Publications by authors named "Robertus van Aalst"

31 Publications

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

Vaccines (Basel) 2021 Sep 24;9(10). Epub 2021 Sep 24.

Vaccine Epidemiology and Modelling, Sanofi Pasteur, Swiftwater, PA 18370, USA.

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.
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http://dx.doi.org/10.3390/vaccines9101065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8540428PMC
September 2021

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

JAMA Netw Open 2021 Jun 1;4(6):e2111806. Epub 2021 Jun 1.

Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.

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% CI, $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.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.11806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190624PMC
June 2021

Geographic variation in influenza vaccination among U.S. nursing home residents: A national study.

J Am Geriatr Soc 2021 09 20;69(9):2536-2547. Epub 2021 May 20.

Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.

Objectives: Estimates of influenza vaccine use are not available at the county level for U.S. nursing home (NH) residents but are critically necessary to guide the implementation of quality improvement programs aimed at increasing vaccination. Furthermore, estimates that account for differences in resident characteristics between counties are unavailable. We estimated risk-standardized vaccination rates (RSVRs) among short- and long-stay NH residents by U.S. county and identified drivers of geographic variation.

Methods: We conducted a retrospective cohort study utilizing 100% of 2013-2015 fee-for-service Medicare claims, Minimum Data Set assessments, Certification and Survey Provider Enhanced Reports, and Long-Term Care: Facts on Care in the U.S. We separately evaluated short-stay (<100 days) and long-stay (≥100 days) residents aged 65 and older across the 2013-2014 and 2014-2015 influenza seasons. We estimated RSVRs via hierarchical logistic regression adjusting for 32 resident-level covariates. We then used multivariable linear regression models to assess associations between county-level NHs predictors and RSVRs.

Results: The study cohort consisted of 2,817,217 residents in 14,658 NHs across 2798 counties. Short-stay residents had lower RSVRs than long-stay residents (2013-2014: median [interquartile range], 69.6% [62.8-74.5] vs 84.0% [80.8-86.4]), and there was wide variation within each population (range, 11.4-89.8 vs 49.1-92.6). Several modifiable facility-level characteristics were associated with increased RSVRs, including higher registered nurse to total nurse ratio and higher total staffing for licensed practical nurses, speech-language pathologists, and social workers. Characteristics associated with lower RSVRs included higher percentage of residents restrained, with a pressure ulcer, and NH-level hospitalizations per resident-year.

Conclusions: Substantial county-level variation in influenza vaccine use exists among short- and long-stay NH residents. Quality improvement interventions to improve vaccination rates can leverage these results to target NHs located in counties with lower risk-standardized vaccine use.
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http://dx.doi.org/10.1111/jgs.17270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8242857PMC
September 2021

Decomposing Racial and Ethnic Disparities in Nursing Home Influenza Vaccination.

J Am Med Dir Assoc 2021 06 7;22(6):1271-1278.e3. Epub 2021 Apr 7.

Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.

Objectives: Quantify how observable characteristics contribute to influenza vaccination disparities among White, Black, and Hispanic nursing home (NH) residents.

Design: Retrospective cohort.

Setting And Participants: Short- and long-stay U.S. NH residents aged ≥65 years.

Methods: We linked Minimum Data Set (MDS) and Medicare data to LTCFocUS and other facility data. We included residents with 6-month continuous enrollment in Medicare and an MDS assessment between October 1, 2013, and March 31, 2014. Residents were classified as short-stay (<100 days in NH) or long-stay (≥100 days in NH). We fit multivariable logistic regression models to assess the relationships between 27 resident and NH-level characteristics and receipt of influenza vaccination. Using nonlinear Oaxaca-Blinder decomposition, we decomposed the disparity in influenza vaccination between White versus Black and White versus Hispanic NH residents. Analyses were repeated separately for short- and long-stay residents.

Results: Our study included 630,373 short-stay and 1,029,593 long-stay residents. Proportions vaccinated against influenza included 67.2% of White, 55.1% of Black, and 54.5% of Hispanic individuals among short-stay residents and 84.2%, 76.7%, and 80.8%, respectively among long-stay residents. Across 4 comparisons, the crude disparity in influenza vaccination ranged from 3.4 to 12.7 percentage points. By equalizing 27 prespecified characteristics, these disparities could be reduced 37.7% to 59.2%. Living in a predominantly White facility and proxies for NH quality were important contributors across all analyses. Characteristics unmeasured in our data (eg, NH staff attitudes and beliefs) may have also contributed significantly to the disparity.

Conclusions And Implications: The racial/ethnic disparity in influenza vaccination was most dramatic among short-stay residents. Intervening on factors associated with NH quality would likely reduce these disparities; however, future qualitative research is essential to explore potential contributors that were unmeasured in our data and to understand the degree to which these factors contribute to the overall disparity in influenza vaccination.
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http://dx.doi.org/10.1016/j.jamda.2021.03.003DOI Listing
June 2021

DTaP combination vaccine use and adherence: A retrospective cohort study.

Vaccine 2021 02 20;39(7):1064-1071. Epub 2021 Jan 20.

Sanofi Pasteur, 1 Discovery Drive, Swiftwater, PA 18370, USA; University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.

Despite universal recommendation of the 4-dose diphtheria, tetanus, and pertussis (DTaP) vaccine series, coverage and timeliness in the US remain suboptimal. DTaP-containing combination vaccines (i.e. quadrivalent and pentavalent) are presumed to improve vaccine coverage rates and timeliness, but research supporting this claim is limited. We sought to investigate the associations between DTaP-containing vaccine use and adherence to the recommended DTaP immunization schedule among children in the US. Using a large claims database, we identified privately insured children born between 2009 and 2016 that received ≥1 DTaP-containing vaccine and had ≥24 months of enrollment from birth, excluding those with DTaP vaccinations not aligned with approved dose indications. Children were classified by DTaP-containing vaccine receipt: combination vaccines only, stand-alone vaccines only, or a mixture of both. Outcome measures included: 1) completion of the 4-dose series and 2) timely receipt of doses. Outcomes were adjusted for gender, birth year, race, and socioeconomic status. The study cohort contained 412,441 children. Of these, 40.5% (167,084) received combination vaccines only, 14.9% (61,342) received stand-alone vaccines only, and 44.6% (184,015) received a mixture of both. Combination vaccine recipients were nearly 3 times as likely to complete the 4-dose series (OR 2.93 (95% CI: 2.88, 2.99)) and for all doses received, more than 4 times as likely to receive doses on time (OR 4.12 (4.04, 4.21), relative to stand-alone vaccine recipients. Significance disparities in adherence were also observed, where minorities were up to 30% less likely (OR 0.70 (0.68, 0.71)) to complete the 4-dose series and up to 27% less likely (OR 0.73 (0.72, 0.75)) to receive doses on time, relative to white children. Our findings demonstrated that adherence to the recommended DTaP immunization schedule was significantly greater among combination vaccine recipients, relative to stand-alone recipients. Further research is needed to investigate underlying causes of disparities in adherence.
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http://dx.doi.org/10.1016/j.vaccine.2021.01.009DOI Listing
February 2021

Laboratory-confirmed influenza infection and acute myocardial infarction among United States senior Veterans.

PLoS One 2020 11;15(12):e0243248. Epub 2020 Dec 11.

Sanofi Pasteur, Swiftwater, Pennsylvania, United States of America.

Background: Previous studies established an association between laboratory-confirmed influenza infection (LCI) and hospitalization for acute myocardial infarction (AMI) but not causality. We aimed to explore the underlying mechanisms by adding biological mediators to an established study design used by earlier studies.

Methods: With data on biomarkers, we used a self-controlled case-series design to evaluate the effect of LCI on hospitalization for AMI among Veterans Health Administration (VHA) patients. We included senior Veterans (age 65 years and older) with LCI between 2010 through 2015. Patient-level data from VHA electronic medical records were used to capture laboratory results, hospitalizations, and baseline patient characteristics. We defined the "risk interval" as the first 7 days after specimen collection and the "control interval" as 1 year before and 1 year after the risk interval. More importantly, using mediation analysis, we examined the role of abnormal white blood cell (WBC) and platelet count in the relationship between LCI and AMI to explore the thrombogenic nature of this association, thus potential causality.

Results: We identified 391 hospitalizations for AMI that occurred within +/-1 year of a positive influenza test, of which 31 (31.1 admissions/week) occurred during the risk interval and 360 (3.5/per week) during the control interval, resulting in an incidence ratio (IR) for AMI admission of 8.89 (95% confidence interval [CI]: 6.16-12.84). In stratified analyses, AMI risk was significantly elevated among patients with high WBC count (IR, 12.43; 95% CI: 6.99-22.10) and high platelet count (IR, 15.89; 95% CI: 3.59-70.41).

Conclusion: We confirmed a significant association between LCI and AMI. The risk was elevated among those with high WBC or platelet count, suggesting a potential role for inflammation and platelet activation in the underlying mechanism.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243248PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732109PMC
January 2021

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

Clin Infect Dis 2020 Sep 29. Epub 2020 Sep 29.

Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.

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.
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http://dx.doi.org/10.1093/cid/ciaa1484DOI Listing
September 2020

Association between dementia and psychiatric disorders in long-term care residents: An observational clinical study.

Medicine (Baltimore) 2020 Jul;99(31):e21412

Division of Infectious Diseases, Brown University.

We examine the relationship between dementia and psychiatric disorder diagnoses among long-term care residents in nursing homes across the state of Rhode Island (RI), USA.Observational clinical study.Two hundred fifty-five residents with and without the diagnosis of dementia were included in this study.Prevalence analysis was used to elucidate information on psychiatric disorders in the overall cohort, and among residents with dementia. Questions from the quality of life questionnaire (EQ-5D-3L) that provides information on self-care, anxiety/depression, and resident's view of how healthy they are, were used to evaluate their association with dementia and psychiatric disorders. A logistic regression analysis was conducted to understand the relationship between dementia and mental illness diagnoses in long-term care facilities. Finally, a subgroup logistic regression analysis was performed for residents with Alzheimer disease.65.1% of all residents suffered from at least 1 psychiatric disorder. Anxiety was the most common diagnosis (36.5%), followed by depression (28.6%), and insomnia (14.9%). There was a positive and statistically significant association between any mental illness diagnosis and dementia (adjusted OR: 3.73; 95% CI: 1.34-10.41). Bipolar disorder and insomnia were negatively and statistically significantly associated with dementia (adjusted OR: 0.17; 95% CI: 0.03-0.89 AND adjusted OR: 0.39; 95% CI: 0.16-0.96 respectively). Age and COPD were also statistically associated with dementia (adjusted OR: 1.07; 95% CI: 1.03-1.11 AND adjusted OR: 0.28, 95% CI: 0.12-0.66). Alzheimer disease was positively and significantly associated with the diagnosis of any mental illness (adjusted OR: 3.77; 95% CI: 1.17-12.20).We studied the relationship between dementia and diagnoses of psychiatric disorders present in long-term care residents. We found that residents with a diagnosis of dementia were more likely to suffer from at least 1 psychiatric disorder. Further work is needed to establish the neuropathophysiological relationship between psychiatric disorders and dementia.
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http://dx.doi.org/10.1097/MD.0000000000021412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402876PMC
July 2020

Varying Vaccination Rates Among Patients Seeking Care for Acute Respiratory Illness: A Systematic Review and Meta-analysis.

Open Forum Infect Dis 2020 Jul 19;7(7):ofaa234. Epub 2020 Jun 19.

Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Background: Complications following influenza infection are a major cause of morbidity and mortality, and the Centers for Disease Control Advisory Committee on Immunization Practices recommends universal annual vaccination. However, vaccination rates have remained significantly lower than the Department of Health and Human Services goal. The aim of this work was to assess the vaccination rate among patients who present to health care providers with influenza-like illness and identify groups with lower vaccination rates.

Methods: We performed a systematic search of the PubMed and EMBASE databases with a time frame of January 1, 2010, to March 1, 2019 and focused on the vaccination rate among patients seeking care for acute respiratory illness in the United States. A random effects meta-analysis was performed to estimate the pooled seasonal influenza vaccination rate, and we used a time trend analysis to identify differences in annual vaccination over time.

Results: The overall pooled influenza vaccination rate was 48.61% (whites: 50.87%; blacks: 36.05%; Hispanics: 41.45%). There was no significant difference among gender groups (men: 46.43%; women: 50.11%). Interestingly, the vaccination rate varied by age group and was significantly higher among adults aged >65 (78.04%) and significantly lower among children 9-17 years old (36.45%). Finally, we found a significant upward time trend in the overall influenza vaccination rate among whites (coef. = .0107;  = .027).

Conclusions: In conclusion, because of the significantly lower influenza vaccination rates in black and Hispanic communities, societal initiatives and community outreach programs should focus on these populations and on children and adolescents aged 9-17 years.
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http://dx.doi.org/10.1093/ofid/ofaa234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357453PMC
July 2020

On the Causal Interpretation of Rate-Change Methods: The Prior Event Rate Ratio and Rate Difference.

Am J Epidemiol 2021 01;190(1):142-149

A growing number of studies use data before and after treatment initiation in groups exposed to different treatment strategies to estimate "causal effects" using a ratio measure called the prior event rate ratio (PERR). Here, we offer a causal interpretation for PERR and its additive scale analog, the prior event rate difference (PERD). We show that causal interpretation of these measures requires untestable rate-change assumptions about the relationship between 1) the change of the counterfactual rate before and after treatment initiation in the treated group under hypothetical intervention to implement the control strategy; and 2) the change of the factual rate before and after treatment initiation in the control group. The rate-change assumption is on the multiplicative scale for PERR but on the additive scale for PERD; the 2 assumptions hold simultaneously under testable, but unlikely, conditions. Even if investigators can pick the most appropriate scale, the relevant rate-change assumption might not hold exactly, so we describe sensitivity analysis methods to examine how assumption violations of different magnitudes would affect study results. We illustrate the methods using data from a published study of proton pump inhibitors and pneumonia.
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http://dx.doi.org/10.1093/aje/kwaa122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784529PMC
January 2021

Comparing the impact of high-dose versus standard dose influenza vaccines on hospitalization cost for cardiovascular and respiratory diseases: Economic assessment in the US Veteran population during 5 respiratory seasons using an instrumental variable method.

Vaccine 2021 03 20;39 Suppl 1:A51-A55. Epub 2020 Jun 20.

Clinical Epidemiology Program, Veterans Affairs Medical Center, White River Junction, VT, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.

Objectives: Cost savings associated with high-dose (HD) as compared to standard-dose (SD) influenza vaccination in the United States (US) Veteran's Health Administration (VHA) population have been attributed to better protection against hospitalization for cardiac and respiratory diseases. The relative contribution of each of these disease categories to the reported savings remains to be explored.

Methods: During a recently completed study of HD versus SD vaccine effectiveness (conducted in the VHA over five respiratory seasons from 2010/11 through 2014/15), we collected cost data for all healthcare services provided at both VHA and Medicare-funded facilities. In that analysis, we compared the costs of vaccination and hospital care for patients admitted with either cardiovascular or respiratory disease. Treatment selection bias and other confounding factors were adjusted using an instrumental variable (IV) method. In this brief report we use the same study cohort and methods to stratify the results by patients admitted for cardiovascular disease (CVD) and those admitted for respiratory disease.

Results: We analyzed 3.5 million SD and 0.16 million HD person-seasons. The IV-adjusted rVEs were 14% (7-20%) against hospitalizations for CVD and 15% (5-25%) against respiratory hospitalizations. Net cost savings per HD recipient were $138 ($66-$200) for CVD related hospitalizations and $62 ($10-$107) for respiratory disease related hospitalizations.

Conclusions: In the US VHA population, the reduction in hospitalizations for CVD over five respiratory seasons contributed twice the cost savings (per HD recipient) of the reduction in hospitalizations for respiratory disease.
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http://dx.doi.org/10.1016/j.vaccine.2020.05.080DOI Listing
March 2021

The process of obtaining informed consent to research in long term care facilities (LTCFs): An Observational Clinical Study.

Medicine (Baltimore) 2020 May;99(21):e20225

Division of Infectious Diseases, Brown University.

We examined the process of obtaining informed consent (IC) for clinical research purposes in long-term care facilities (LTCFs) in Rhode Island (RI), USA. We assessed factors that were associated with resident ability to consent, such as Brief Interview for Mental Status scores. We used a self-administered questionnaire to further understand the effect of LTCF staff evaluation of ability to consent on residents' autonomy and control over their medical decision making.Observational clinical studyLong-term care setting.LTCF personnel provided us with residents' names, as well as their professional assessment of resident ability to consent. We used Brief Interview for Mental Status (BIMS) scores to assess the cognitive capacity of all residents to assess, and compare it to the assessment provided by LTCF personnel. A logistic regression analysis was performed to determine the relationship between LTCF assessment of resident ability to consent and BIMS score or confirmed diagnosis of dementia as seen from residents' medical charts. A self-administered questionnaire was filled out by the personnel of 10 LTCFs across RI, USA.LTCF personnel in 9 out of 10 recruited facilities reported that their assessment of resident ability to consent was based on subjective assessment of the resident as alert and oriented. There was a statistically significant relationship between the LTCF assessment of resident ability to consent and previously diagnosed dementia (OR: 0.211, 95% CI 0.107-0.415). Therefore, as BIMS scores increased, the likelihood that the resident would be deemed able to consent by LTCF personnel also increased. Furthermore, there was a statistically significant relationship between LTCF assessment of resident ability to consent and BIMS scores (OR: 1.430, 95% CI 1.274-1.605).There is no standard on obtaining IC for research studies conducted in LTCFs. We recommend that standardizing the process of obtaining IC in LTCFs can enhance the ability to perform research with LTCF residents.
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http://dx.doi.org/10.1097/MD.0000000000020225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249968PMC
May 2020

High-dose influenza vaccination and mortality among predominantly male, white, senior veterans, United States, 2012/13 to 2014/15.

Euro Surveill 2020 05;25(19)

Leslie Dan School of Pharmacy, University of Toronto, Toronto, Canada.

IntroductionIt is unclear whether high-dose influenza vaccine (HD) is more effective at reducing mortality among seniors.AimThis study aimed to evaluate the relative vaccine effectiveness (rVE) of HD. MethodsWe linked electronic medical record databases in the Veterans Health Administration (VHA) and Medicare administrative files to examine the rVE of HD vs standard-dose influenza vaccines (SD) in preventing influenza/pneumonia-associated and cardiorespiratory mortality among VHA-enrolled veterans 65 years or older during the 2012/13, 2013/14 and 2014/15 influenza seasons. A multivariable Cox proportional hazards model was performed on matched recipients of HD vs SD, based on vaccination time, location, age, sex, ethnicity and VHA priority level. ResultsAmong 569,552 person-seasons of observation, 207,574 (36%) were HD recipients and 361,978 (64%) were SD recipients, predominantly male (99%) and white (82%). Pooling findings from all three seasons, the adjusted rVE estimate of HD vs SD during the high influenza periods was 42% (95% confidence interval (CI): 24-59) against influenza/pneumonia-associated mortality and 27% (95% CI: 23-32) against cardiorespiratory mortality. Residual confounding was evident in both early and late influenza periods despite matching and multivariable adjustment. Excluding individuals with high 1-year predicted mortality at baseline reduced the residual confounding and yielded rVE of 36% (95% CI: 10-62) and 25% (95% CI: 12-38) against influenza/pneumonia-associated and cardiorespiratory mortality, respectively. These were confirmed by results from two-stage residual inclusion estimations.DiscussionThe HD was associated with a lower risk of influenza/pneumonia-associated and cardiorespiratory death in men during the high influenza period.
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http://dx.doi.org/10.2807/1560-7917.ES.2020.25.19.1900401DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238741PMC
May 2020

Influenza vaccine effectiveness against influenza-associated hospitalization in children: A systematic review and meta-analysis.

Vaccine 2020 03 27;38(14):2893-2903. Epub 2020 Feb 27.

Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, RI, USA. Electronic address:

Vaccination remains the most effective way to prevent influenza infection, albeit vaccine effectiveness (VE) varies by year. Compared to other age groups, children and elderly adults have the highest risk of developing influenza-related complications and requiring hospitalization. During the last years, "test negative design" (TND) studies have been implemented in order to estimate influenza VE. The aim of this systematic review and meta-analysis was to summarize the findings of TND studies reporting influenza VE against laboratory-confirmed influenza-related hospitalization in children aged 6 months to 17 years. We searched the PubMed and Embase databases and identified 2615 non-duplicate studies that required detailed review. Among them, 28 met our inclusion criteria and we performed a random-effects meta-analysis using adjusted VE estimates. In our primary analysis, influenza vaccine offered significant protection against any type influenza-related hospitalization (57.48%; 95% CI 49.46-65.49). When we examined influenza VE per type and strain, VE was higher against H1N1 (74.07%; 95% CI: 54.85-93.30) and influenza B (50.87%; 95% CI: 41.75-59.98), and moderate against H3N2 (40.77%; 95% CI: 25.65-55.89). Notably, influenza vaccination offered higher protection in children who were fully vaccinated (61.79%; 95% CI: 54.45-69.13), compared to those who were partially vaccinated (33.91%; 95% CI: 21.12 - 46.69). Also, influenza VE was high in children less than 5 years old (61.71%; 95% CI: 49.29-74.12) as well as in children 6-17 years old (54.37%; 95% CI: 35.14-73.60). In conclusion, in the pediatric population, influenza vaccination offered significant protection against influenza-related hospitalization and complete annual vaccination should be encouraged.
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http://dx.doi.org/10.1016/j.vaccine.2020.02.049DOI Listing
March 2020

Patient and practice level factors associated with seasonal influenza vaccine uptake among at-risk adults in England, 2011 to 2016: An age-stratified retrospective cohort study.

Vaccine X 2020 Apr 13;4:100054. Epub 2020 Jan 13.

Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.

We sought to gain insights into the determinants of seasonal influenza vaccine (SIV) uptake by conducting an age-stratified analysis (18-64 and 65+) of factors associated with SIV uptake among at-risk adults registered to English practices. Records for at-risk English adults between 2011 and 2016 were identified using the Clinical Practice Research Datalink database. SIV uptake was assessed annually. The associations of patient, practice, and seasonal characteristics with SIV uptake were assessed via cross-sectional and longitudinal analyses, using mixed-effects and general estimating equation logistic regression models. Overall SIV uptake was 35.3% and 74.0% for adults 18-64 and 65+, respectively. Relative to white patients, black patients were least likely to be vaccinated (OR: 0.82 (95% CI: 0.80, 0.85); OR: 0.59 (95% CI: 0.56, 0.62)), while Asian patients among 18-64 year olds were most likely to be vaccinated (OR: 1.10 (95% CI: 1.07, 1.13)). Females were more likely than males to be vaccinated among 18-64 year olds (OR: 1.19 (95% CI: 1.18, 1.20)). Greater socioeconomic deprivation was associated with decreased odds of uptake among older patients (OR: 0.74 (95% CI: 0.71, 0.77)). For each additional at-risk condition, odds of uptake increased (OR: 2.33 (95% CI: 2.31, 2.36); OR: 1.39 (95% CI: 1.38, 1.39)). Odds of uptake were highest among younger patients with diabetes (OR: 4.25 (95% CI: 4.18, 4.32)) and older patients with chronic respiratory disease (OR: 1.60 (95% CI: 1.58, 1.63)), whereas they were lowest among morbidly obese patients of all ages (OR: 0.68 (95% CI: 0.67, 0.70); OR: 0.97 (95% CI: 0.94, 0.99)). Prior influenza season severity and vaccine effectiveness were marginally predictive of uptake. Our age-stratified analysis uncovered SIV uptake disparities by ethnicity, sex, age, socioeconomic deprivation, and co-morbidities, warranting further attention by GPs and policymakers alike.
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http://dx.doi.org/10.1016/j.jvacx.2020.100054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011080PMC
April 2020

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

BMC Geriatr 2020 02 10;20(1):47. Epub 2020 Feb 10.

Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-6, Providence, RI, 02912, USA.

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.
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http://dx.doi.org/10.1186/s12877-020-1457-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011520PMC
February 2020

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

Clin Infect Dis 2020 11;71(8):e202-e205

Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.

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.
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http://dx.doi.org/10.1093/cid/ciaa081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643743PMC
November 2020

Assessing the prior event rate ratio method via probabilistic bias analysis on a Bayesian network.

Stat Med 2020 02 1;39(5):639-659. Epub 2019 Dec 1.

Sanofi Pasteur, Swiftwater, Pennsylvania.

Background: Unmeasured confounders are commonplace in observational studies conducted using real-world data. Prior event rate ratio (PERR) adjustment is a technique shown to perform well in addressing such confounding. However, it has been demonstrated that, in some circumstances, the PERR method actually increases rather than decreases bias. In this work, we seek to better understand the robustness of PERR adjustment.

Methods: We begin with a Bayesian network representation of a generalized observational study, which is subject to unmeasured confounding. Previous work evaluating PERR performance used Monte Carlo simulation to calculate joint probabilities of interest within the study population. Here, we instead use a Bayesian networks framework.

Results: Using this streamlined analytic approach, we are able to conduct probabilistic bias analysis (PBA) using large numbers of combinations of parameters and thus obtain a comprehensive picture of PERR performance. We apply our methodology to a recent study that used the PERR in evaluating elderly-specific high-dose (HD) influenza vaccine in the US Veterans Affairs population. That study obtained an HD relative effectiveness of 25% (95% CI: 2%-43%) against influenza- and pneumonia-associated hospitalization, relative to standard-dose influenza vaccine. In this instance, we find that the PERR-adjusted result is more like to underestimate rather than to overestimate the relative effectiveness of the intervention.

Conclusions: Although the PERR is a powerful tool for mitigating the effects of unmeasured confounders, it is not infallible. Here, we develop some general guidance for when a PERR approach is appropriate and when PBA is a safer option.
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http://dx.doi.org/10.1002/sim.8435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027899PMC
February 2020

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

Vaccine 2020 01 9;38(2):372-379. Epub 2019 Oct 9.

Vaccine Epidemiology and Modelling, Sanofi Pasteur, Swiftwater, PA, USA; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.

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.
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http://dx.doi.org/10.1016/j.vaccine.2019.09.105DOI Listing
January 2020

The burden of respiratory infections among older adults in long-term care: a systematic review.

BMC Geriatr 2019 08 5;19(1):210. Epub 2019 Aug 5.

Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.

Background: Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature.

Methods: We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively.

Results: A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%.

Conclusions: The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts.
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http://dx.doi.org/10.1186/s12877-019-1236-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683564PMC
August 2019

Economic assessment of a high-dose versus a standard-dose influenza vaccine in the US Veteran population: Estimating the impact on hospitalization cost for cardio-respiratory disease.

Vaccine 2019 07 28;37(32):4499-4503. Epub 2019 Jun 28.

Clinical Epidemiology Program, Veterans Affairs Medical Center, White River Junction, Vermont, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.

Objective: To compare the economic impact of high-dose trivalent (HD) versus standard-dose trivalent (SD) influenza vaccination on direct medical costs for cardio-respiratory hospitalizations in adults aged 65 years or older enrolled in the United States (US) Veteran's Health Administration (VHA).

Methods: Leveraging a relative vaccine effectiveness study of HD versus SD over five respiratory seasons (2010/11 through 2014/15), we collected cost data for healthcare provided to the same study population both at VHA and through Medicare services. Our economic assessment compared the costs of vaccination and hospital care for patients experiencing acute cardio-vascular or respiratory illness.

Results: We analyzed 3.5 million SD and 158,636 HD person-seasons. The average cost of HD and SD vaccination was $23.48 (95% CI: $21.29 - $25.85) and $12.21 (95% CI: $11.49 - $13.00) per recipient, respectively, while the hospitalization rates for cardio-respiratory disease in HD and SD recipients were 0.114 (95% CI: 0.108-0.121) and 0.132 (95% CI: 0.132-0.133) per person-season, respectively. Attributing the average cost per hospitalization of $11,796 (95% CI: $11,685 - $11,907) to the difference in hospitalization rates, we estimated savings attributable to HD to be $202 (95% CI: $115 - $280) per vaccinated recipient.

Conclusions: For the five-season period of 2010/11 through 2014/15, HD influenza vaccination was associated with net cost savings due to fewer hospitalizations, and therefore lower direct medical costs, for cardio-respiratory disease as compared to SD influenza vaccination in the senior US VHA population.
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http://dx.doi.org/10.1016/j.vaccine.2019.06.066DOI Listing
July 2019

Long-term Care Facility Variation in the Incidence of Pneumonia and Influenza.

Open Forum Infect Dis 2019 Jun 15;6(6):ofz230. Epub 2019 May 15.

Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.

Background: Pneumonia and influenza (P&I) increase morbidity and mortality among older adults, especially those residing in long-term care facilities (LTCFs). Facility-level characteristics may affect the risk of P&I beyond resident-level risk factors. However, the relationship between facility characteristics and P&I is poorly understood. To address this, we identified potentially modifiable facility-level characteristics that influence the incidence of P&I across LTCFs.

Methods: We conducted a retrospective cohort study using 2013-2015 Medicare claims linked to Minimum Data Set and LTCF-level data. Short-stay (<100 days) and long-stay (100+ days) LTCF residents were followed for the first occurrence of hospitalization, LTCF discharge, Medicare disenrollment, or death. We calculated LTCF risk-standardized incidence rates (RSIRs) per 100 person-years for P&I hospitalizations by adjusting for over 30 resident-level demographic and clinical covariates using hierarchical logistic regression.

Results: We included 1 767 241 short-stay (13 683 LTCFs) and 922 863 long-stay residents (14 495 LTCFs). LTCFs with lower RSIRs had more licensed independent practitioners (nurse practitioners or physician assistants) among short-stay (44.9% vs 41.6%, < .001) and long-stay residents (47.4% vs 37.9%, < .001), higher registered nurse hours/resident/day among short-stay and long-stay residents (mean [SD], 0.5 [0.7] vs 0.4 [0.4], < .001), and fewer residents for whom antipsychotics were prescribed among short-stay (21.4% [11.6%] vs 23.6% [13.2%], < .001) and long-stay residents (22.2% [14.3%] vs 25.5% [15.0%], < .001).

Conclusions: LTCF characteristics may play an important role in preventing P&I hospitalizations. Hiring more registered nurses and licensed independent practitioners, increasing staffing hours, and higher-quality care practices may be modifiable means of reducing P&I in LTCFs.
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http://dx.doi.org/10.1093/ofid/ofz230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565378PMC
June 2019

The Effect of Influenza Vaccination on Mortality and Risk of Hospitalization in Patients With Heart Failure: A Systematic Review and Meta-analysis.

Open Forum Infect Dis 2019 Apr 2;6(4):ofz159. Epub 2019 Apr 2.

Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, Rhode Island.

Background: Influenza is a major cause of morbidity and mortality in patients diagnosed with heart failure. The aim of this study was to evaluate the effectiveness of influenza vaccination in this population in terms of reduction in all-cause mortality and rate of hospitalization.

Methods: We conducted a systematic review and meta-analysis using PubMed and EMBASE entries from January of 2000 through April 2018. Publication bias was examined using the Egger's regression test. Statistical heterogeneity was examined using the Higgins statistic. Subgroup analyses were performed to examine the effect of vaccination during the influenza and noninfluenza seasons.

Results: We identified 8 studies that included a total of 82 354 patients with heart failure. In patients with heart failure who were vaccinated against influenza, we found a reduced risk of all-cause mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.51-0.87). No evidence of publication bias was found, and the effect was more pronounced during influenza season (HR, 0.49; 95% CI, 0.30-0.69), compared with noninfluenza season (HR, 0.79; 95% CI, 0.68-0.89). In terms of heart failure hospitalizations, we did not identify a statistically significant difference between the cohorts (HR, 0.62; 95% CI, 0.00-1.23).

Conclusions: Influenza vaccination was associated with a decreased risk of all-cause mortality in patients with heart failure, and this effect was more prominent during the influenza season.
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http://dx.doi.org/10.1093/ofid/ofz159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6483130PMC
April 2019

Analysis of relative effectiveness of high-dose versus standard-dose influenza vaccines using an instrumental variable method.

Vaccine 2019 03 8;37(11):1484-1490. Epub 2019 Feb 8.

Sanofi Pasteur, Swiftwater, PA, USA; Leslie Dan School of Pharmacy, University of Toronto, Toronto, ON, Canada. Electronic address:

Background: Observational studies of the relative effectiveness of influenza vaccines are essential for public health decision making. Their estimates, however, are subject to bias due to unmeasured confounders. Instrumental variable (IV) methods can control for observed and unobserved confounders.

Methods: We used linked electronic medical record databases in the Veterans Health Administration (VHA) as well as Medicare administrative files to examine the relative vaccine effectiveness (rVE) of high-dose influenza vaccine (HD) versus standard-dose influenza vaccines (SD) in preventing hospitalizations among VHA-enrolled Veterans ≥65 years of age during 5 influenza seasons (2010-2011 through 2014-2015). Using multivariable IV Poisson regression modeling to address unmeasured confounding and bias, we analyzed the data by each season and through longitudinal analysis of all five seasons.

Findings: We included 3,638,924 person-influenza seasons of observation where 158,636 (4%) were among HD vaccine recipients and 3,480,288 (96%) were among SD vaccine recipients. Of the 1,728,562 Veterans, 1,702,824 (98.5%) were male and 1,299,412 (75%) were non-Hispanic white. Based on the longitudinal analysis of all five seasons, the IV-adjusted rVE estimate of HD vs. SD was 10% (95% CI, 8-12%) against all-cause hospitalization; 18% (95% CI, 15-21%) against cardiorespiratory-associated hospitalization; and 14% (95% CI, 6-22%) against influenza/pneumonia-associated hospitalization. The findings by season were similar.

Interpretation: Our analysis of VHA clinical data collected from approximately 1.7 million Veterans 65 years and older during five seasons demonstrates that high-dose influenza vaccine is more effective than standard-dose influenza vaccines in preventing influenza- or pneumonia-associated hospitalizations, cardiorespiratory hospitalizations, and all-cause hospitalizations.
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http://dx.doi.org/10.1016/j.vaccine.2019.01.063DOI Listing
March 2019

Using an Inpatient Quality Improvement Curriculum for Internal Medicine Residents to Improve Pneumococcal Conjugate Vaccine Administration Rates.

Jt Comm J Qual Patient Saf 2018 Jun 3;44(6):328-333. Epub 2018 May 3.

Background: Pneumococcal infections are an important source of morbidity and mortality in older adults and persons with compromised immune systems. New recommendations from the Advisory Committee on Immunization Practices (ACIP) became available September 2014, which included recommendations for the use of the 13-valent pneumococcal conjugate vaccine (PCV13). A study was conducted to increase the PCV13 vaccination rates of hospitalized patients at the White River Junction Veterans Affairs Medical Center (White River Junction, Vermont) through the use of a resident-driven quality improvement (QI) project.

Methods: From December 2014 through April 2016, 16 internal medicine inpatient residents addressed inpatient PCV13 vaccination rates by participating in the facility's QI curriculum. Eight Plan-Do-Study-Act cycles were used, including discharge template editing, electronic reminders, and the discovery of a vaccination administration documentation error in the record through data validation. The measure was the monthly percentage of patients who received PCV13 vaccination (vaccination completion rate) of those discharged from the hospital medicine service who were due for PCV13 vaccination.

Results: The percentage of veterans discharged with an up-to-date PCV13 vaccination on discharge increased from approximately 30% to 87% and was sustained.

Conclusion: Despite being driven by many different residents, this project demonstrates that continuous improvement can be achieved through a structured and iterative process while providing active learning of core QI concepts to residents. It also displays a method in which new guidelines can be incorporated into practice in an effective manner. Finally, this project is an example of how resident-driven data validation can lead to further improvement.
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http://dx.doi.org/10.1016/j.jcjq.2017.12.005DOI Listing
June 2018

Relative Vaccine Effectiveness of High-Dose Versus Standard-Dose Influenza Vaccines Among Veterans Health Administration Patients.

J Infect Dis 2018 05;217(11):1718-1727

Leslie Dan School of Pharmacy, University of Toronto, Ontario, Canada.

Background: We examined whether a high-dose inactivated influenza vaccine was more efficacious in preventing hospitalizations than a standard-dose vaccine in the Veterans Health Administration (VHA) senior population.

Methods: This study estimated the relative vaccine effectiveness (rVE) of high dose versus standard dose using a retrospective cohort of VHA patients 65 years of age or older in the 2015-2016 influenza season. To adjust for measured confounders, we matched each high-dose recipient with up to 4 standard-dose recipients vaccinated at the same location within a 2-week period and having 2 or more pre-existing medical comorbidities. We used the previous event rate ratio method (PERR), a type of difference-in-differences analysis, to adjust for unmeasured confounders.

Results: We evaluated 104965 standard-dose and 125776 high-dose recipients; matching decreased the population to 49091 standard-dose and 24682 high-dose recipients. The matched, PERR-adjusted rVE was 25% (95% confidence interval [CI], 2%-43%) against influenza- or pneumonia-associated hospitalization, 7% (95% CI, -2% to 14%) against all-cause hospitalization, 14% (95% CI, -8% to 32%) against influenza- or pneumonia-associated outpatient visit, 5% (95% CI, 2%-8%) against all-cause outpatient visit, and 38% (95% CI, -5% to 65%) against laboratory-confirmed influenza.

Conclusions: In protecting senior VHA patients against influenza- or pneumonia-associated hospitalization, a high-dose influenza vaccine is more effective than a standard-dose vaccine.
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http://dx.doi.org/10.1093/infdis/jiy088DOI Listing
May 2018

Impact of The Daily Plan on Length of Stay and Readmission.

J Nurs Care Qual 2018 Apr/Jun;33(2):123-127

National Center for Patient Safety (Mss King and Neily and Dr Young-Xu, Mr Lee, and Drs Shiner and Mills) and Clinical Epidemiology Program (Dr Young-Xu and Mr van Aalst and Ms Eickhoff), Veterans Affairs Medical Center, White River Junction, Vermont; and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Drs Young-Xu and Shiner).

The Veterans Health Administration implemented The Daily Plan (TDP) to improve patient safety. We compared length of stay and readmission between intervention and control units. Length of stay decreased for both groups. Readmission rates increased for controls (21.3%-25.0%, P = .02) and barely changed for TDP units (21.7%-22.5%, P = .37). Although there were no efficiency improvements, TDP's ultimate goal was safety. Not all patient safety actions improve efficiency; nonetheless, their value continues.
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http://dx.doi.org/10.1097/NCQ.0000000000000271DOI Listing
April 2018

The Annual Burden of Seasonal Influenza in the US Veterans Affairs Population.

PLoS One 2017 3;12(1):e0169344. Epub 2017 Jan 3.

Health Outcomes and Economics, Sanofi Pasteur, Swiftwater, Pennsylvania, United States of America.

Seasonal influenza epidemics have a substantial public health and economic burden in the United States (US). On average, over 200,000 people are hospitalized and an estimated 23,000 people die from respiratory and circulatory complications associated with seasonal influenza virus infections each year. Annual direct medical costs and indirect productivity costs across the US have been found to average respectively at $10.4 billion and $16.3 billion. The objective of this study was to estimate the economic impact of severe influenza-induced illness on the US Veterans Affairs population. The five-year study period included 2010 through 2014. Influenza-attributed outcomes were estimated with a statistical regression model using observed emergency department (ED) visits, hospitalizations, and deaths from the Veterans Health Administration of the Department of Veterans Affairs (VA) electronic medical records and respiratory viral surveillance data from the Centers for Disease Control and Prevention (CDC). Data from VA's Managerial Cost Accounting system were used to estimate the costs of the emergency department and hospital visits. Data from the Bureau of Labor Statistics were used to estimate the costs of lost productivity; data on age at death, life expectancy and economic valuations for a statistical life year were used to estimate the costs of a premature death. An estimated 10,674 (95% CI 8,661-12,687) VA ED visits, 2,538 (95% CI 2,112-2,964) VA hospitalizations, 5,522 (95% CI 4,834-6,210) all-cause deaths, and 3,793 (95% CI 3,375-4,211) underlying respiratory or circulatory deaths (inside and outside VA) among adult Veterans were attributable to influenza each year from 2010 through 2014. The annual value of lost productivity amounted to $27 (95% CI $24-31) million and the annual costs for ED visits were $6.2 (95% CI $5.1-7.4) million. Ninety-six percent of VA hospitalizations resulted in either death or a discharge to home, with annual costs totaling $36 (95% CI $30-43) million. The remaining 4% of hospitalizations were followed by extended care at rehabilitation and skilled nursing facilities with annual costs totaling $5.5 (95% CI $4.4-6.8) million. The annual monetary value of quality-adjusted life years (QALYs) lost amounted to $1.1 (95% CI $1.0-1.2) billion. In total, the estimated annual economic burden was $1.2 (95% CI $1.0-1.3) billion, indicating the substantial burden of seasonal influenza epidemics on the US Veterans Affairs population. Premature death was found to be the largest driver of these costs, followed by hospitalization.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0169344PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5207669PMC
August 2017

Clinical and Educational Outcomes of an Integrated Inpatient Quality Improvement Curriculum for Internal Medicine Residents.

J Grad Med Educ 2016 Oct;8(4):563-568

Background : Integrating teaching and hands-on experience in quality improvement (QI) may increase the learning and the impact of resident QI work.

Objective : We sought to determine the clinical and educational impact of an integrated QI curriculum.

Methods : This clustered, randomized trial with early and late intervention groups used mixed methods evaluation. For almost 2 years, internal medicine residents from Dartmouth-Hitchcock Medical Center on the inpatient teams at the White River Junction VA participated in the QI curriculum. QI project effectiveness was assessed using statistical process control. Learning outcomes were assessed with the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and through self-efficacy, interprofessional care attitudes, and satisfaction of learners. Free text responses by residents and a focus group of nurses who worked with the residents provided information about the acceptability of the intervention.

Results : The QI projects improved many clinical processes and outcomes, but not all led to improvements. Educational outcome response rates were 65% (68 of 105) at baseline, 50% (18 of 36) for the early intervention group at midpoint, 67% (24 of 36) for the control group at midpoint, and 53% (42 of 80) for the late intervention group. Composite QIKAT-R scores (range, 0-27) increased from 13.3 at baseline to 15.3 at end point ( < .01), as did the self-efficacy composite score ( < .05). Satisfaction with the curriculum was rated highly by all participants.

Conclusions : Learning and participating in hands-on QI can be integrated into the usual inpatient work of resident physicians.
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http://dx.doi.org/10.4300/JGME-D-15-00412.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5058590PMC
October 2016
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