Economic Assessment of High-Dose Versus Adjuvanted Influenza Vaccine:An Evaluation of Hospitalization Costs Based on a Cohort Study

Two influenza vaccines are licensed in the U.S. exclusively for the 65 years and older population: a trivalent inactivated high-dose influenza vaccine (HD-IIV3) and a trivalent inactivated adjuvanted influenza vaccine (aIIV3). In a recent publication, we estimated a relative vaccine effectiveness (rVE) of HD-IIV3 vs. aIIV3 of 12% (95% CI: 3.3–20%) for influenza-related hospitalizations using a retrospective study design, but did not report the number of prevented hospitalizations nor the associated avoided cost. In this paper we report estimations for both. Methods: Leveraging the rVE of a cohort study over two influenza seasons (2016/17 and 2017/18), we collected cost data for healthcare provided to the same study population. Vaccine costs were obtained from the Medicare pricing schedule. Our economic assessment compared cost of vaccination and hospital care for patients experiencing acute respiratory or cardiovascular illness. Results: We analyzed 1.9 million HD-IIV3 and 223,793 aIIV3 recipients. Average vaccine list prices were $46.23 for HD-IIV3 and$48.26 for aIIV3. The hospitalization rates for respiratory disease in HD-IIV3 and aIIV3 recipients were 187 (95% CI: 185–189) and 212 (195–231) per 10,000 persons-years, respectively. Attributing the average cost per hospitalization of $12,652 ($12,214–$13,090) to the difference in hospitalization rates, we estimate net savings of HD-IIV3 to be$34 ($10–$62) per recipient. Conclusion: Pooled over two predominantly A/H3N2 respiratory seasons, vaccination with HD-IIV3 was associated with lower hospitalization rates and associated costs compared to aIIV3 in senior members of a large national managed health care company in the U.S. Reduced hospitalizations affect healthcare utilization overall, and therefore other costly health outcomes

Comparative effectiveness of high dose versus adjuvanted influenza vaccine:A retrospective cohort study

Background: Adults 65 years and older (seniors) experience more complications following influenza infection than younger adults. We estimated the relative vaccine effectiveness (rVE) of a trivalent high dose (HD-IIV3) versus an adjuvanted trivalent influenza vaccine (aIIV3) in seniors for respiratory-related hospitalizations. Methods: We conducted a retrospective cohort study using claims data from Optum's Clinformatics® Data Mart to compare outcome rates between seniors who received HD-IIV3 versus aIIV3 during the 2016/17 and 2017/18, predominantly A/H3N2 respiratory seasons. Rates were adjusted for demographic characteristics, comorbid conditions, previous influenza vaccination, and geography. We used the previous event rate ratio (PERR) approach to address bias by time-fixed unmeasured confounders. Results: We identified 842,282 HD-IIV3 and 34,157 aIIV3 recipients for the 2016/17 season and 1,058,638 HD-IIV3 and 189,636 aIIV3 recipients for the 2017/18 season. The pooled rVE of HD-IIV3 versus aIIV3 for respiratory-related hospitalizations over both seasons was 12% (95% confidence interval: 3.3%–20%); 13% (−6.4% to 32%) for the 2016/17 season and 12% (2.1%–21%) for the 2017/18 season. Conclusions: Pooled over two predominantly A/H3N2 respiratory seasons, HD-IIV3 was associated with fewer respiratory hospital admissions than aIIV3 in senior members of large national managed health care company in the U.S

Risk factors for pneumonia and influenza hospitalizations in long-term care facility residents:a retrospective cohort study

Abstract Background Older adults who reside in long-term care facilities (LTCFs) are at particularly high risk for infection, morbidity and mortality from pneumonia and influenza (P&I) compared to individuals of younger age and those living outside institutional settings. The risk factors for P&I hospitalizations that are specific to LTCFs remain poorly understood. Our objective was to evaluate the incidence of P&I hospitalization and associated person- and facility-level factors among post-acute (short-stay) and long-term (long-stay) care residents residing in LTCFs from 2013 to 2015. Methods In this retrospective cohort study, we used Medicare administrative claims linked to Minimum Data Set and LTCF-level data to identify short-stay (< 100 days, index = admission date) and long-stay (100+ days, index = day 100) residents who were followed from the index date until the first of hospitalization, LTCF discharge, Medicare disenrollment, or death. We measured incidence rates (IRs) for P&I hospitalization per 100,000 person-days, and estimated associations with baseline demographics, geriatric syndromes, clinical characteristics, and medication use using Cox regression models. Results We analyzed data from 1,118,054 short-stay and 593,443 long-stay residents. The crude 30-day IRs (95% CI) of hospitalizations with P&I in the principal position were 26.0 (25.4, 26.6) and 34.5 (33.6, 35.4) among short- and long-stay residents, respectively. The variables associated with P&I varied between short and long-stay residents, and common risk factors included: advanced age (85+ years), admission from an acute hospital, select cardiovascular and respiratory conditions, impaired functional status, and receipt of antibiotics or Beers criteria medications. Facility staffing and care quality measures were important risk factors among long-stay residents but not in short-stay residents. Conclusions Short-stay residents had lower crude 30- and 90-day incidence rates of P&I hospitalizations than long-stay LTCF residents. Differences in risk factors for P&I between short- and long-stay populations suggest the importance of considering distinct profiles of post-acute and long-term care residents in infection prevention and control strategies in LTCFs. These findings can help clinicians target interventions to subgroups of LTCF residents at highest P&I risk

1829. A Systems Approach to Nursing Home Antimicrobial Stewardship

Background: Up to 70% of nursing home (NH) residents receive one or more courses of antibiotics (ATB) annually, of which over half may be inappropriate and risk harm. The current availability of in-house NH data is often insufficient to measure and track appropriateness, due to incomplete data or unusable formatting. Our 3-year project to improve antimicrobial stewardship (AMS) used the Centers for Disease Control and Prevention’s (CDC) Core Elements of AMS for NHs, with guided input from NH providers to develop and implement an electronic ATB de-escalation decision support tool that also captures otherwise inaccessible data. Methods: Our baseline assessment identified wide variation in providers’ knowledge, attitudes, and beliefs regarding ATB prescribing, leading us to identify de-escalation as the most feasible NH AMS intervention. Using facilitated open-ended conversations with leaders from three NH corporations, we developed an electronic decision support tool to systematically prompt de-escalation 48–72 hours post-prescribing. Subsequent site visits with NH clinical teams at a convenience sample of sites allowed us to explore how to incorporate decision support into their electronic health record (EHR). Results: We developed a tool anchored on data capture for the “acute change in condition” that triggers prescriber interactions. It uses clinical and laboratory data to prompt structured communication between nurses and prescribers. Placing this tool in the EHR reduced duplicate charting, enabled guidance from McGeer and Loeb criteria, and promoted its adoption into practice while ensuring data capture to assess appropriateness of ATB prescribing. Conclusion: Our electronic decision support tool captures clinical and laboratory data, which it then uses to systematically prompt conversations about de-escalation between nurses and prescribers, reducing variation in practice. Upon completion, the assessment ensures availability of data to assess, track, and report appropriate prescribing practices among prescribers. This tool proved acceptable to NH providers in three different corporations, suggesting feasibility of further expansion of this approach to a broader group of NH providers

The Influence of Multimorbidity on Leading Causes of Death in Older Adults With Cognitive Impairment

Objective: The aim of this study is to evaluate the relationship of leading causes of death with gradients of cognitive impairment and multimorbidity. Method: This is a population-based study using data from the linked 1992- 2010 Health and Retirement Study and National Death Index (n = 9,691). Multimorbidity is defined as a combination of chronic conditions, functional limitations, and geriatric syndromes. Regression trees and Random Forest identified which combinations of multimorbidity associated with causes of death. Results: Multimorbidity is common in the study population. Heart disease is the leading cause in all groups, but with a larger percentage of deaths in the mild and moderate/severe cognitively impaired groups than among the noncognitively impaired. The different “paths” down the regression trees show that the distribution of causes of death changes with different combinations of multimorbidity. Discussion: Understanding the considerable heterogeneity in chronic conditions, functional limitations, geriatric syndromes, and causes of death among people with cognitive impairment can target care management and resource allocation

Variation in influenza vaccine assessment, receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes

BACKGROUND: More older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents. METHODS: We analyzed 2014–2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination. RESULTS: There were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (−3.10 pp, 95% CL: −3.53 pp, −2.68 pp), or high (−4.63 pp, 95% CL: −5.11 pp, −4.15 pp) MA compared with NHs with the lowest prevalence of MA. CONCLUSION: A higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings

Estimated Cardiorespiratory Hospitalizations Attributable to Influenza and Respiratory Syncytial Virus Among Long-term Care Facility Residents

IMPORTANCE: Older adults residing in long-term care facilities (LTCFs) are at a high risk of being infected with respiratory viruses, such as influenza and respiratory syncytial virus (RSV). Although these infections commonly have many cardiorespiratory sequelae, the national burden of influenza- and RSV-attributable cardiorespiratory events remains unknown for the multimorbid and vulnerable LTCF population. OBJECTIVE: To estimate the incidence of cardiorespiratory hospitalizations that were attributable to influenza and RSV among LTCF residents and to quantify the economic burden of these hospitalizations on the US health care system by estimating their associated cost and length of stay. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used national Medicare Provider Analysis and Review inpatient claims and Minimum Data Set clinical assessments for 6 respiratory seasons (2011-2017). Long-stay residents of LTCFs were identified as those living in the facility for at least 100 days (index date), aged 65 years or older, and with 6 months of continuous enrollment in Medicare Part A were included. Follow-up occurred from the resident’s index date until the first hospitalization, discharge from the LTCF, disenrollment from Medicare, death, or the end of the study. Residents could re-enter the sample; thus, long-stay episodes of care were identified. Data analysis was performed between January 1 and September 30, 2020. EXPOSURES: Seasonal circulating pandemic 2009 influenza A(H1N1), human influenza A(H3N2), influenza B, and RSV. MAIN OUTCOMES AND MEASURES: Cardiorespiratory hospitalizations (eg, asthma exacerbation, heart failure) were identified using primary diagnosis codes. Influenza- and RSV-attributable cardiorespiratory events were estimated using a negative binomial regression model adjusted for weekly circulating influenza and RSV testing data. Length of stay and costs of influenza- and RSV-attributable events were then estimated. RESULTS: The study population comprised 2 909 106 LTCF residents with 3 138 962 long-stay episodes and 5 079 872 person-years of follow-up. Overall, 10 939 (95% CI, 9413-12 464) influenza- and RSV-attributable cardiorespiratory events occurred, with an incidence of 215 (95% CI, 185-245) events per 100 000 person-years. The cost of influenza- and RSV-attributable cardiorespiratory events was $91 055 393 (95$77 885 316-$104 225 470), and the length of stay was 56 858 (95% CI, 48 757-64 968) days. CONCLUSIONS AND RELEVANCE: This study found that many cardiorespiratory hospitalizations among LTCF residents in the US were attributable to seasonal influenza and RSV. To minimize the burden these events place on the health care system and residents of LTCFs and to prevent virus transmission, additional preventive measures should be implemented

Persistence of Racial Inequities in Receipt of Influenza Vaccination among Nursing Home Residents in the United States

BACKGROUND: We sought to determine if the racial differences in influenza vaccination among nursing home (NH) residents during the 2008-09 influenza season persisted in 2018-19. METHODS: We conducted a cross-sectional study of NHs certified by the U.S. Centers for Medicare & Medicaid Services during the 2018-19 influenza season in U.S. states with ≥ 1% black NH residents and a white-black gap in influenza vaccination of NH residents (N=2,233,392) of at least one percentage point (N=40 states). NH Residents during October 1, 2018 through March 31, 2019 aged ≥ 18 years and self-identified as black or white race were included. Residents' influenza vaccination status (vaccinated, refused, and not offered) was assessed. Multilevel modeling was used to estimate facility-level vaccination status and inequities by state. RESULTS: The white-black gap in influenza vaccination was 9.9 percentage points. In adjusted analyses, racial inequities in vaccination were more prominent at the facility- than at the state-level. Black residents disproportionately lived in NHs with majority blacks, which generally had the lowest vaccination. Inequities were most concentrated in the Midwestern region, also the most segregated. Not being offered the vaccine was negligible by difference in absolute percentage points among whites (2.6%) and blacks (4.8%) whereas refusals were higher among black (28.7%) than white residents (21.0%). CONCLUSIONS: The increase in the white-black vaccination gap among NH residents is occurring at the facility-level, in more states, especially those with the most segregation. Standing orders for vaccinations, previously reported to narrow the racial gap in vaccination among NH residents, should be considered

Geographic Variation in Pneumonia and Influenza in Long-Term Care Facilities:A National Study

There is large county-level geographic variation in pneumonia and influenza hospitalizations among short-stay and long-stay long-term care facility residents in the United States. Long-term care facilities in counties in the Southern and Midwestern regions had the highest rates of pneumonia and influenza from 2013 to 2015. Future research should identify reasons for these geographic differences

Causes and timing of 30-day rehospitalization from skilled nursing facilities after a hospital admission for pneumonia or sepsis

BACKGROUND: Pneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis. METHODS AND FINDINGS: This national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up. CONCLUSION: Among older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions