-risk regimen with ≥1 risk factor, all others), FN risk during the course was 17%, 16%, and 14%, respectively. More than 90% of FN episodes required hospitalization, and FN-related mortality was 14%. Among metastatic breast cancer patients, 56% received a high-risk regimen (46%) or an intermediate-risk regimen and had ≥1 FN risk factor (10%); among this subset, 30% did not receive PP-CSF and their FN risk was 16%.

Conclusions: In this real-world evaluation of patients with metastatic cancer of the breast or other sites receiving chemotherapy at four large US health systems, over two-thirds of patients who were candidates for PP-CSF (per clinical guidelines) did not receive it. Among the subset of candidates who did not receive PP-CSF, FN risk was high (16%) and associated consequences were severe. Careful consideration should be given to identifying metastatic patients at elevated risk of FN—based on their chemotherapy regimen and risk factors—to ensure appropriate use of supportive care.

Table. FN risk factors and chemotherapy FN risk level among metastatic patientsBreast Cancer (N = 380)Colorectal Cancer (N = 360)Lung Cancer (N = 626)NHL (N = 91)All (N = 1,457)FN Risk FactorsAge ≥65y, %20.821.137.240.729.2Prior chemotherapy or radiation therapy, %39.234.248.445.142.3Prior neutropenia, %1.82.22.69.92.7Bone marrow involvement, %27.12.830.024.222.2Recent surgery, %40.042.216.914.329.0Liver dysfunction (bilirubin &gt;2.0), %0.81.40.50.00.8Renal dysfunction (creatinine clearance &lt;50), %45.362.259.365.956.8Chemotherapy FN Risk Level, %High45.80.017.417.620.5Intermediate10.554.726.450.530.7Low8.922.541.20.025.6Unclassified34.722.815.031.923.1

Citation Format: Derek Weycker, Amanda Silvia, Ahuva Hanau, Lois Lamerato, Kathryn Richert-Boe, Manpreet Kaur, Neel Shah, Mark Hatfield, Gary H Lyman. Risk of chemotherapy-induced febrile neutropenia (FN) in patients with metastatic cancer of the breast or other sites not receiving colony-stimulating factor prophylaxis (CSF) in US clinical practice [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-08-24.

Cardiovascular comorbidities in a United States patient population with hemophilia A: A comprehensive chart review

PURPOSE

Previous retrospective claims database analyses reported increased prevalence and earlier onset of cardiovascular comorbidities in patients with versus without hemophilia A. A comprehensive chart review was designed to further investigate previous findings.

METHODS

This retrospective chart review study was conducted at Henry Ford Health System (Detroit, MI, USA). Baseline demographics, bleeding events, treatment parameters, coexisting diseases, hemophilia-associated events, Charlson Comorbidity Index score, and prevalence of 12 cardiovascular risk factors and associated diseases were compared between hemophilia A and control cohorts. P values from a chi-square test for categorical variables and a t test for continuous variables were calculated. Because of small sample sizes (N = 0-90, most <50), statistical differences between cohorts were also assessed using absolute standardized difference.

RESULTS

Both groups were well matched by age, race, healthcare payer, and study year. The Charlson Comorbidity Index score was similar between groups. Prevalence of bleeds, hepatitis B and C, and HIV/AIDS was higher in the hemophilia cohort. Hemophilia A severity was severe, moderate, mild, or unknown in 52.7%, 10.8%, 10.8%, and 25.7% of patients, respectively. Prevalence of 12 cardiovascular risk factors and diseases was numerically higher in the control cohort, but differences were statistically significant (P ≤ 0.05) only for diabetes and hyperlipidemia. Meaningful statistical differences using standardized differences were not reached for venous and arterial thrombosis and atrial fibrillation.

CONCLUSIONS

This retrospective chart review did not confirm statistically significant differences in cardiovascular comorbidities and their earlier onset in hemophilia A versus controls. Results suggest numerically higher comorbidities in controls.

Diabetes mellitus and hyperglycemia control on the risk of colorectal adenomatous polyps: a retrospective cohort study

Background

Colorectal cancer (CRC) develops from colorectal adenomatous polyps. This study is to determine if diabetes mellitus (DM), its treatment, and hemoglobin A1c (HbA1c) level are associated with increased risk of colorectal adenomatous polyps.

Methods

This was a retrospective cohort study that included patients who had at least one colonoscopy and were continuously enrolled in a single managed care organization during a 10-year period (2002–2012). Of these patients (N = 11,933), 1800 were randomly selected for chart review to examine the details of colonoscopy and pathology findings and to confirm the diagnosis of DM. Multivariable logistic regression analyses were performed to assess the associations between DM, its treatment, HbA1c level and adenomatous polyps (our main outcome).

Results

Among the total of 11,933 patients with a mean (standard deviation) age of 56 (± 8.8) years, 2306 (19.3%) had DM and 75 (0.6%) had CRC. Among the 1800 under chart review, 445 (24.7%) had DM, 11 (0.6%) had CRC and 537 (29.8%) had adenomatous polyps. In bivariate analysis, patients with DM had 1.45 odds of developing adenomatous polyps compared to those without DM. This effect was attenuated (odds ratio = 1.25, 95% CI: 0.96–1.62, p = 0.09) after adjusting for confounders such as age, gender, race/ethnicity, and body mass index. There was no significant association between type or duration of DM treatment or HbA1c level and adenomatous polyps.

Conclusions

Our study confirmed the known increased risk of adenomatous polyps with advancing age, male gender, Hispanic race/ethnicity and higher body mass index. Although it suggested an association between DM and adenomatous polyps, a statistically significant association was not observed after controlling for other potential confounders. Further studies with a larger sample size are needed to further elucidate this relationship.

Severe morbidity among hospitalised adults with acute influenza and other respiratory infections: 2014-2015 and 2015-2016

Our objective was to identify predictors of severe acute respiratory infection in hospitalised patients and understand the impact of vaccination and neuraminidase inhibitor administration on severe influenza. We analysed data from a study evaluating influenza vaccine effectiveness in two Michigan hospitals during the 2014-2015 and 2015-2016 influenza seasons. Adults admitted to the hospital with an acute respiratory infection were eligible. Through patient interview and medical record review, we evaluated potential risk factors for severe disease, defined as ICU admission, 30-day readmission, and hospital length of stay (LOS). Two hundred sixteen of 1119 participants had PCR-confirmed influenza. Frailty score, Charlson score and tertile of prior-year healthcare visits were associated with LOS. Charlson score >2 (OR 1.5 (1.0-2.3)) was associated with ICU admission. Highest tertile of prior-year visits (OR 0.3 (0.2-0.7)) was associated with decreased ICU admission. Increasing tertile of visits (OR 1.5 (1.2-1.8)) was associated with 30-day readmission. Frailty and prior-year healthcare visits were associated with 30-day readmission among influenza-positive participants. Neuraminidase inhibitors were associated with decreased LOS among vaccinated participants with influenza A (HR 1.6 (1.0-2.4)). Overall, frailty and lack of prior-year healthcare visits were predictors of disease severity. Neuraminidase inhibitors were associated with reduced severity among vaccine recipients.

Comparative evaluation of treatment patterns and healthcare utilization of newly-diagnosed rheumatoid arthritis patients by anti-cyclic citrullinated peptide antibody status

BACKGROUND

Anti-cyclic citrullinated peptide (CCP) antibody positivity is an established diagnostic factor for severe disease activity and joint damage and a prognostic factor for aggressive disease in rheumatoid arthritis (RA).

OBJECTIVE

To compare RA-related treatment, healthcare utilization, and joint erosion between anti-CCP-positive and anti-CCP-negative RA patients.

METHODS

Newly-diagnosed RA patients were identified from the Henry Ford Health System database between January 1, 2009 and December 31, 2014; the date of the first RA diagnosis within the study period was the index date. Baseline anti-CCP test was used to categorize patients as anti-CCP-positive or anti-CCP-negative, and outcomes were evaluated in the 6 months post-index.

RESULTS

There were 217 anti-CCP-positive and 191 anti-CCP-negative RA patients included in the study. A higher proportion of anti-CCP-positive patients were initiated on RA treatment than anti-CCP-negative patients (70.5% vs 23.0%; p < .0001). More anti-CCP-positive patients received methotrexate (73.2% vs 56.8%; p = .0374), while more anti-CCP-negative patients received hydroxychloroquine (31.8% vs 13.1%; p = .0037) in first-line therapy. A higher proportion of anti-CCP-negative patients were tested for rheumatoid factor (RF) and erythrocyte sedimentation rate (ESR). Of those tested, there were more positive test results in the anti-CCP-positive cohort compared to the anti-CCP-negative cohort (RF: 84.4% vs 18.2%, p < .0001; C-reactive protein [CRP]: 69.7% vs 48.3%, p = .0008; and ESR: 89.5% vs 53.9%, p < .0001). Outpatient utilization predominated, with more anti-CCP-positive patients having any outpatient physician office visit (96.3% vs 77.5%, p < .0001) and a higher mean number of visits (5.3 vs 2.5, p < .0001) than anti-CCP-negative patients. Among anti-CCP-positive (n = 113) and anti-CCP-negative (n = 58) patients with imaging results, more anti-CCP-positive patients had joint erosion compared to anti-CCP-negative patients (18.6% vs 8.6%; p = .0858); however, statistical significance was not reached.

CONCLUSION

RA patients with positive anti-CCP antibodies had higher degrees of inflammation and disease activity as indicated by laboratory results, which likely contributed to their higher rates of healthcare utilization, joint erosion, and proportions of RA treatment.

Influenza Vaccination and Treatment with Antiviral Agents Among Hospitalized Adults in the 2014–2015 and 2015–2016 Influenza Seasons

Background

Vaccination and treatment with neuraminidase inhibitors can reduce incidence and severity of influenza. Observational studies suggest antiviral treatment reduces influenza symptom duration and severe outcomes among hospitalized patients. The interaction of the effects of vaccination and antiviral treatment against severe influenza has not been established.

Methods

We used data from a test-negative influenza vaccine effectiveness study. The parent study enrolled adults admitted to two hospitals in Michigan with an acute respiratory illness of ≤10 days duration during the 2014–2015 and 2015–2016 influenza seasons. Respiratory swabs from enrolled patients were tested for influenza by RT-PCR; influenza-positive individuals were included in this analysis. We evaluated predictors of vaccination and antiviral treatment using logistic regression. We also assessed the association between antiviral treatment and hospital length of stay (LOS) using linear regression models stratified by vaccination status.

Results

We included 200 individuals in the analysis; 103 (51.5%) were vaccinated and 135 (67.5%) were treated with antivirals. Significant predictors of vaccination included age ≥65, white race, a Charlson comorbidity index (CCI) score ≥3, study site, and increased past-year health care visits. Antiviral treatment varied by study site and was more common in the 2015–2016 season and among those aged 18–49. Vaccination was not associated with antiviral treatment or with time from illness onset to treatment. Antiviral treatment was associated with reduced LOS (percent change in LOS: −23.6% (−39.2%, −4.1%), P = 0.02) among vaccinated participants but not among unvaccinated participants (21.1% (−10.9%, 64.8%), P = 0.22) after adjustment for sex, age, influenza subtype, site, CCI, frailty, and past-year health care contacts. When an interaction term was used in lieu of stratification the interaction was significant (P = 0.01). This difference in antiviral effectiveness by vaccination status held across age groups, but was most dramatic for those aged 18–49.

Conclusion

Vaccinated individuals were more likely than unvaccinated individuals to benefit from antiviral treatment. This finding warrants confirmation in other populations.

Disclosures

A. S. Monto, sanofi pasteur: Grant Investigator, Research grant. Novartis: Consultant, Consulting fee. Protein Sciences: Consultant, Consulting fee. E. T. Martin, Pfizer: Scientific Advisor, Research grant. Merck: Scientific Advisor, Research grant. Multiparty Group For Advice on Science: Scientific Advisor, Research grant.

Impact of Tablet Burden and Antiretroviral Therapy (ART) Choice on Virologic Outcomes in Treatment Naive HIV+ Individuals Attending an Inner City Clinic

Background

The durability and effectiveness of single tablet regimens (STR) in treating ART naïve patients in real world, inner city settings, has not been well established.

Methods

Data was abstracted from administrative/medical records at Henry Ford Health System, serving metropolitan Detroit, for HIV+ patients initiating ART (1/1/2007–9/30/2015), who were enrolled in the Health Alliance Plan (HAP) or had ≥1 clinician contact per year and ≥1 viral load (VL)/CD4 test result ≤90 days prior to ART initiation. Patients were followed from initiation to first of: change in ART, death, HAP disenrollment, study end (03/31/2016), or lost to follow-up. Cox regression estimated impact of tablet burden on ART regimen duration, achievement of viral suppression (VS) and viral failure—(VF) failure to suppress plasma HIV RNA to <50 copies/mL or rebound after VS.

Results

Among 390 eligible patients, 79% were male, 74% African-American. Median (IQR) age was 37 years (27–47), 49% MSM and 22% presented with AIDS. The majority (65%) initiated on an STR; 35% on multiple tablet regimens (MTR). The majority of STR initiators (63%) began with EFV/FTC/TDF; 24% with EVG/c/FTC/TDF; and 8% with DTG/ABC/3TC. The most frequent MTR were DRV+RTV+TDF/FTC (26%) and ATV+RTV+TDF/FTC (20%). Median (IQR) log10 VL at baseline was 4.8 (4.3–5.2) in STR; 4.8 (4.4–5.4) in MTR cohorts. Median CD4 cells/µL (IQR) was 277 (115–407) in STR; 231 (37–371) in MTR. VL suppression occurred in 81% (85% STR, 74% MTR, P < 0.01) of patients and in 91% of INSTI regimens (91% STR, 90% MTR, P = 0.757).VF occurred in 19% (15% STR, 25% MTR, P = 0.015) and in 10% of INSTI regimens (9% STR, 13% MTR, 
P = 0.459). Resistance occurred in 15% of VF patients, predominantly with NNRTI mutations. A total of 22% of STR and 60% of MTR initiators experienced a change in their initial ART regimen (P < 0.0001). Cox model results suggest STR initiators were 59% less likely to experience regimen change (P < 0.0001), 46% less likely to experience VF (P < 0.05) and 30% more likely to achieve viral suppression (P < 0.05) compared with MTR initiators.

Conclusion

Inner city, HIV treatment naïve patients, initiating ART with a STR are significantly more likely to achieve viral suppression and less likely to experience a change in ART regimen.

Disclosures

B. Tidwell, ViiV Healthcare: Research Contractor, Research support; L. Lamerato, ViiV Healthcare: Collaborator, Research support; S. Zelt, ViiV Healthcare: Employee and Shareholder, Salary and Stock; R. D’Amico, ViiV Healthcare: Employee and Shareholder, Salary and Stock; K. Schulman, ViiV Healthcare: Research Contractor, Research support

Association Between Complementary and Alternative Medicine Use and Breast Cancer Chemotherapy Initiation: The Breast Cancer Quality of Care (BQUAL) Study

IMPORTANCE

Not all women initiate clinically indicated breast cancer adjuvant treatment. It is important for clinicians to identify women at risk for noninitiation.

OBJECTIVE

To determine whether complementary and alternative medicine (CAM) use is associated with decreased breast cancer chemotherapy initiation.

DESIGN, SETTING, AND PARTICIPANTS

In this multisite prospective cohort study (the Breast Cancer Quality of Care [BQUAL] study) designed to examine predictors of breast cancer treatment initiation and adherence, 685 women younger than 70 years with nonmetastatic invasive breast cancer were recruited from Columbia University Medical Center, Kaiser Permanente Northern California, and Henry Ford Health System and enrolled between May 2006 and July 31, 2010. Overall, 306 patients (45%) were clinically indicated to receive chemotherapy per National Comprehensive Cancer Network guidelines. Participants were followed for up to 12 months.

EXPOSURES

Baseline interviews assessed current use of 5 CAM modalities (vitamins and/or minerals, herbs and/or botanicals, other natural products, mind-body self-practice, mind-body practitioner-based practice). CAM use definitions included any use, dietary supplement use, mind-body use, and a CAM index summing the 5 modalities.

MAIN OUTCOMES AND MEASURES

Chemotherapy initiation was assessed via self-report up to 12 months after baseline. Multivariable logistic regression models examined a priori hypotheses testing whether CAM use was associated with chemotherapy initiation, adjusting for demographic and clinical covariates, and delineating groups by age and chemotherapy indication.

RESULTS

A cohort of 685 women younger than 70 years (mean age, 59 years; median age, 59 years) with nonmetastatic invasive breast cancer were recruited and followed for up to 12 months to examine predictors of breast cancer treatment initiation. Baseline CAM use was reported by 598 women (87%). Chemotherapy was initiated by 272 women (89%) for whom chemotherapy was indicated, compared with 135 women (36%) for whom chemotherapy was discretionary. Among women for whom chemotherapy was indicated, dietary supplement users and women with high CAM index scores were less likely than nonusers to initiate chemotherapy (odds ratio [OR], 0.16; 95% CI, 0.03-0.51; and OR per unit, 0.64; 95% CI, 0.46-0.87, respectively). Use of mind-body practices was not related to chemotherapy initiation (OR, 1.45; 95% CI, 0.57-3.59). There was no association between CAM use and chemotherapy initiation among women for whom chemotherapy was discretionary.

CONCLUSIONS AND RELEVANCE

CAM use was high among patients with early-stage breast cancer enrolled in a multisite prospective cohort study. Current dietary supplement use and higher number of CAM modalities used but not mind-body practices were associated with decreased initiation of clinically indicated chemotherapy. Oncologists should consider discussing CAM with their patients during the chemotherapy decision-making process.

The Real-World Utilization Pattern of Increased Utilization of Advanced Topical Adjunctive Hemostats in a Vertically Integrated Healthcare System

Hemostasis products, such as SURGICEL®, have been increasingly used across a wide variety of surgical procedures to mitigate bleeding-related risks and complications. This retrospective observational study described the utilization pattern of the SURGICEL® family of oxidized regenerated cellulose products (SURGICEL® ORIGINAL, SURGICEL® FIBRILLAR™, SURGICEL SNoW®) in a large, vertically integrated healthcare system, by utilizing electronic medical records (EMR) extracted from August 2013 through June 2015 at Henry Ford Health System (HFHS). Descriptive measurements were compared between SURGICEL® ORIGINAL and advanced SURGICEL® products (SURGICEL® FIBRILLAR™ and SURGICEL SNoW®) for pooled common surgical procedures. Among 1471 patients, 450 received SURGICEL® ORIGINAL, and 1021 received advanced SURGICEL® products. A significantly greater proportion of patients given advanced SURGICEL® products had comorbidities (91.0% vs 85.6%, p=.0024), prior bleeding conditions (49.9% vs 30.9%, p<.0001), and prior use of anticoagulants (27.7% vs 5.3%, p<.0001). Advanced SURGICEL® products were more likely to be used in coronary artery bypass grafting (13.7% vs 1.6%, p<.0001). Among a sub-set of 1420 patients with complete package size information (988 Advanced and 432 ORIGINAL), significantly fewer mean normalized units of Advanced SURGICEL® were used per patient case (3.9 vs 5.5, p<.0001). Despite Advanced SURGICEL® products being utilized in higher risk bleeding situations compared to cases where SURGICEL® ORIGINAL was utilized, fewer overall normalized units of Advanced SURGICEL® were required per patient case. Further research is needed to investigate the implications of topical hemostat use in continuous oozing bleeding situations on outcomes, hospital costs, and resources.

"You need to be an advocate for yourself": Factors associated with decision-making regarding influenza and pneumococcal vaccine use among US older adults from within a large metropolitan health system

In the United States, influenza and pneumonia account significantly to emergency room use and hospitalization of adults >65 y. The Centers for Disease Control and Prevention recommends use of the annual influenza vaccine and 2 pneumococcal vaccines for older adults to decrease risks of morbidity and mortality. However, actual vaccine up-take is estimated at 61.3% for pneumococcal vaccines and 65% for influenza vaccine in the 2013-2014 season. Vaccine up-take is affected by multiple socio-cultural and economic factors including general healthcare access and utilization, social networks and norms, communication with health providers and health information sources, as well as perceptions related to vaccines and targeted diseases. In this study, 8 focus group discussions (total N = 48) were conducted with adults 65+ years living in urban and suburban communities in the Detroit Metropolitan Area. The research objective was to increase understanding of barriers and facilitators to vaccine up-take in this age cohort within the context of general healthcare availability and accessibility, social networks, information sources, and personal perceptions of diseases and vaccines. The data suggest the need to integrate broader health care service experiences, concepts of knowledge of one's own well-being and vulnerabilities, and self-advocacy as factors associated with older adults' vaccine-use decisions. These data also support recognition of multiple levels of vaccine acceptance which can be disease specific. Implications include potential for increasing vaccine up-take through general improvement in health care delivery and services, as well as specific vaccine-focused patient and provider education programs.

Psychosocial factors related to non-persistence with adjuvant endocrine therapy among women with breast cancer: the Breast Cancer Quality of Care Study (BQUAL)

Non-adherence to adjuvant endocrine therapy (ET) for breast cancer (BC) is common. Our goal was to determine the associations between psychosocial factors and ET non-persistence. We recruited women with BC receiving care in an integrated healthcare system between 2006 and 2010. Using a subset of patients treated with ET, we investigated factors related to ET non-persistence (discontinuation) based on pharmacy records (≥90 days gap). Serial interviews were conducted at baseline and every 6 months. The Functional Assessment of Cancer Therapy (FACT), Medical Outcomes Survey, Treatment Satisfaction Questionnaire (TSQM), Impact of Events Scale (IES), Interpersonal Processes of Care measure, and Decision-making beliefs and concerns were measured. Multivariate models assessed factors associated with non-persistence. Of the 523 women in our final cohort who initiated ET and had a subsequent evaluation, 94 (18 %) were non-persistent over a 2-year follow-up. The cohort was primarily white (74.4 %), stage 1 (60.6 %), and on an aromatase inhibitor (68.1 %). Women in the highest income category had a lower odds of being non-persistent (OR 0.43, 95 % CI 0.23-0.81). Quality of life and attitudes toward ET at baseline were associated with non-persistence. At follow-up, the FACT, TSQM, and IES were associated with non-persistence (p < 0.001). Most women continued ET. Women who reported a better attitude toward ET, better quality of life, and more treatment satisfaction, were less likely to be non-persistent and those who reported intrusive/avoidant thoughts were more likely to be non-persistent. Interventions to enhance the psychosocial well-being of patients should be evaluated to increase adherence.

Abstract PD4-05: Complementary and alternative medicine use and breast cancer chemotherapy initiation: The BQUAL study

PURPOSE: Adjuvant therapy is associated with improved survival for women with breast cancer, but not all women who could benefit initiate treatment. Women's belief systems are related to treatment initiation. It has been hypothesized that complementary and alternative (CAM) use is associated with decreased initiation of standard oncology treatments because patients may be exploring alternative treatment approaches. However, there are limited data on the association between CAM use and cancer treatment initiation. We examined the association between CAM use and initiation of adjuvant breast cancer chemotherapy in a prospective cohort of early stage breast cancer patients.

PATIENTS AND METHODS: Subjects participated in a multi-center prospective cohort study of women with early stage invasive breast cancer (n=1,156). National Comprehensive Cancer Network guidelines were used to define groups based on whether chemotherapy was indicated. Three subgroups were created: chemotherapy indicated for subjects &lt;70 years, chemotherapy discretionary for subjects &lt;70 years, and chemotherapy discretionary for subjects ≥70 years. CAM use was assessed based upon self-reported use of 5 CAM modalities, including vitamin/mineral supplements, herbal supplements, other over-the-counter natural products, mind-body based approaches, and body/energy-based treatments. Psychosocial factors potentially related to chemotherapy initiation were assessed. Multivariable logistic regression models evaluated the associations between CAM use and chemotherapy initiation, adjusted for demographic, clinical and psychosocial factors.

RESULTS: Current CAM use was reported by 87% of women and 38% reporting current use of ≥3 modalities. The most commonly used CAM modalities were mind body therapies (63%) and other natural products (41%). In bivariate analyses, among women &lt;70 years where chemotherapy was indicated, women who reported current use of vitamins/minerals or current use of all 5 CAM modalities were less likely to initiate chemotherapy compared to non-users (P&lt;.0001), but this was not observed among women for whom chemotherapy was discretionary. Psychosocial factors were also associated with high levels of current CAM use in this group, including higher expectations of adverse effects from chemotherapy, more concerns about the physical effects of chemotherapy, lower beliefs in the benefits of chemotherapy, and lower positive decision balance while making chemotherapy decisions (all P&lt;.05). Among women age &lt;70 years for whom chemotherapy was indicated, 89% initiated treatment, and current use of all 5 CAM modalities was inversely associated with initiation in multivariable analyses adjusted for demographic and clinical factors (OR=0.08, CI: 0.02-0.32). The association remained after separately adjusting for psychosocial factors (all P&lt;.05), except for positive decision balance, which was no longer statistically significant.

CONCLUSIONS: High use of CAM was associated with decreased chemotherapy initiation among women with breast cancer for whom chemotherapy was indicated. It is important for oncologists to discuss CAM use with their patients, especially since high CAM use is associated with negative expectations and beliefs about chemotherapy.

Citation Format: Greenlee H, Neugut AI, Falci L, Hillyer GC, Buono D, Roh JM, Ergas IJ, Kwan ML, Lee M, Tsai WY, Shi Z, Lamerato L, Mandelblatt JS, Kushi LH, Hershman DL. Complementary and alternative medicine use and breast cancer chemotherapy initiation: The BQUAL study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD4-05.

All-Cause Mortality and Progression Risks to Hepatic Decompensation and Hepatocellular Carcinoma in Patients Infected With Hepatitis C Virus

BACKGROUND

A key question in care of patients with chronic hepatitis C virus (HCV) infection is beginning treatment immediately vs delaying treatment. Risks of mortality and disease progression in "real world" settings are important to assess the implications of delaying HCV treatment.

METHODS

This was a cohort study of HCV patients identified from 4 integrated health systems in the United States who had liver biopsies during 2001-2012. The probabilities of death and progression to hepatocellular carcinoma, hepatic decompensation (hepatic encephalopathy, esophageal varices, ascites, or portal hypertension) or liver transplant were estimated over 1, 2, or 5 years by fibrosis stage (Metavir F0-F4) determined by biopsy at beginning of observation.

RESULTS

Among 2799 HCV-monoinfected patients who had a qualifying liver biopsy, the mean age at the time of biopsy was 50.7 years. The majority were male (58.9%) and non-Hispanic white (66.9%). Over a mean observation of 5.0 years, 261 (9.3%) patients died and 34 (1.2%) received liver transplants. At 5 years after biopsy, the estimated risk of progression to hepatic decompensation or hepatocellular carcinoma was 37.2% in stage F4, 19.6% in F3, 4.7% in F2, and 2.3% in F0-F1 patients. Baseline biopsy stage F3 or F4 and platelet count below normal were the strongest predictors of progression to hepatic decompensation or hepatocellular carcinoma.

CONCLUSIONS

The risks of death and progression to liver failure varied greatly by fibrosis stage. Clinicians and policy makers could use these progression risk data in prioritization and in determining the timing of treatment for patients in early stages of liver disease.

Chronic hepatitis C infection as a risk factor for renal cell carcinoma

BACKGROUND

Chronic hepatitis C virus (HCV) infection causes cirrhosis and hepatocellular carcinoma but is also etiologically linked to several extrahepatic medical conditions including renal disorders. HCV is also associated with extrahepatic malignancies and may be oncogenic. Whether HCV confers an increased risk of renal cell carcinoma (RCC) remains controversial.

AIMS

Prospectively determine whether chronic HCV is associated with an increased risk of RCC.

METHODS

At an integrated medical center in Detroit, Michigan, adult patients with suspected RCC or newly diagnosed colon cancer (controls) were screened for hepatitis C antibody (HCAB) and HCV RNA. Renal or colon cancers were confirmed histologically. The proportion of patients with HCAB and HCV RNA in each group was compared, and risk factors for renal cell carcinoma were determined by multivariable logistic regression analysis.

RESULTS

RCC patients had a higher rate of HCAB positivity (11/140, 8 %) than colon cancer patients (1/100, 1 %) (p < 0.01). Of the HCAB-positive patients, 9/11 RCC and 0/1 controls had detectable HCV RNA. HCV RNA positivity was a significant risk factor for RCC (OR 24.20; 95 % CL 2.4, >999.9; p = 0.043). Additionally, viremic RCC patients were significantly younger than RCC patients who were HCV RNA negative (p = 0.013).

CONCLUSIONS

Patients with chronic HCV are at heightened risk of RCC.

Abstract P1-11-09: Early discontinuation of adjuvant chemotherapy in women with early stage breast cancer: The BQUAL study

BACKGROUND

Adjuvant chemotherapy for early stage breast cancer decreases recurrence and increases survival. However, early discontinuation of chemotherapy occurs frequently and has a negative influence on patient outcomes.

METHODS

The Breast Cancer Quality of Care Study (BQUAL) is a prospective cohort study designed to investigate factors associated with early discontinuation of adjuvant chemotherapy among women diagnosed with non-metastatic breast cancer at three sites in the U.S between 2006 and 2010 (Columbia University Medical Center, Kaiser-Permanente of Northern California, Henry Ford Health System). Chemotherapy regimens were classified based on NCCN guidelines. Regimens were further categorized as standard and non-standard/experimental. Early discontinuation for standard treatments was defined as missing 20% of the recommended number of treatments for the prescribed regimen. We used multivariate analysis to examine the association between early discontinuation and sociodemographic factors, tumor characteristics, and baseline psychosocial factors.

RESULTS

Of 1157 women recruited, 478 patients initiated chemotherapy; 35 women received non-standard/experimental chemotherapy and an additional 17 did not complete all interviews and were excluded from the analysis. Of the remaining 426 patients, 59 (13.9%) did not complete the full course of prescribed chemotherapy. In multivariate analysis, compared to those who completed their full prescribed course of adjuvant chemotherapy, those who discontinued were more often &gt;50 years of age (p=0.04). Early discontinuation of chemotherapy was less likely among Asian women (OR 0.12, 95% CI 0.01-0.96), those who held positive beliefs related to the efficacy of chemotherapy (OR 0.43, 95% CI 0.22-0.81), and those who were more optimistic (OR 0.93, 95% CI 0.86-0.99). Women prescribed chemotherapy regimens that had more cycles (&gt;5 cycles) or contained paclitaxel/docetaxel were significantly more likely (OR 7.54, 95% CI 2.68-21.20 and OR 5.02, 95% CI 1.59-15.83, respectively) to discontinue chemotherapy treatment early than regimens with 6 or less cycles.

CONCLUSIONS

Women prescribed longer regimens were significantly more likely not to complete the full course. Positive beliefs about the efficacy of treatment were associated with continuation of treatment. Educational interventions focused on the importance of completing therapy may increase chemotherapy adherence.

Citation Format: Alfred I Neugut, Grace C Hillyer, Lawrence W Kushi, Lois Lamerato, Jinjoo Shim, Dana H Bovberg, David Nathanson, Christine B Ambrisone, Jeanne S Mandelblatt, Carol Magai, Wei Yann Tsai, Judith S Jacobson, Dawn L Hershman. Early discontinuation of adjuvant chemotherapy in women with early stage breast cancer: The BQUAL study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-09.

Use of influenza antiviral medications among outpatients at high risk for influenza-associated complications during the 2013-2014 influenza season

During the 2013-2014 influenza season, we analyzed data from 6004 outpatients aged ≥6 months with acute respiratory illness (ARI). Among the 2786 ARI patients at higher risk for influenza complications, 835 (30%) presented to care ≤2 days from symptom onset; among those, 126 (15%) were prescribed an antiviral medication.

Economic implications of weight change in patients with type 2 diabetes mellitus

OBJECTIVE

Assess the impact of weight change on costs, resource use, and treatment discontinuation among metformin-treated patients with type 2 diabetes mellitus (T2DM).

STUDY DESIGN

Observational, retrospective cohort.

METHODS

Adults with T2DM who were pre existing metformin-treated patients were included. Insulin users were excluded. Administrative data from January 1, 2000, to December 31, 2010, were linked to clinical data, and patients were placed into cohorts based on relative change in body weight. Three cohorts were created: weight loss (decrease >3%), and weight neutral (change ≤3%), weight gain (increase > 3%). Inter-cohort differences in resource utilization, costs (2010 US$), and treatment discontinuation were evaluated using statistical models that adjusted for baseline characteristics.

RESULTS

A total of 2110 patients (weight loss = 967; weight neutral = 970; weight gain = 173) were included; mean age was 59.6 years, 52.2% were women, 64.1% were Caucasian, and average baseline weight was 98.7 kg. The weight-loss cohort incurred significantly lower costs per year compared with the weight-neutral cohort, driven mainly by lower medical costs from reduced utilization. Weight reduction was associated with approximately $2200 and approximately $440 lower annual all-cause and T2DM-specific costs (P < .05), respectively. Patients who lost weight were 21% less likely to discontinue therapy. Weight gain was associated with a significant increase in all-cause costs of $3400 per year compared with the weight-neutral cohort; however, differences in T2DM-specific costs and discontinuation rates did not reach significance levels.

CONCLUSIONS

Weight loss (> 3%) among patients with T2DM was associated with decreased costs and lower rates of treatment discontinuation. Hence weight-focused treatment approaches can help reduce the economic burden for patients with T2DM.

Can dialysis patients be accurately identified using healthcare claims data?

BACKGROUND

While health insurance claims data are often used to estimate the costs of renal replacement therapy in patients with end-stage renal disease (ESRD), the accuracy of methods used to identify patients receiving dialysis - especially peritoneal dialysis (PD) and hemodialysis (HD) - in these data is unknown.

METHODS

The study population consisted of all persons aged 18 - 63 years in a large US integrated health plan with ESRD and dialysis-related billing codes (i.e., diagnosis, procedures) on healthcare encounters between January 1, 2005, and December 31, 2008. Using billing codes for all healthcare encounters within 30 days of each patient's first dialysis-related claim ("index encounter"), we attempted to designate each study subject as either a "PD patient" or "HD patient." Using alternative windows of ± 30 days, ± 90 days, and ± 180 days around the index encounter, we reviewed patients' medical records to determine the dialysis modality actually received. We calculated the positive predictive value (PPV) for each dialysis-related billing code, using information in patients' medical records as the "gold standard."

RESULTS

We identified a total of 233 patients with evidence of ESRD and receipt of dialysis in healthcare claims data. Based on examination of billing codes, 43 and 173 study subjects were designated PD patients and HD patients, respectively (14 patients had evidence of PD and HD, and modality could not be ascertained for 31 patients). The PPV of codes used to identify PD patients was low based on a ± 30-day medical record review window (34.9%), and increased with use of ± 90-day and ± 180-day windows (both 67.4%). The PPV for codes used to identify HD patients was uniformly high - 86.7% based on ± 30-day review, 90.8% based on ± 90-day review, and 93.1% based on ± 180-day review.

CONCLUSIONS

While HD patients could be accurately identified using billing codes in healthcare claims data, case identification was much more problematic for patients receiving PD.