A systematic literature review of the economic and healthcare resource burden of cytomegalovirus

OBJECTIVE

Cytomegalovirus (CMV) can infect individuals at any age, including infants, who may contract it from infected mothers (congenital CMV [cCMV]). Whereas CMV infection is typically asymptomatic or causes mild illness in healthy individuals, infection can result in severe outcomes in immunocompromised individuals and in infants with cCMV. This systematic review aims to characterize the economic impact of CMV and cCMV infections.

METHODS

Medline, Embase, and LILACS databases were searched for publications reporting the economic impact of cCMV and CMV infections across all age groups. Manuscripts published between 2010 and 2020 from Australia, Latin America, Canada, Europe, Israel, Japan, the United States, and global (international, worldwide) studies were included; congress materials were excluded. Outcomes of interest included cCMV- and CMV-attributable direct costs/charges, resource utilization, and indirect/societal costs.

RESULTS

Of 751 records identified, 518 were excluded based on duplication, population, outcome, study design, or country. Overall, 55 articles were eligible for full-text review; 25 were further excluded due to population, outcome, study design, or congress abstract. Two publications were additionally identified, resulting in economic impact data compiled from 32 publications. Of these, 24 publications reported cost studies of cCMV or CMV, including evaluation of direct costs/charges, healthcare resource utilization, and indirect/societal costs, and 7 publications reported economic evaluations of interventions. The populations, methods and outcomes used across these studies varied widely.

CONCLUSIONS

CMV and cCMV infections impose a considerable economic impact on different countries, populations, and outcomes. There are substantial evidence gaps where further research is warranted.

Factors associated with receipt of mRNA-1273 vaccine at a United States national retail pharmacy during the COVID-19 pandemic

INTRODUCTION

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) prompted accelerated vaccine development of novel messenger RNA (mRNA)-based vaccines by Moderna and Pfizer, which received FDA Emergency Use Authorization in December 2020. The purpose of this study was to examine trends in primary series administration and multi-dose completion rates with Moderna's mRNA-1273 vaccine administered at a United States retail pharmacy.

METHODS

Walgreens pharmacy data were joined to publicly available data sets to examine trends in mRNA-1273 primary series and multi-dose completion across patient race/ethnicity, age, gender, distance to first vaccination, and community characteristics. Eligible patients received their first dose of mRNA-1273 administered by Walgreens between December 18, 2020 and February 28, 2022. Variables significantly associated with on-time second dose (all patients) and third dose (immunocompromised patients) in univariate analyses were included in linear regression models. A subset of patients in selected states were studied to identify differences in early and late vaccine adoption.

RESULTS

Patients (N = 4,870,915) who received ≥ 1 dose of mRNA-1273 were 57.0% White, 52.6% female, and averaged 49.4 years old. Approximately 85% of patients received a second dose during the study period. Factors associated with on-time second dose administration included older age, race/ethnicity, traveling ≤ 10 miles for the first dose, higher community-level health insurance, and residing in areas with low social vulnerability. Only 51.0% of immunocompromised patients received the third dose as recommended. Factors associated with third dose administration included older age, race/ethnicity, and small-town residence. Early adopters accounted for 60.6% of patients. Factors associated with early adoption included older age, race/ethnicity, and metropolitan residence.

CONCLUSION

Over 80% of patients received their on-time second dose of mRNA-1273 vaccine per CDC recommendations. Patient demographics and community characteristics were associated with vaccine receipt and series completion. Novel approaches to facilitate series completion during a pandemic should be further studied.

A systematic literature review on the humanistic burden of cytomegalovirus

OBJECTIVE

Cytomegalovirus (CMV) infection is typically asymptomatic in healthy individuals; however, certain populations are vulnerable to infection and may develop serious sequelae. CMV infection may also have a broad impact on humanistic outcomes, including patient health status and quality of life (QoL). We conducted a systematic literature review (SLR) to describe the global humanistic burden of CMV and congenital CMV (cCMV) infections across all age groups.

METHODS

Medline, Embase, and LILACS were searched to identify studies on humanistic outcomes following CMV infection, including health status/QoL and any outcomes in domains such as auditory, cognitive ability, developmental status, intelligence, language, memory, mental health, motor performance, social communication, speech, and vocabulary. The SLR included articles published from 2000-2020 and focused geographically on Australia, Europe, Israel, Japan, Latin America, and North America.

RESULTS

Sixty-three studies met the inclusion criteria. In general, individuals with symptomatic cCMV infection experience a greater burden of disease and more substantial impact on QoL versus those with asymptomatic cCMV infection. Children with hearing loss due to cCMV infection, both symptomatic and asymptomatic, showed improved auditory outcomes following cochlear implantation. Newborns, infants, and children with cCMV infections had worse cognitive outcomes in psychological development, sequential and simultaneous processing, phonological working memory, and attention control versus age-matched controls without cCMV infection. CMV infection was also associated with cognitive decline in elderly populations.

CONCLUSIONS

CMV infection can have substantial, lifelong, heterogenous impacts on humanistic outcomes, including health status and QoL, which should be considered when developing and implementing treatment and prevention strategies.

Hepatitis A and B vaccination in adults at risk: A survey of US healthcare providers' attitudes and practices

This study aimed to evaluate the attitudes and practices of US healthcare professionals (HCPs) regarding the Advisory Committee on Immunization Practices (ACIP) vaccination recommendations on HepA and HepB for adult patients at risk of contracting these infections or experiencing complications of hepatitis disease. This cross-sectional, web-based survey of 400 US HCPs, which included nurse practitioners and family medicine, internal medicine, infectious disease, emergency department, and gastroenterology physicians, assessed HCPs' attitudes and practices regarding the ACIP recommendations for adult patients at risk for hepatitis disease. HCP participants were identified via a survey research panel. A recruitment quota of 400 HCPs was set, including 50 NPs, 100 FMs, 100 IMs, 50 GIs, 50 EDs, and 50 IDs. The most frequently reported reasons for not recommending either HepA or HepB vaccines were "I think the risk of HepA infection is low in this patient population" and "I am uncertain about what the guidelines say about vaccinating this population." The most reported factors considered when determining eligibility for either vaccine were medical history and the patient's willingness/motivation to be vaccinated. Most reported it was extremely or moderately important to prevent hepatitis disease by vaccinating adult patients at risk, and most also reported recommending a HepA vaccine or HepB vaccine to patients at risk. Although most HCPs reported recommending HepA and HepB vaccines to patients at risk, these findings contrast with the low reported vaccination rates among these populations, and improved awareness of the ACIP recommendations among HCPs is needed.

A systematic literature review of the global seroprevalence of cytomegalovirus: possible implications for treatment, screening, and vaccine development

Background

Cytomegalovirus (CMV) is a common pathogen that affects individuals of all ages and establishes lifelong latency. Although CMV is typically asymptomatic in healthy individuals, infection during pregnancy or in immunocompromised individuals can cause severe disease. Currently, treatments are limited, with no prophylactic vaccine available. Knowledge of the current epidemiologic burden of CMV is necessary to understand the need for treatment and prevention. A systematic literature review (SLR) was conducted to describe the most recent epidemiologic burden of CMV globally.

Methods

Medline, Embase, and LILACS were searched to identify data on CMV prevalence, seroprevalence, shedding, and transmission rates. The SLR covered the time period of 2010–2020 and focused geographically on Australia, Europe, Israel, Japan, Latin America (LATAM), and North America. Studies were excluded if they were systematic or narrative reviews, abstracts, case series, letters, or correspondence. Studies with sample sizes < 100 were excluded to focus on studies with higher quality of data.

Results

Twenty-nine studies were included. Among adult men, CMV immunoglobulin G (IgG) seroprevalence ranged from 39.3% (France) to 48.0% (United States). Among women of reproductive age in Europe, Japan, LATAM, and North America, CMV IgG seroprevalence was 45.6-95.7%, 60.2%, 58.3-94.5%, and 24.6-81.0%, respectively. Seroprevalence increased with age and was lower in developed than developing countries, but data were limited. No studies of CMV immunoglobulin M (IgM) seroprevalence among men were identified. Among women of reproductive age, CMV IgM seroprevalence was heterogenous across Europe (1.0-4.6%), North America (2.3-4.5%), Japan (0.8%), and LATAM (0-0.7%). CMV seroprevalence correlated with race, ethnicity, socioeconomic status, and education level. CMV shedding ranged between 0% and 70.2% depending on age group. No findings on CMV transmission rates were identified.

Conclusions

Certain populations and regions are at a substantially higher risk of CMV infection. The extensive epidemiologic burden of CMV calls for increased efforts in the research and development of vaccines and treatments.

Trial registration

N/A.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13971-7.

The potential clinical impact of implementing different COVID-19 boosters in fall 2022 in the United States

OBJECTIVE

Emerging SARS-COV-2 variants are spurring the development of adapted vaccines as public health authorities plan for fall vaccinations. This study estimated the number of infections and hospitalizations prevented by three potential booster strategies for adults (≥18 years) in the United States: boosting with either Moderna's (1) licensed first generation monovalent vaccine mRNA-1273 (ancestral strain) or (2) candidate bivalent vaccine mRNA-1273.214 (ancestral + BA.1 variant of concern [VOC]) starting in September 2022, or (3) Moderna's updated candidate bivalent vaccine mRNA-1273.222 (ancestral + BA.4/5 VOC) starting November 2022 due to longer development time.

METHODS

An age-stratified, transmission dynamic, Susceptible-Exposed-Infection-Recovered (SEIR) model, adapted from previous literature, was used to estimate infections over time; the model contains compartments defined by SEIR and vaccination status. A decision tree was used to estimate clinical consequences of infections. Calibration was performed so the model tracks the actual course of the pandemic to present time.

RESULTS

Vaccinating with mRNA-1273(Sept), mRNA-1273.214(Sept), and mRNA-1273.222(Nov) is predicted to reduce infections by 34%, 40%, and 18%, respectively, and hospitalizations by 42%, 48%, and 25%, respectively, over 6 months compared to no booster. Sensitivity analyses around transmissibility, vaccine coverage, masking, and waning illustrate that boosting with mRNA-1273.214 in September prevented more cases of infection and hospitalization than the other vaccines.

LIMITATIONS AND CONCLUSIONS

With the emergence of new variants, key characteristics of the virus that affect estimates of spread and clinical impact also evolve, making parameter estimation difficult. Our analysis demonstrated that boosting with mRNA-1273.214 was more effective over 6 months in preventing infections and hospitalizations with a BA.4/5 subvariant than the tailored vaccine, simply because it could be deployed 2 months earlier. We conclude that there is no advantage to delay boosting until a more effective BA.4/5 vaccine is available; earlier boosting with mRNA-1273.214 will prevent the most infections and hospitalizations.

Factors influencing series completion rates of recombinant herpes zoster vaccine in the United States: A retrospective pharmacy and medical claims analysis

BACKGROUND/OBJECTIVES

Vaccination against herpes zoster (HZ) is an effective strategy in protecting the population against consequences of varicella zoster virus reactivation. Optimal immunogenicity with recombinant zoster vaccine (RZV) relies on completion of the 2-dose series within 2-6 months from the first dose. The objectives of this study were to estimate RZV completion rates and adherence with the recommended administration schedule in the general United States population aged at least 50 years and to evaluate factors influencing completion rates.

METHODS

Longitudinal, open-source pharmacy and medical claims databases were analyzed for adults aged at least 50 years with a first RZV prescription filled between October 2017 and September 2019. The data were linked to Experian Marketing Services Consumer View data to obtain information regarding race. Completion rates and adherence were calculated overall and stratified according to claim source, age class, sex, and payer type. Logistic regression models were built for each subpopulation of interest to identify factors correlating with completion rates.

RESULTS

Overall, cumulative completion rates were 70.41% and 81.80% at 6 and 12 months, respectively. Median time to second dose was approximately 4 months (4.08-5.13 months) and adherence 67.62%. Completion rates were lower in the medical claims database compared with the pharmacy claims database (48.98% vs. 73.23% at 6 months). Regression models confirmed that pharmacy claim was an independent factor for higher completion rates, while African American race and Medicaid status were associated with lower completion rates. Most comorbidities, including chronic obstructive pulmonary disease and type 2 diabetes mellitus, were associated with lower completion rates.

CONCLUSION

Pharmacists contribute substantially to the overall high RZV completion rates in the United States. However, completion rates can be improved, especially in people receiving their first RZV dose at a physician's office. Future strategies should aim at lowering barriers to completing vaccination series in African Americans, Medicaid beneficiaries, and people with comorbidities.

Time and cost of administering COVID-19 mRNA vaccines in the United States

In early 2020, the World Health Organization (WHO) declared the coronavirus disease 2019 (COVID-19) outbreak a global pandemic. In response, two novel messenger RNA (mRNA)-based vaccines: mRNA-1273 (Moderna) and BNT162b2 (Pfizer-BioNTech) were rapidly developed. A thorough understanding of the differences in workflow requirements between the two vaccines may lead to improved efficiencies and reduced economic burden, both of which are crucial for streamlining vaccine deployment and minimizing wastage. Vaccine administration workflow costs are borne by providers and reimbursed separately from dose acquisition in the United States. Currently, mRNA-1273 and BNT162b2 are the most administered COVID-19 vaccines in the United States. In this study, US-licensed and practicing pharmacists were interviewed to collect data on differences in terms of labor costs associated with the workflows for mRNA-1273 and BNT162b2. Results suggest the cost differential for mRNA-1273 compared to BNT162b2 is -$0.82 (or -$1.01 when assuming volume equivalency). If extrapolated to even just a proportion of the remaining unvaccinated US population, this can amount to significant workflow efficiencies and lower vaccine administration costs. Further, as key differences in the vaccine workflow steps between the two vaccines would be similar in other settings/regions, these findings are likely transferable to health-care systems worldwide.

What can Europe learn from HCP knowledge and attitudes towards hepatitis A vaccination in the US?

Background

An estimated &gt;100 million new hepatitis A (hepA) infections occur annually worldwide. Centres for disease control and prevention reported 38795 hepA cases in the US since 2016, and 4475 outbreak-confirmed cases in Europe between 2016-2018. HepA outbreaks resulted mainly from person-to-person contact, especially among homeless, illegal drug users (IDU) and men who have sex with men (MSM). In 2020, we surveyed US health care providers (HCPs) to understand their knowledge and attitudes towards hepA vaccination in these populations at higher risk of infection and complications.

Methods

This was a cross-sectional, web-based survey of 400 HCPs (primary care providers, nurse practitioners, gastroenterologists, internal medicine and infectious disease specialists [IDs], emergency room physicians [ERs]) who had recommended and/or administered hepA vaccines to ≥ 19-year-olds.

Results

85% of 371 HCPs reported recommending hepA vaccine to homeless, 87% of 393 to IDU and 83% of 397 to MSM, although vaccination may not actually occur after recommendation. Results varied by specialty, 16% fewer ERs than IDs reported recommending the vaccine in these at-risk populations. Moreover, 64%, 75% and 71% of all (400) HCPs reported extremely important that homeless, IDU and MSM, respectively, get vaccinated for hepA, while 6%, 7% and 8% of all HCPs reported this as slightly, or not important. Reasons for not recommending hepA vaccine to homeless, IDU and MSM included uncertainty on guidelines (reported by 22/56, 24/50 and 29/66 HCPs, respectively) and low risk of infection (reported by 20/56, 30/50 and 27/66 HCPs, respectively).

Conclusions

Despite recent hepA outbreaks and strengthened recommendations for vaccination in at-risk populations, knowledge gaps persist among US HCPs. This survey may motivate European countries to reinforce national hepA vaccination recommendations and, in parallel, consider efforts to raise vaccination awareness.

Funding

GlaxoSmithKline Biologicals SA

Key messages

Education on hepatitis A vaccination recommendations in at-risk populations is needed. Health care providers’ vaccination knowledge plays a critical role to control the hepatitis A outbreak in the US and preventing hepatitis A in Europe.

Vaccinating Adolescents and Children Significantly Reduces COVID-19 Morbidity and Mortality across All Ages: A Population-Based Modeling Study Using the UK as an Example

Debate persists around the risk-benefit balance of vaccinating adolescents and children against COVID-19. Central to this debate is quantifying the contribution of adolescents and children to the transmission of SARS-CoV-2, and the potential impact of vaccinating these age groups. In this study, we present a novel SEIR mathematical disease transmission model that quantifies the impact of different vaccination strategies on population-level SARS-CoV-2 infections and clinical outcomes. The model employs both age- and time-dependent social mixing patterns to capture the impact of changes in restrictions. The model was used to assess the impact of vaccinating adolescents and children on the natural history of the COVID-19 pandemic across all age groups, using the UK as an example. The base case model demonstrates significant increases in COVID-19 disease burden in the UK following a relaxation of restrictions, if vaccines are limited to those ≥18 years and vulnerable adolescents (≥12 years). Including adolescents and children in the vaccination program could reduce overall COVID-related mortality by 57%, and reduce cases of long COVID by 75%. This study demonstrates that vaccinating adolescents and children has the potential to play a vital role in reducing SARS-CoV-2 infections, and subsequent COVID-19 morbidity and mortality, across all ages. Our results have major global public health implications and provide valuable information to inform a potential pandemic exit strategy.

Estimated Public Health Impact of the Recombinant Zoster Vaccine

OBJECTIVE

To investigate the potential public health impact of adult herpes zoster (HZ) vaccination with the adjuvanted recombinant zoster vaccine (RZV) in the United States in the first 15 years after launch.

METHODS

We used a publicly available model accounting for national population characteristics and HZ epidemiological data, vaccine characteristics from clinical studies, and anticipated vaccine coverage with RZV after launch in 2018. Two scenarios were modeled: a scenario with RZV implemented with 65% coverage after 15 years and a scenario continuing with zoster vaccine live (ZVL) with coverage increasing 10% over the same period. We estimated the numbers vaccinated, and the clinical outcomes and health care use avoided yearly, from January 1, 2018, to December 31, 2032. We varied RZV coverage and investigated the associated impact on HZ cases, complications, and health care resource use.

RESULTS

With RZV adoption, the numbers of individuals affected by HZ was predicted to progressively decline with an additional 4.6 million cumulative cases avoided if 65% vaccination with RZV was reached within 15 years. In the year 2032, it was predicted that an additional 1.3 million physicians' visits and 14.4 thousand hospitalizations could be avoided, compared with continuing with ZVL alone. These numbers could be reached 2 to 5 years earlier with 15% higher RZV vaccination rates.

CONCLUSION

Substantial personal and health care burden can be alleviated when vaccination with RZV is adopted. The predicted numbers of HZ cases, complications, physicians' visits, and hospitalizations avoided, compared with continued ZVL vaccination, depends upon the RZV vaccination coverage achieved.

Early examination of real-world uptake and second-dose completion of recombinant zoster vaccine in the United States from October 2017 to September 2019

Shingrix (Recombinant zoster vaccine, RZV) was approved in October 2017 in the United States (US) for the prevention of herpes zoster in adults aged 50 years and older. The vaccine is administered in two doses, with the second dose administration recommended between two and six months after the first dose. Examination of uptake and series completion is important to ensure appropriate use, especially at the time of vaccine introduction. This report provides demographic characteristics of patients receiving RZV between October 2017 and September 2019, first- and second-dose uptake, and a cumulative estimation of second-dose completion by month for US adults aged 50 years and older. Monthly uptake increased rapidly since October 2017; overall, 7,097,441 first doses of RZV were administered along with 4,277,636 second doses during the observed timeframe. Among people with an observed first-dose administration, 70% and 80% completed the two-dose series within six and 12 months post initial dose, respectively. This evidence suggests that RZV has rapidly been adopted by a large population in the US and most are following manufacturer or policy recommendations regarding series completion. Further analyses are needed to explore potential patient, provider, and policy-relevant characteristics associated with second-dose completion that could serve as targets for further improvement.

1716. Prospective Multicenter Observational Cohort Study to Assess the Burden of Herpes Zoster Disease in the Eye: Baseline Results of Initial Patients

Background

Herpes Zoster Ophthalmicus (HZO) affects 10-20% of adults with herpes zoster; ≥ 50% of these cases manifest as serious ocular diseases. This 1-year prospective observational cohort study aims to determine patient-reported HZO symptoms as well as economic and quality of life burden among 300 HZO patients from 6 major US ophthalmology practices. Here, we report baseline data from 13 initial enrollees.

Methods

Inclusion criteria were: participants ≥ 18 years, diagnosis of clinically active HZO, English or Spanish speaking, be willing and able to respond to study assessments, not be enrolled in a concurrent interventional HZO trial. Information are collected via 1) a clinical assessment form completed by the practice (baseline) and 2) patient questionnaires (baseline, 3, 6, and 12 months) on symptoms, medications, healthcare use, vision function, depression, and work productivity impact. Baseline results are presented for patients recruited during the first 6 months of enrollment from the first 4 sites to go live: diagnoses, and patient-reported symptoms and outcomes (eight-item Patient Health Questionnaire [PHQ-8] for depressive symptoms, National Eye Institute 25-item Visual Function Questionnaire [NEI-VFQ-25] for vision-related quality of life, and Zoster Brief Pain Inventory [ZBPI] for pain).

Results

The mean age of participants is 71 years; 11 are female and 9 are retired. Seven participants are college graduates or hold other degrees. All have health insurance coverage, with most (10) having primary insurance through Medicare. HZO diagnoses (Table 1) were: keratitis (4), iridocyclitis (4), conjunctivitis (1), other HZO diagnosis (3), other ocular diagnosis (6). Patient-reported symptoms (Table 2) were: pain above the eye, sensitivity to light, redness, feeling of sand/grit in the eye (9 each). The mean overall PHQ-8 and NEI-VFQ-25 scores were 5.9 (Standard Deviation [SD]:4.5) and 74.6 (SD:13.9), respectively; the mean ZBPI score for worst pain severity was 3.3 (SD:3.8) (Table 3).

Table 1. HZO Diagnosis at Baseline based on Clinical Assessment Form (N=13)

Conclusion

This study represents the first large scale effort to quantify HZO burden. Findings will inform development of a formal patient-reported symptom scale for use in research and clinical practice.

Funding

GlaxoSmithKline Biologicals SA (GSK study identifiers: 209235/HO-17-17967)

Disclosures

Laura T. Pizzi, PharmD, MPH, ORCID: 0000-0002-7366-7661, GlaxoSmithKline (Research Grant or Support) Soham Shukla, PharmD, ORCID: 0000-0002-4139-0856, GSK (Employee)Rutgers University (Employee) Brandon J. Patterson, PharmD, PhD, GSK (Employee, Shareholder) Debora A. Rausch, MD, ORCID: 0000-0001-9759-2687, GSK (Employee) Philip O. Buck, PhD, MPH, ORCID: 0000-0002-3898-3669, GSK (Employee, Shareholder) Ann P. Murchison, MD, MPH, GSK (Grant/Research Support)

17. Assessment of Recombinant Zoster Vaccine Second Dose Completion in the United States

Background

Recombinant Zoster Vaccine (RZV) was licensed in the United States (US) in October 2017 for the prevention of herpes zoster in adults ≥ 50 years of age (YOA). The vaccine is administered in a two-dose sequence with a 2- to 6-month interval; however, the Center for Disease Control & Prevention has advised against restarting a series after the prescribed window. This study describes an assessment of 2nd dose completion and compliance of RZV in the US.

Methods

Primary analysis was conducted on a cohort ≥ 50 YOA who received an initial RZV dose between October 2017 and September 2018 as indicated in the IQVIA longitudinal prescription claims or medical claims databases. Subjects were required to have ≥ 1 year of observable time post initial dose. A sensitivity analysis was conducted using all eligible subjects regardless of observable time post initial dose. Endpoints of analyses were monthly and cumulative 2nd dose label-compliant proportions at 6 months and completers by 12-month intervals and time to completion from initial RZV vaccine administration with stratifications by age, sex, claim source and payer type.

Results

The primary sample included 1,225,088 subjects, while the sensitivity analysis included 7,097,441 (Table 1). Overall, 2nd RZV dose completion was 70.4% within 6 months and 81.8% within 12 months. Minimal variation for 12-month completion was demonstrated across age (77.2–84.5%), sex (81.7–81.9%), and Commercial vs. Medicare (80.9–83.0%). However, larger variations were seen across claim sources and other payer type, with medical claims (64.9%), Medicaid patients (72.8%) and Cash patients (74.7%) having lower rates at 12 months (Table 2). Overall, the average time to completion was around 4 months regardless of stratification except by claims source, with medical claims taking 5 months on average to complete. The sensitivity analysis of the variable follow-up cohort demonstrated findings consistent with that of the primary sample.

Conclusion

Assessment of RZV suggests high levels of completion across age, sex, payer type and claim sources. More effort is needed to understand barriers to completion rates in Medicaid patients and settings where vaccination claims are processed outside of the vaccine recipient’s pharmacy benefit.

Disclosures

Brandon J. Patterson, PharmD, PhD, GSK (Employee, Shareholder) Chi-Chang Chen, PhD, MSPharm, GSK (Research Grant or Support) Catherine B. McGuiness, MA, MS, GSK (Research Grant or Support)Pfizer (Shareholder) Lisa I. Glasser, MD, GSK (Employee, Shareholder) Kainan Sun, MS, PhD, GSK (Research Grant or Support) Philip O. Buck, PhD, MPH, ORCID: 0000-0002-3898-3669, GSK (Employee, Shareholder)

Retrospective study of the use of an influenza disease two-tiered classification system to characterize clinical severity in US children

In children <5 years, influenza is associated with higher risk of serious disease and hospitalization when compared with other age groups. Influenza vaccination reduces the risk of influenza and vaccination may attenuate the severity of disease. Recent studies in Europe suggest that classifying influenza disease as mild versus moderate-to-severe (M-S) using a novel definition may be clinically significant. We retrospectively evaluated whether this M-S definition also characterized influenza severity in a cohort of US children. We included children <18 years at Kaiser Permanente Northern California with PCR-confirmed influenza during the 2013–2014 influenza season. We classified children as M-S if they had ≥1 symptom: fever >39°C, acute otitis media, lower respiratory tract infection (LRTI), or extra-pulmonary complications; otherwise, they were classified as mild. We used multivariable log-binomial models to assess whether M-S influenza disease was associated with increased healthcare utilization. Nearly half of the 1,105 influenza positive children were classified as M-S. Children 6–35 months had the highest proportion of M-S disease (35.1%), mostly due to LRTI (63.2%) and fever (44.6%). Children ≥6 months who had M-S disease were associated with a 1.6 to 2.8 times increased likelihood of having had an emergency department or any follow-up outpatient visits. Those who had M-S disease were associated with an increased likelihood of receiving antibiotics, with the highest likelihood in children 6–35 months (RR 9.0, 95% CI 4.1, 19.8). While more studies are needed, an influenza classification system may distinguish children with more clinically significant disease.

Constrained Optimization for the Selection of Influenza Vaccines to Maximize the Population Benefit: A Demonstration Project

BACKGROUND

Influenza is an infectious disease causing a high annual economic and public health burden. The most efficient management of the disease is through prevention with vaccination. Many influenza vaccines are available, with varying efficacy and cost, targeting different age groups. Therefore, strategic decision-making about which vaccine to deliver to whom is warranted to improve efficiency.

OBJECTIVE

We present the use of a constrained optimization (CO) model to evaluate targeted strategies for providing influenza vaccines in three adult age groups in the USA.

METHODS

CO was considered for identifying an influenza vaccine provision strategy that maximizes the benefits at constrained annual budgets, by prioritizing vaccines based on return on investment. The approach optimizes a set of predefined outcome measures over several years resulting from an increasing investment using the best combination of influenza vaccines.

RESULTS

Results indicate the importance of understanding the relative differences in benefits for each vaccine type within and across age groups. Scenario and threshold analyses demonstrate the impact of changing budget distribution over time, price setting per vaccine type, and selection of outcome measure to optimize.

CONCLUSION

Significant gains in cost efficiency can be realized for a decision maker using a CO model, especially for a disease like influenza with many vaccine options. Testing the model under different scenarios offers powerful insights into maximum achievable benefit overall and per age group within the predefined constraints of a vaccine budget.

Maternal Immunization in the U.S.: A Nationwide Retrospective Cohort Study

INTRODUCTION

At present, pregnant women in the U.S. are recommended to receive tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) and influenza vaccines. This study assessed maternal coverage of these 2 vaccinations.

METHODS

Data for this retrospective cohort study were extracted from 2 large administrative claims databases, the MarketScan Commercial and Multi-State Medicaid Databases, for 2009-2017 and analyzed in 2018. Women aged 15-44 years on the date of pregnancy end were included. Pregnancies with gestational age of less than 23 weeks were excluded from the Tdap vaccination endpoint owing to the optimal recommended gestational age for Tdap vaccination. Multivariable logistic regression models identified predictors of vaccination.

RESULTS

The Tdap vaccination subpopulation included 1,421,452 Commercial and 523,635 Medicaid pregnancies; the influenza vaccination subpopulation included 1,862,705 Commercial and 628,079 Medicaid pregnancies. There were marked increases in vaccination coverage from 2010 to 2017: from 1.0% to 56.3% (Commercial) and from 0.5% to 31.4% (Medicaid) for Tdap, and from 14.7% to 31.3% (Commercial) and from 9.7% to 17.5% (Medicaid) for influenza. The likelihood of Tdap/influenza vaccination increased significantly with receipt of the other vaccine and more pregnancy-related healthcare visits.

CONCLUSIONS

Although maternal Tdap and influenza vaccination coverage increased substantially from 2010 to 2017 among large, geographically diverse U.S. cohorts, coverage remained suboptimal, potentially putting newborns at risk of pertussis and influenza. Strategies to increase maternal vaccination coverage could target women identified to have a reduced likelihood of vaccination: those who are younger, black, residing in rural areas, with multiple gestation, and a prepregnancy inpatient admission.

Is patient insurance type related to physician recommendation, administration and referral for adult vaccination? A survey of US physicians

This study evaluated physician practices and perceived barriers for influenza, tetanus, diphtheria, pertussis (Tdap), and zoster vaccination of adults in the United States (US), with emphasis on patients with Medicare versus commercial insurance. A cross-sectional internet-based survey of board-certified general/family practitioners and internists (N = 1,000) recruited from a national US physician panel was conducted in May 2017. For influenza, rates of physician recommendation (84% of Medicare patients, 82% of commercially-insured patients), administration (80% Medicare, 78% commercial), and referral (11% Medicare, 11% commercial) were similar regardless of insurance type. Tdap recommendation was higher for commercial compared to Medicare patients (59% vs. 54%, p < 0.001); while zoster recommendation was higher for Medicare patients than commercial (59% vs. 55%, p < 0.001). For Tdap and zoster, higher administration rates were reported in commercial patients (64% Tdap, 36% zoster) than Medicare (56% Tdap, 32% zoster), and referral rates were higher for Medicare patients (19% Tdap, 49% zoster) than commercial (14% Tdap, 42% zoster). Over 40% of physicians would be much more likely to administer Tdap and zoster vaccines if they were covered under Medicare Part B, with more physicians indicating financial barriers as “major” or “moderate” for Medicare than commercial patients. These differences may be related to financial barriers associated with adult vaccinations that are covered under Medicare Part D and involve patient out-of-pocket costs. Efforts to reduce financial barriers associated with adult vaccinations covered under Medicare Part D and to improve patient and physician knowledge could positively impact physician recommendation, administration, and referral for adult vaccination in the US.

Cost-effectiveness of an adjuvanted recombinant zoster vaccine in older adults in the United States who have been previously vaccinated with zoster vaccine live

Zoster Vaccine Live (ZVL) is marketed in the US since 2008, and a non-live adjuvanted Recombinant Zoster Vaccine (RZV) was approved in 2017. Literature suggests that waning of ZVL efficacy may necessitate additional vaccination. The Advisory Committee on Immunization Practices recommended vaccination with RZV in immunocompetent adults aged 50+ years old, including those previously vaccinated with ZVL. The objective of this study was to determine the cost-effectiveness of vaccinating US adults aged 60+ years old, previously vaccinated with ZVL. The ZOster ecoNomic Analysis (ZONA) model, a deterministic Markov model, was adapted to follow a hypothetical 1 million(M)-person cohort of US adults previously vaccinated with ZVL. Model inputs included demographics, epidemiology, vaccine characteristics, utilities and costs. Costs and quality-adjusted life-years (QALYs) were presented over the lifetimes of the cohort from the year of additional vaccination, discounted 3% annually. The model estimated that, vaccination with RZV 5 years after previous vaccination with ZVL, would reduce disease burden compared with no additional vaccination, resulting in a gain of 1,633 QALYs at a total societal cost of $96M (incremental cost-effectiveness ratio: $58,793/QALY saved). Compared with revaccinating with ZVL, vaccination with RZV would result in a gain of 1,187 QALYs and societal cost savings of almost $84M. Sensitivity, scenario, and threshold analyses demonstrated robustness of these findings. Vaccination with RZV is predicted to be cost-effective relative to no additional vaccination, assuming a threshold of $100,000/QALY, and cost-saving relative to ZVL revaccination of US adults aged 60+ years old who have been previously vaccinated with ZVL.

Age-appropriate compliance and completion of up to five doses of pertussis vaccine in US children

Background: In the United States (US), diphtheria, tetanus, and acellular pertussis (DTaP) vaccination is recommended at 2, 4, and 6 months (doses 1-3), 15-18 months (dose 4), and 4-6 years (dose 5). The objective of this study (GSK study identifier: HO-14-14383) was to examine DTaP completion and compliance rates among commercially insured and Medicaid-enrolled children. Secondarily, the study aimed at identifying predictors of compliance/completion. Methods: Truven Health MarketScan Commercial and Multi-State Medicaid databases (2005-2013) were analyzed separately. Children born during 2005-2011 with ≥ 2 years continuous enrollment from birth provided data for doses 1-4; those with continuous enrollment from birth to their seventh birthday provided dose 5 data. Series compliance (each recommended dose by 3, 5, and 7 months; 19 months; seventh birthday) and completion (3 doses by 8 months; 4 by 24 months; 5 by seventh birthday) were calculated. Predictors of compliance/completion were identified using multivariable logistic regression. Results: A total of 367,493 commercially insured and 766,153 Medicaid-enrolled children were followed for ≥ 2 years; and 23,574 and 41,284, respectively, for ≥ 7 years. Series compliance to doses 1-3, 1-4, and 1-5 were 67.2%, 55.3%, 47.5% (commercial) and 37.4%, 27.3%, 14.4% (Medicaid), respectively. Predictors of better compliance/completion included: later birth year (commercial/Medicaid) and higher household income (commercial); predictors of worse compliance/completion included: Northeast residence (commercial), birth hospitalization ≥ 14 days (commercial/Medicaid), and Black race/ethnicity (Medicaid). Conclusions: DTaP series compliance/completion improved over time, but appear to be suboptimal. As this could increase pertussis risk, greater awareness of the importance of timely vaccination completion is needed. GSK study identifier: HO-14-14383.

National survey of pharmacy-based immunization services

INTRODUCTION

Pharmacists in the United States (U.S.) are authorized to administer vaccines. This study described: how and to what extent immunization services are offered, promoted, and documented in community pharmacies; reasons for referral to other locations for vaccination; and perceived barriers to immunization services.

METHODS

A mixed-mode (mail/electronic) survey of a stratified random sample of 1999 nationally-representative community pharmacies in the U.S. was conducted in April-July 2017. Survey instrument development was informed by validated scales and 10 in-depth interviews with community pharmacists; content and face validity were ensured via pre- (n = 5) and pilot-tests (n = 26) among community pharmacists. Potential non-response bias was investigated and descriptive statistics were used to analyze survey responses.

RESULTS

Of the 1999 community pharmacies, 119 pharmacies were deemed ineligible. Of those eligible pharmacies, complete responses were provided by 292 respondents, each representing a unique pharmacy (15.5% response rate). Respondents were evenly split male/female (52.5/47.5%) and about half were pharmacy managers (51.3%). The majority (79.5%) reported offering at least one type of vaccine in 2016, with the most commonly administered vaccine types (average doses in 2016) being: Influenza (484), Pneumococcal 13-valent conjugate (55), Herpes Zoster (41), and Pneumococcal polysaccharide (39). Two-thirds (66.7%) of immunizing pharmacies provided adolescent vaccinations. Most frequently reported referral reasons were patients' insurance not covering vaccine administration at the pharmacy and patients' age not within approved protocol, policy or state law. The majority of respondents did not perceive organizational and environmental factors as barriers; however, they reported patient-related factors, especially cost and insurance coverage, as important barriers.

CONCLUSIONS

The majority of U.S. community pharmacies reported offering at least one type of vaccine. The scope of pharmacy engagement in immunization services varied in terms of how and to what extent they were offered and documented. Addressing patient-related barriers is needed to further enhance pharmacy-based immunization services.

Assessment of the Potential Herpes Zoster and Post Herpetic Neuralgia Case Avoidance with Vaccination in the United States

Background

Herpes zoster (HZ), commonly referred to as shingles, is a reactivation of latent varicella zoster virus in patients previously infected. Clinical characteristics of HZ include painful rash with potential complications, including post herpetic neuralgia (PHN). Care for HZ and PHN incurs significant costs and vaccination is beneficial. The aim of this study was to compare the impact on HZ and PHN case avoidance of two HZ vaccines, an available live-attenuated zoster vaccine (zoster vaccine live [ZVL]) vs. a candidate non-live adjuvanted HZ subunit vaccine (HZ/su), in the US population.

Methods

A Markov model called ZONA (ZOster ecoNomic Analyses) was developed following two age cohorts (≥60 years to represent the current ACIP recommendation and ≥65 years to represent the Medicare population) over their lifetimes from the year of vaccination. Demographic data were obtained from the US Census, whereas HZ incidence and the proportion of HZ individuals developing PHN were derived from published US-specific sources. Age-specific vaccine efficacy and waning rates were based on published clinical trial data. Vaccine coverage for both vaccines was assumed to be 30.6% and 34.2% in the two age cohorts, respectively, based on CDC data; compliance of the second dose of the HZ/su vaccine was 69%, based on data from clinical trials and Hepatitis B seconddose completion. Sensitivity analyses demonstrated robustness of the base analysis findings.

Results

In the US, for cohorts of 66.83 million (M) persons aged 60+ and 47.76M aged 65+ it was estimated that the HZ/su vaccine would reduce the number of HZ cases by 2.12M and 1.55M in the two age cohorts, respectively, compared with 0.65M and 0.45M using the ZVL. Furthermore, the HZ/su vaccine would reduce the number of PHN cases by 0.23M and 0.18M in the two age cohorts, respectively, compared with 0.10M and 0.09 using the ZVL. The number needed to vaccinate to prevent one HZ case were 10 and 11, in the respective cohorts, using the HZ/su vaccine compared with 31 and 37, in the respective cohorts, using the ZVL.

Conclusion

Due to higher and sustained vaccine efficacy, the candidate HZ/su vaccine demonstrated superior public health impact in the US compared with the currently available ZVL.

Disclosures

B. J. Patterson, GSK: Employee and Shareholder, GSK stock options or restricted shares and Salary; Pennsylvania Pharmacists Association: Scientific Advisor, stipend; P. O. Buck, GSK: Employee and Shareholder, GSK stock options or restricted shares and Salary; J. Carrico, RTI Health Solutions: Employee, Salary GSK: Research Contractor, Research support; K. A. Hicks, RTI: Employee, Salary GSK: Research Contractor, Research support; D. Curran, GSK: Employee and Shareholder, GSK stock options or restricted shares and Salary; D. Van Oorschot, GSK: Employee, Salary; J. E. Pawlowski, GSK: Employee and Shareholder, GSK stock options or restricted shares and Salary; B. Y. Lee, GSK: Consultant, Consulting fee; B. P. Yawn, GSK: Consultant and Scientific Advisor, Consulting fee

A review of the value of quadrivalent influenza vaccines and their potential contribution to influenza control

The contribution of influenza B to the seasonal influenza burden varies from year-to-year. Although 2 antigenically distinct influenza B virus lineages have co-circulated since 2001, trivalent influenza vaccines (TIVs) contain antigens from only one influenza B virus. B-mismatch or co-circulation of both B lineages results in increased morbidity and mortality attributable to the B lineage absent from the vaccine. Quadrivalent vaccines (QIVs) contain both influenza B lineages. We reviewed currently licensed QIVs and their value by focusing on the preventable disease burden. Modeling studies support that QIVs are expected to prevent more influenza cases, hospitalisations and deaths than TIVs, although estimates of the case numbers prevented vary according to local specificities. The value of QIVs is demonstrated by their capacity to broaden the immune response and reduce the likelihood of a B-mismatched season. Some health authorities have preferentially recommended QIVs over TIVs in their influenza prevention programmes.

Waning protection following 5 doses of a 3-component diphtheria, tetanus, and acellular pertussis vaccine

BACKGROUND

The effectiveness of diphtheria, tetanus, and acellular pertussis (DTaP) vaccines wanes substantially after the 5^th dose given at ages 4-6years, but has not been described following 5 doses of the same type of DTaP vaccine. We investigated waning effectiveness against pertussis in California over nearly 10years, which included large pertussis outbreaks, following 5 doses of GSK DTaP vaccines (DTaP₃).

METHODS

We conducted a case-control study (NCT02447978) of children who received 5 doses of DTaP at Kaiser Permanente Northern California from 01/2006 through 03/2015. We compared time since the 5^th dose in confirmed pertussis polymerase chain reaction (PCR)-positive cases with pertussis PCR-negative controls. We used logistic regression adjusted for calendar time, age, sex, race, and service area to estimate the effect of time since the 5^th DTaP dose on the odds of pertussis. Our primary analysis evaluated waning after 5 doses of DTaP₃. We also examined waning after 5 doses of any type of DTaP vaccines.

RESULTS

Our primary analysis compared 340 pertussis cases diagnosed at ages 4-12years with 3841 controls. The any DTaP analysis compared 462 pertussis cases with 5649 controls. The majority of all DTaP doses in the study population were DTaP₃ (86.8%). Children who were more remote from their 5^th dose were less protected than were children whose 5^th dose was more recent; the adjusted odds of pertussis increased by 1.27 per year (95% CI 1.10, 1.46) after 5 doses of DTaP₃ and by 1.30 per year (95% CI 1.15, 1.46) after any 5 DTaP vaccines doses.

CONCLUSIONS

Waning protection after DTaP₃ was similar to that following 5 doses of any type of DTaP vaccines. This finding is not unexpected as most of the DTaP vaccines administered were DTaP_3. Following 5 doses of DTaP₃ vaccines, protection from pertussis waned 27% per year on average. NCT number: NCT02447978.

Value of peripheral blood eosinophil markers to predict severity of asthma

Background

Asthma represents a significant clinical and economic burden to the US healthcare system. Along with other clinical manifestations of the disease, elevated sputum and blood eosinophil levels are observed in patients experiencing asthma exacerbations. The aim of this study was to evaluate the association between blood eosinophil levels and asthma severity defined using Expert Panel Report 3 guidelines.

Methods

Patients with asthma diagnosis between 2004 and 2011 were extracted from the EMRClaims+ database (eMAX Health, White Plains, NY) containing electronic medical records linked to insurance claims for over 675,000 patients. The date of first asthma diagnosis was defined as the ‘index date’. Patients were required to have at least 1 peripheral eosinophil test (elevated defined as ≥ 400 cells/μL) in the 12 month ‘assessment’ period following the index date. We classified patients as those with mild asthma and moderate-to-severe asthma based on the pattern of medication use, as recommended by the 2007 National Institutes of Health Expert Panel Report. Logistic regression models were used to determine if patients with moderate-to-severe asthma had increased likelihood of an elevated peripheral eosinophil count, after accounting for demographics and comorbidities.

Results

Among 1,144 patients with an asthma diagnosis, 60 % were classified as having moderate-to-severe asthma. Twenty four percent of patients with moderate-to-severe asthma and 19 % of patients with mild asthma had an elevated peripheral eosinophil count (p = 0.053). Logistic regression showed that moderate-to-severe asthma was associated with 38 % increased odds of elevated eosinophil level (OR 1.38, 95 % CI: 1.02 to 1.86, p = 0.04).

Conclusion

Patients with moderate-severe asthma are significantly more likely to have an elevated peripheral eosinophil count than patients with mild asthma.

Burden of asthma with elevated blood eosinophil levels

Background

Asthma is a common chronic condition with an economic burden of almost $56 billion annually in the US. Biologic markers like blood eosinophils, that help predict the risk of exacerbation could help guide more optimal treatment plans and reduce cost. The purpose of this study was to determine whether healthcare resource use and expenditures vary by eosinophil level among patients with asthma.

Methods

Patients with a diagnosis of asthma defined by ICD-9-CM code 493.xx between January 2004 and July 2011 were extracted from EMRClaims + database (eMAX Health, White Plains NY). Patients were classified as mild, moderate, or severe by medication use following diagnosis, based on recommendations of National Institutes of Health Expert Panel Report 3. Patients were classified as those with elevated eosinophils (≥400 cells/μL) and normal eosinophil level (<400 cells/μL). Patients were followed for resource use, defined as hospitalizations, ER visits and outpatient visit and associated costs were calculated to assess whether an economic difference exists between eosinophil groups. Non-parametric tests were used to compare resource use and associated cost between elevated and normal eosinophil groups. Multivariate modeling was performed to assess the contribution of eosinophil level on the likelihood of study outcomes among patients with severe asthma.

Results

Among the 2,164 patients meeting eligibility criteria, 1,144 had severity designations. Of these, 179(16 %) of patients had severe asthma of which 20 % (n = 35) had elevated eosinophils. Seventeen percent of patients with elevated eosinophils were admitted to the hospital during the follow-up period, significantly greater than patients with normal eosinophil levels (12 %; p = 0.011). Overall, compared to patients with normal eosinophil levels (n = 1734), patients with elevated eosinophil levels (n = 430) had significantly greater mean annual hospital admissions (0.51 vs. 0.21/year, p = 0.006) and hospital costs (2,536 vs. $1,091, p = 0.011). Logistic regressions showed that elevated eosinophil level was associated with 5.14 times increased odds of all cause admissions (95 % CI:1.76–14.99, p = 0.003) and 4.07 times increased odds of asthma related admissions (95 % CI: 1.26–13.12, p = 0.019).

Conclusion

Eosinophil elevation was associated with greater healthcare resource use in patients with asthma.

ALCOHOL-INVOLVED RAPES: ARE THEY MORE VIOLENT?

Alcohol's psychological, cognitive, and motor effects contribute to rape. Based on theory and past research, we hypothesized that there would be a curvilinear relationship between the quantity of alcohol consumed by perpetrators and how aggressively they behaved. Moderate levels of intoxication encourage aggressiveness; however, extreme levels severely inhibit cognitive and motor capacity. We also hypothesized that victims' alcohol consumption would have a curvilinear relationship to their resistance. These hypotheses were examined with data from 132 college women who had been the victims of attempted or completed rape. Although there was a curvilinear result for perpetrators, the slope of the curve suggested that aggressiveness was worst when no alcohol or the highest levels of alcohol were consumed. There was a negative linear relationship between victims' alcohol consumption and resistance. Difficulties associated with accurately assessing degree of intoxication from survey data are discussed and suggestions are made for improving alcohol measurement in rape research.

Estimated incidence of pertussis in people aged <50 years in the United States

The introduction of pertussis vaccination in the United States (US) in the 1940s has greatly reduced its burden. However, the incidence of pertussis is difficult to quantify, as many cases are not laboratory-confirmed or reported, particularly in adults. This study estimated pertussis incidence in a commercially insured US population aged <50 years. Data were extracted from IMS' PharMetrics Plus claims database for patients with a diagnosis of pertussis or cough illness using International Classification of Diseases (ICD-9) codes, a commercial outpatient laboratory database for patients with a pertussis laboratory test, and the Centers for Disease Control influenza surveillance database. US national pertussis incidence was projected using 3 methods: (1) diagnosed pertussis, defined as a claim for pertussis (ICD-9 033.0, 033.9, 484.3) during 2008–2013; (2) based on proxy pertussis predictive logistic regression models; (3) using the fraction of cough illness (ICD-9 033.0, 033.9, 484.3, 786.2, 466.0, 466.1, 487.1) attributed to laboratory-confirmed pertussis, estimated by time series linear regression models. Method 1 gave a projected annual incidence of diagnosed pertussis of 9/100,000, which was highest in those aged <1 year. Method 2 gave an average annual projected incidence of 21/100,000. Method 3 gave an overall regression-estimated weighted annual incidence of pertussis of 649/100,000, approximately 58–93 times higher than method 1 depending on the year. These estimations, which are consistent with considerable underreporting of pertussis in people aged <50 years and provide further evidence that the majority of cases go undetected, especially with increasing age, may aid in the development of public health programs to reduce pertussis burden.

ReCAP: Treatment Patterns and Cost of Care Associated With Initial Therapy Among Patients Diagnosed With Operable Early-Stage Human Epidermal Growth Factor Receptor 2-Overexpressed Breast Cancer in the United States: A Real-World Retrospective Study

PURPOSE

Overexpression of the human epidermal growth factor receptor 2 (HER2) protein negatively affects survival in breast cancer. This study aimed to assess real-world treatment patterns and costs associated with resected nonmetastatic HER2-positive breast cancer in the United States.

PATIENTS AND METHODS

Commercially insured patients with HER2-positive breast cancer were identified from oncology registry data linked to a large US commercial administrative claims database. Treatment patterns and health care use and costs in the initial phase of care were examined.

RESULTS

Among the 915 patients who met the study criteria, 662 (72%) were hormone receptor (HR) positive, and 253 (28%) were HR negative. Overall, 72% (n = 662) of patients received HER2-targeted therapy (HR positive, 69% v HR negative, 80%; P < .01), specifically trastuzumab. The most common treatment regimens, regardless of HR status, were carboplatin, docetaxel, and trastuzumab (47% of patients) during neoadjuvant therapy and carboplatin, docetaxel, and trastuzumab ± hormone therapy (30% of patients) during adjuvant therapy. Overall unadjusted cost of treatment per patient per month (HR positive, $11,906 v HR negative, $14,367; P < .001) was mainly cancer related (HR positive, $10,513 v HR negative, $13,073; P < .001). Adjusted 12-month cost was $176,779 (HR positive, $167,088 v HR negative, $180,226; P > .05).

CONCLUSION

Although trastuzumab-based therapy is considered standard of care among patients with HER2-positive early-stage breast cancer, approximately 28% of these patients did not receive HER2-targeted therapy. Additional studies are warranted to examine whether patients who have not received targeted therapy are eligible for and would benefit from an HER2-targeted approach.

Abstract P4-15-10: Initial therapy among patients newly diagnosed with operable early stage human epidermal growth factor receptor 2-overexpressed (HER2+) breast cancer in the US: A real-world retrospective study

BACKGROUND: Prognosis and appropriate treatment of breast cancer patients (pts) is influenced by tumor molecular characteristics. However, few existing retrospective studies have investigated the treatment patterns and outcomes of breast cancer pts by tumor biomarkers. The objective of this study was to assess the current real-world treatment patterns associated with resected non-metastatic HER2+ breast cancer in the US.

METHODS: This was a retrospective study of physician-reported clinical information (including date and stage at diagnosis, HER2 status and hormone receptor (HR) status) for commercially insured breast cancer pts from the Oncology Management Registry linked with medical and pharmacy claims from a large, national health plan in the US from 01/2008 to 8/2013. The date of initial diagnosis was the index date. The inclusion criteria were: adult pts (≥18 years old), enrolled in the health plan for ≥6 months after the index date, diagnosed with HER2+ Stage I-III disease, known HR status, received breast cancer specific surgery (mastectomy or lumpectomy) and anti-cancer systemic therapy (ACST) and/or radiation within 6 months of index date. Pts with other primary cancers during the study period were excluded. The initial phase of care included initial therapy (surgery and ACST and/or radiation) until 30 days after the last therapy received (surgery, ACST or radiation) prior to a 90-day gap in treatment. Treatment patterns during the initial phase of care by HR status were examined.

RESULTS: Among 915 pts who met all study criteria, 662 (72%) and 253 (28%) were HR+ and HR-, respectively. Mean age was 52 years (standard deviation=9) and was not significantly different by HR cohort. Approximately 82% (n=749) were diagnosed with Stage I/II disease. Most pts (80%, n=732) received adjuvant therapy only, 19% (n=177) received both neo-adjuvant and adjuvant therapy, and &lt;1% (n=6) were observed to have neo-adjuvant therapy only. Among pts who received neo-adjuvant therapy, mean time from diagnosis to ACST was 21 days (median=21). Among pts who received only adjuvant therapy, mean time from diagnosis to initial breast cancer specific surgery was 24 days (median=20). Overall, 72% of pts received HER2 targeted therapy (69% HR+, 80% HR-; p&lt;0.01) during their initial phase of care. During neo-adjuvant therapy, 72% of pts received trastuzumab (67% HR+, 81% HR-; p&lt;0.05). During adjuvant therapy, 72% of pts received trastuzumab (69% HR+, 81% HR-; p&lt;0.05). The most common neo-adjuvant regimen regardless of HR status was carboplatin+docetaxel+trastuzumab (&gt;40% pts). The most common regimens during the adjuvant therapy period were carboplatin+docetaxel+trastuzumab with or without hormone therapy (∼30% of pts).

CONCLUSION: In this real-world population of commercially insured breast cancer pts treated for operable, early stage HER2+ disease in the US, 28% of pts did not receive targeted therapy. More pts with HR- status received targeted therapy than those with HR+ status. Further studies are warranted to examine whether pts that have not received targeted therapy are eligible and would benefit from an HER2 targeted approach.

Citation Format: Stacey DaCosta Byfield, Philip O Buck, Cori Blauer-Peterson, Sara A Poston. Initial therapy among patients newly diagnosed with operable early stage human epidermal growth factor receptor 2-overexpressed (HER2+) breast cancer in the US: A real-world retrospective 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 P4-15-10.

Treatment Patterns and Health Resource Utilization Among Patients Diagnosed With Early Stage Resected Non-Small Cell Lung Cancer at US Community Oncology Practices

Data on adjuvant therapy in resected non-small cell lung cancer (NSCLC) in routine practice are lacking in the United States. This retrospective observational database study included 609 community oncology patients with resected stage IB to IIIA NSCLC. Use of adjuvant therapy was 39.1% at disease stage IB and 64.9% to 68.2% at stage II to IIIA. The most common regimen at all stages was carboplatin and paclitaxel.

BACKGROUND

Platin-based adjuvant chemotherapy has extended survival in clinical trials in patients with completely resected non-small cell lung cancer (NSCLC). There are few data on the use of adjuvant therapy in community-based clinical practice in the United States.

MATERIALS AND METHODS

This was a retrospective observational study using electronic medical record and billing data collected during routine care at US community oncology sites in the Vector Oncology Data Warehouse between January 2007 and January 2014. Patients aged ≥ 18 years with a primary diagnosis of stage IB to IIIA NSCLC were eligible if they had undergone surgical resection. Treatment patterns, health care resource use, and cost were recorded, stratified by stage at diagnosis.

RESULTS

The study included 609 patients (mean age, 64.8 years, 52.9% male), of whom 215 had stage IB disease, 130 stage IIA/II, 110 stage IIB, and 154 stage IIIA. Adjuvant systemic therapy after resection was provided to 345 (56.7%) of 609 patients, with lower use in patients with stage IB disease (39.1%) than stage II to IIIA disease (64.9-68.2%) (P < .0001). The most common adjuvant regimen at all stages was the combination of carboplatin and paclitaxel. There were no statistically significant differences in office visits or incidence of hospitalization by disease stage. During adjuvant treatment, the total monthly median cost per patient was $17,389.75 (interquartile range, $8,815.61 to $23,360.85).

CONCLUSION

Adjuvant systemic therapy was used in some patients with stage IB NSCLC and in the majority of patients with stage IIA to IIIA disease. There were few differences in regimen or health care resource use by disease stage.

Examination of the UPDRS bradykinesia subscale: equivalence, reliability and validity

Administering items or subscales separately from the measure for which they were designed to be a part may have unintended consequences for research and practice in Parkinson's disease (PD). The current study tested the equivalence of the bradykinesia subscale when administered alone versus as a component of the full 14-item Unified Parkinson's Disease Rating Scale (UPDRS) motor examination, as well as examined the reliability and validity of the bradykinesia subscale. The study sample consisted of 112 patients with PD. Patients were randomly assigned to either the bradykinesia subscale alone group (n = 56), who were administered the bradykinesia subscale separately from the rest of the UPDRS motor examination, or the full scale group (n = 56), who were administered the UPDRS motor examination in its standard format. The two one-sided t-test (TOST) procedure was used to test for mean equivalency between the two administration groups. Additionally, reliability and validity analyses were performed. The bradykinesia subscale mean scores from the full scale group and the subscale alone group were not statistically equivalent. However, in both groups, the bradykinesia subscale had exceptional reliability and was strongly and similarly related to age, activities of daily living, disability, and other assessments of motor symptom severity. The bradykinesia subscale is a valid and reliable assessment when administered separately from the rest of the UPDRS motor examination; however, caution should be taken when comparing mean scores across studies or occasions when different administrations are used.

Improving asthma management: the case for mandatory inclusion of dose counters on all rescue bronchodilators

Background

Asthma remains a serious global health challenge. Poor control of asthma symptoms is due in part to incorrect use of oral inhaler devices that deliver asthma medications, such as poor inhalation technique or use of a metered dose inhaler (MDI) after the recommended number of doses is expelled.

Objective

To review published research on the potential for patients to overestimate or underestimate the amount of asthma rescue medication in MDIs without integrated dose-counting mechanisms.

Methods

We searched PubMed and EMBASE using search terms “dose counter and asthma” and “dose counter and metered dose inhaler” for English language publications up to July, 2012, with a manual search of references from relevant articles.

Results

Up to 40% of patients believe they are taking their asthma medication when they actually are activating an empty or nearly empty MDI. Device design makes it impossible for an MDI to cease delivering drug doses at an exact point, and the number of actuations in an MDI may be twice the nominal number of recommended medication doses. Once the recommended number of medication doses is expelled, remaining actuations deliver decreasing concentrations of active medication and increasing concentrations of propellants and excipients. This phenomenon, called “tail-off,” is particularly problematic when medications are formulated as suspensions, as are rescue medications to control acute bronchospasm. Reliable inhalation of rescue medication could reduce asthma-related morbidity.

Conclusion

By helping to ensure that patients receive accurate metered doses of asthma rescue medication to relieve bronchoconstriction, dose counters may help to improve asthma management.

Medical costs and adherence in patients receiving aqueous versus pressurized aerosol formulations of intranasal corticosteroids

Intranasal corticosteroid (INS) formulations have different sensory attributes that influence patient preferences, and thereby possibly adherence and health outcomes. This study compares health care use and costs and medication adherence in matched cohorts of patients with allergic rhinitis (AR) using a chlorofluorocarbon-propelled pressurized metered-dose inhaler (pMDI) or aqueous intranasal corticosteroid (A-INS). Florida Medicaid retrospective claims analysis was performed of enrollees aged ≥12 years with at least 1 year of continuous enrollment before their initial AR diagnosis, 1 year for continuous enrollment before their index INS claim, and 18 months of continuous enrollment after their index INS claim during which they received either pMDI or A-INS. pMDI and A-INS patients were matched 1:2 using propensity scores. Nonparametric analyses compared outcomes between matched cohorts at 6, 12, and 18 months of follow-up. A total of 585 patients were matched (pMDI = 195, A-INS = 390). pMDI patients were more adherent to INS, as reflected in their higher median medication possession ratio (53.2% versus 32.7%; p < 0.0001) and fewer median days between fills (73 days versus 111 days; p = 0.0003). Significantly lower median per patient pharmacy fills (34.0 versus 50.5; p < 0.05) and costs ($1282 versus $2178; p < 0.01) were observed among pMDI patients versus A-INS patients 18 months after INS initiation and were maintained when analyses excluded INS fills. Adherence to INS and health care utilization and costs following INS initiation for AR differed by type of formulation received. Our findings suggest patient preferences for INS sensory attributes can drive adherence and affect disease control, and ultimately impact health care costs.

Psychometric validation of the revised SCOPA-Diary Card: expanding the measurement of non-motor symptoms in Parkinson's disease

Background

To identify key non-motor symptoms of Parkinson's disease (PD) to include in a daily diary assessment for off-time, revise the Scales for Outcomes of Parkinson's disease Diary Card (SCOPA-DC) to include these non-motor symptoms, and investigate the validity, reliability and predictive utility of the Revised SCOPA-DC in a U.S. population.

Methods

A convenience sample was used to recruit four focus groups of PD patients. Based on findings from focus groups, the SCOPA-DC was revised and administered to a sample of 101 PD patients. Confirmatory factor analysis was conducted to test the domain structure of the Revised SCOPA-DC. The reliability, convergent and discriminant validity, and ability to predict off-time of the Revised SCOPA-DC were then assessed.

Results

Based on input from PD patients, the Revised SCOPA-DC included several format changes and the addition of non-motor symptoms. The Revised SCOPA-DC was best represented by a three-factor structure: Mobility, Physical Functioning and Psychological Functioning. Correlations between the Revised SCOPA-DC and other Health-Related Quality of Life scores were supportive of convergent validity. Known-groups validity analyses indicated that scores on the Revised SCOPA-DC were lower among patients who reported experiencing off-time when compared to those without off-time. The three subscales had satisfactory predictive utility, correctly predicting off-time slightly over two-thirds of the time.

Conclusions

These findings provide evidence of content validity of the Revised SCOPA-DC and suggest that a three-factor structure is an appropriate model that provides reliable and valid scores to assess symptom severity among PD patients with symptom fluctuations in the U.S.

Tolerability and safety of novel half milliliter formulation of glatiramer acetate for subcutaneous injection: an open-label, multicenter, randomized comparative study

Daily glatiramer acetate (GA) 20 mg/1.0 mL is a first-line treatment for relapsing-remitting multiple sclerosis (RRMS). To reduce the occurrence of injection pain and local injection site reactions (LISRs), a reduced volume formulation of GA was developed. This study compared pain and LISRs after injecting the marketed and the novel formulations. RRMS patients currently injecting GA participated in this multicenter, randomized, crossover comparative study. All patients administered once-daily subcutaneous injections of GA 20 mg/1.0 mL (marketed formulation) or GA 20 mg/0.5 mL (reduced volume formulation) for 14 days. Patients were crossed-over to the alternate treatment for an additional 14 days. Using a Visual Analog Scale (VAS), patients recorded in daily diaries the severity of injection pain immediately and 5 min post-injection, and the presence and severity of LISRs (swelling, redness, itching, lump) within 5 min and 24 h post-injection. VAS pain scores were ranked significantly lower immediately and 5 min after GA 20 mg/0.5 mL injections (p < 0.0001). Although LISRs were rare for both preparations, the severity of reactions ranked significantly lower and fewer symptoms occurred within 5 min and 24 h of using the reduced volume formulation (p < 0.0001). GA injected subcutaneously in a reduced volume formulation is a more tolerable option.

Condom use with a casual partner: what distinguishes college students' use when intoxicated?

Determining alcohol's precise role in sexual risk taking has proven to be an elusive goal. Past research has produced mixed results, depending on characteristics of individuals, their partners, and the situation, as well as how the link between alcohol consumption and sexual behavior was assessed. In this study, cross-sectional predictors of the frequency of condom use were examined for 298 heterosexual college students at a large urban university. In hierarchical multiple regression analyses that controlled for frequency of condom use when sober, alcohol expectancies regarding sexual risk taking and self-efficacy regarding condom use when intoxicated were significant predictors of frequency of condom use when intoxicated. These findings highlight the importance of targeting beliefs about alcohol's disinhibiting effects in STD- and HIV-prevention programs.

Understanding alcohol expectancy effects: revisiting the placebo condition

This article summarizes a symposium organized and cochaired by Maria Testa and presented at the 2005 Annual Meeting of the Research Society on Alcoholism, in Santa Barbara, California. The symposium explored issues relevant to understanding the function of placebo conditions and to interpreting placebo effects. Cochair Mark Fillmore began with an overview of the use of placebo conditions in alcohol research, focusing on methodological issues. Jeanette Norris and her colleagues conducted a review of studies examining placebo conditions among women. They conclude that expectancy effects are limited to a few domains. Maria Testa and Antonia Abbey presented papers suggesting that placebo manipulations may result in unanticipated compensatory effects in actual or hypothetical social situations. That is, placebo participants may compensate for anticipated cognitive impairment through vigilant attention to situational cues. John Curtin's research suggests that the compensatory strategies of placebo participants appear to involve a sensitization of evaluative control, resulting in improved performance. Kenneth Leonard provided concluding remarks on the meaning of placebo effects and the value of placebo conditions in research.

Understanding alcohol expectancy effects: revisiting the placebo condition

This article summarizes a symposium organized and cochaired by Maria Testa and presented at the 2005 Annual Meeting of the Research Society on Alcoholism, in Santa Barbara, California. The symposium explored issues relevant to understanding the function of placebo conditions and to interpreting placebo effects. Cochair Mark Fillmore began with an overview of the use of placebo conditions in alcohol research, focusing on methodological issues. Jeanette Norris and her colleagues conducted a review of studies examining placebo conditions among women. They conclude that expectancy effects are limited to a few domains. Maria Testa and Antonia Abbey presented papers suggesting that placebo manipulations may result in unanticipated compensatory effects in actual or hypothetical social situations. That is, placebo participants may compensate for anticipated cognitive impairment through vigilant attention to situational cues. John Curtin's research suggests that the compensatory strategies of placebo participants appear to involve a sensitization of evaluative control, resulting in improved performance. Kenneth Leonard provided concluding remarks on the meaning of placebo effects and the value of placebo conditions in research.

The effects of acute alcohol consumption, cognitive reserve, partner risk, and gender on sexual decision making

OBJECTIVE

In past alcohol administration studies, intoxicated college students have been more willing to have unprotected sex with a hypothetical new partner than sober or placebo students. The objective of the present research was to extend past work by examining the effects of gender, cognitive reserve, and partner risk on intoxicated sexual decision making.

METHOD

Before assigning participants (60 women and 60 men) to a drink condition, cognitive reserve was assessed with the reading subtest of the Wide Range Achievement Test 3 (WRAT3). After drinking, participants watched a video of a male and female college student in a sexual situation. There were two versions of the video that were identical, except for information that suggested the opposite-gender character had many past sexual partners or only a few.

RESULTS

There was a significant interaction between drink condition and cognitive reserve such that intoxicated participants with lower WRAT3 scores were more likely than other participants to indicate that they would have unprotected sex if they were in this situation. Partner risk did not influence participants' willingness to have unprotected sex; however, they were less interested in dating the high-risk partner.

CONCLUSIONS

As expected, participants with less cognitive reserve made riskier decisions when intoxicated. Unexpectedly, although participants clearly perceived the high- and low-risk partners differently, this did not affect their willingness to have unprotected sex with this hypothetical partner. These findings demonstrate the need for sexually transmitted disease/ HIV prevention programs that go beyond factual presentations and provide students with the skills they need to assess risk realistically and the need for programs with messages tailored for individuals with low cognitive skills.

Explicating alcohol's role in acquaintance sexual assault: complementary perspectives and convergent findings

This article summarizes the proceedings of a symposium presented at the 2004 meeting of the Research Society on Alcoholism (RSA) in Vancouver, British Columbia, Canada. There were four presentations and a discussant. The symposium was co-chaired by Tina Zawacki and Jeanette Norris. The first presentation was made by Jeanette Norris, who found that alcohol consumption and preexisting alcohol expectancies affected women's hypothetical responses to a vignette depicting acquaintance sexual aggression. The second presentation was made by Joel Martell, who reported that alcohol-induced impairment of executive cognitive functioning mediated the effect of intoxication on men's perceptions of a sexual assault vignette. In the third presentation, Antonia Abbey found that the experiences of women whose sexual assault involved intoxication or force were more negative than were the experiences of women whose sexual assault involved verbal coercion. The fourth presentation was made by Tina Zawacki, who reported that men who perpetrated sexual assault only in adolescence differed from men who continued perpetration into adulthood in terms of their drinking patterns and attitudes toward women. William H. George discussed these findings in terms of their implications for theory development and prevention programming.

THE EFFECTS OF PAST SEXUAL ASSAULT PERPETRATION AND ALCOHOL CONSUMPTION ON MEN'S REACTIONS TO WOMEN'S MIXED SIGNALS

Theories about misperception of sexual intent, cognitive distortions among rapists, and alcohol's effects on cognition describe processes that may contribute to acquaintance sexual assault. Drawing on these literatures, an experiment was conducted to examine hypotheses about the effects of past sexual assault perpetration and alcohol consumption on 153 college men's reactions to a female confederate. As compared to nonperpetrators, self-acknowledged rapists and verbal coercers reported being more sexually attracted to the confederate. Trained coders were least certain that rapists noticed specific positive and negative cues that the confederate used and most certain that verbal coercers did. Intoxicated participants perceived themselves and their partner as acting more sexually than did sober or placebo participants. Suggestions are discussed for research and treatment programs with college sexual assault perpetrators.

Sexual assault and alcohol consumption: what do we know about their relationship and what types of research are still needed?

Approximately half of all sexual assaults are associated with either the perpetrator's alcohol consumption, the victim's alcohol consumption, or both. Although the emphasis of this review is on alcohol-involved sexual assaults, their unique aspects can only be evaluated by comparing them to other types of sexual assault. Theoretical perspectives on sexual assault that focus on characteristics of the perpetrator, the victim, and the situation are described. A number of personality traits, attitudes, and past experiences have been systematically linked to sexual assault perpetration, including beliefs about alcohol and heavy drinking. In contrast, only a few experiences have been significantly related to sexual assault victimization, including childhood sexual abuse and heavy drinking. There is support for both psychological and pharmacological mechanisms linking alcohol and sexual assault. Beliefs about alcohol's effects reinforce stereotypes about gender roles and can exacerbate their influence on perpetrators' actions. Alcohol's effects on cognitive and motor skills also contribute to sexual assault through their effects on perpetrators' and victims' ability to process and react to each other's verbal and nonverbal behavior. Limitations with existing research and methodological challenges associated with conducting research on this topic are described. Suggestions are made for future research which can inform prevention and treatment programs.

Perpetrators of Alcohol-Involved Sexual Assaults: How Do They Differ From Other Sexual Assault Perpetrators and Nonperpetrators?

Approximately 50% of sexual assaults involve alcohol. Researchers have documented situational characteristics that distinguish between sexual assaults that do and do not involve alcohol, but little attention has been paid to differences between the perpetrators of these two types of assault. In this study, discriminant function analysis was used to distinguish between college men (N = 356) who reported perpetrating sexual assault that involved alcohol, sexual assault that did not involve alcohol, or no sexual assault. Predictors of sexual assault perpetration that have been documented in past research differentiated nonperpetrators from both types of perpetrators. Perpetrators of sexual assaults that involved alcohol were in most ways similar to perpetrators of sexual assaults that did not, although they did differ on impulsivity, alcohol consumption in sexual situations, and beliefs about alcohol. These findings suggest mechanisms through which alcohol is involved in sexual assault that are relevant to theory and prevention.

The relationship between the quantity of alcohol consumed and the severity of sexual assaults committed by college men

Researchers have suggested that intoxicated perpetrators may act more violently than other perpetrators, although empirical findings have been mixed. Past research has focused on whether or not alcohol was consumed, rather than the quantity consumed, and this may explain these inconsistent findings. The authors hypothesized that the quantity of alcohol consumed would have a curvilinear relationship to the severity of the assault. Data were collected from 113 college men who reported that they had committed a sexual assault since the age of 14. The quantity of alcohol that perpetrators consumed during the assault was linearly related to how much aggression they used and was curvilinearly related to the type of sexual assault committed. The quantity of alcohol that victims consumed during the assault was linearly related to the type of sexual assault committed. Strategies for improving assessment of alcohol consumption in sexual assault research are discussed.