Weinberg ( v e r y q u i e t l y ) : "I 'm n o t prepared." Murphy:"Areyou aware t h a t by n o t... more Weinberg ( v e r y q u i e t l y ) : "I 'm n o t prepared." Murphy:"Areyou aware t h a t by n o t doing s o you a r e subj e c t i n g y o u r s e l f t o probable d i s c i p l i n a r y a c t i o n ? " Weinberg ( s t i l l more q u i e t l y ) : "I--uh--I 'm aware t h a t y o u ' r e going t o do what y o u ' l l t r y t o do." Murphy: " A l l r i g h t . W i l l you--uh--identify y o u r s e l f ? " Weinberg : "No. " Murphy ( i n a dead-pan v o i c e , almost as i f h e were reading a s c r i p t i n s t e a d of t a l k i n g t o a p a r t i c u l a r person) : "I
routine use in the United States for 5 years. Prior U.S. cost-effectiveness analyses have not tak... more routine use in the United States for 5 years. Prior U.S. cost-effectiveness analyses have not taken into account the effect of the vaccine on nonvaccinated persons. Methods: We revised a previously published model to simulate the effects of PCV on children vaccinated between 2000 and 2004, and to incorporate the effect of the vaccine in reducing invasive pneu-mococcal disease (IPD) in nonvaccinated persons during those years. Data from the Active Bacterial Core Surveillance of the Centers for Disease Control and Prevention (2000–2004) were used to estimate changes in the burden of IPD in nonvaccinated adults since the introduction of PCV (compared with the baseline years 1997–1999). Results combined the simulated effects of the vaccine on the vaccinated and nonvaccinated populations. Results: Before incorporating herd effects in the model, the PCV was estimated to have averted 38,000 cases of IPD during its first 5 years of use at a cost of $112,000 per life-year saved. After incorp...
The Kaiser Permanente Medical Care Program in Northern California, like other health care provide... more The Kaiser Permanente Medical Care Program in Northern California, like other health care providers during the current period of rising medical costs, has a pressing need to manage its hospital utilization while maintaining a high quality of medical care. Small Area Analysis (SM), which applies population-based statistical methods to compare hospitalization rates across hospital service areas, can be helpful in identifying high-variability medical diagnoses and procedures where utilization management may be effective. The SAS System application described here produces detailed graphical reports for comparing hospital utilization rates for many diagnoses and procedures across different hospaals, time periods and populations. SASjGRAPH· was chosen for the production of these reports because of its ability to produce a sequence of high quality customized graphs under. control of the macro language.
Vaccine effectiveness studies are subject to biases due to depletion-of-persons at risk of infect... more Vaccine effectiveness studies are subject to biases due to depletion-of-persons at risk of infection, or at especially high risk of infection, at different rates from different groups (depletionof-susceptibles bias), a problem that can also lead to biased estimates of waning effectiveness, including spurious inference of waning when none exists. An alternative study design to identify waning is to study only vaccinated persons, and compare for each day the incidence in persons with earlier or later dates of vaccination to assess waning in vaccine protection as a function of vaccination time (namely whether earlier vaccination would result in lower subsequent protection compared to later vaccination). Prior studies suggested under what conditions this alternative would yield correct estimates of waning. Here we define the depletion-ofsusceptibles process formally and show mathematically that for influenza vaccine waning studies, a randomised trial or corresponding observational study that compares incidence at a specific calendar time among individuals vaccinated at different times before the influenza season begins will not be vulnerable to depletion-of-susceptibles bias in its inference of waning as a function of vaccination time under the null hypothesis that none exists, and willif waning does actually occurunderestimate the extent of waning. Such a design is thus robust in the sense that a finding of waning in that inference framework reflects actual waning of vaccine-induced immunity. We recommend such a design for future studies of waning, whether observational or randomised. Recent studies on influenza vaccine effectiveness (VE) have suggested that effectiveness declines over the course of one season [1-3]. However, these results have been called into question because inferences of waning may be biased. When there is no waning, some study designs (including the classic test-negative observational design [4, 5] and randomised controlled trials ) may nonetheless infer waningmeasured as a decline in VE as the season progresses. This biased inference is predicted to occur when the vaccine offers 'leaky' protection, reducing the probability of infection on exposure by some proportion less than 100%, and either or both of the following conditions holds and is unaccounted for in the analysis[9]: (i) some infections occur unobserved in the study population, such that individuals are infected and (for the season) immune to further infection unbeknownst to the researchers ; or (ii) heterogeneity in the population exists and is unaccounted for, such that certain persons are at higher risk of becoming exposed or, if they are exposed, of becoming infected upon exposure for reasons other than their vaccine status, for example due to age, past-season history of infection or vaccination or occupation . If either or both of these conditions hold, then over the course of the season, there will be unobserved reductions in the population at risk (or, for the second, at high risk) in each arm of the trial, and these reductions will be greater in any group that receives less vaccine protection, more moderate in a group that is more protected. In a classic comparison of vaccinated vs. unvaccinated persons, this 'depletion-of-susceptibles' will reduce the pool of susceptible individuals (and especially of highly susceptible individuals) in the unvaccinated group more than in the vaccinated group, reducing the influenza incidence rate in the unvaccinated group relative to the vaccinated group as time progresses; equivalently, the benefit of the vaccine will appear to wane. Recently, a novel, cohort variant of the test-negative design (TND), was proposed and implemented that sought to circumvent these sources of bias. This design [3] considered only persons who received influenza vaccine and were subsequently tested for influenza infection. As in the classic TND the vaccine history was compared between those testing positive vs. negative for influenza infection, but unlike a classic TND, the time from vaccination to influenza test was the exposure of interest (as the study was limited to those who had received .
Morbidity and Mortality Weekly Report, May 26, 2023
† Medical events with a discharge code consistent with COVID-19-like illness were included. COVID... more † Medical events with a discharge code consistent with COVID-19-like illness were included. COVID-19-like illness diagnoses were obtained from ICD-10 discharge codes. The specific codes used were COVID-19 pneumonia: J12.
Objective To estimate the effectiveness of mRNA vaccines against moderate and severe covid-19 in ... more Objective To estimate the effectiveness of mRNA vaccines against moderate and severe covid-19 in adults by time since second, third, or fourth doses, and by age and immunocompromised status. Design Test negative case-control study. setting Hospitals, emergency departments, and urgent care clinics in 10 US states, 17 January 2021 to 12 July 2022. ParticiPants 893 461 adults (≥18 years) admitted to one of 261 hospitals or to one of 272 emergency department or 119 urgent care centers for covid-like illness tested for SARS-CoV-2. Main OutcOMe Measures The main outcome was waning of vaccine effectiveness with BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna) vaccine during the omicron and delta periods, and the period before delta was dominant using logistic regression conditioned on calendar week and geographic area while adjusting for age, race, ethnicity, local virus circulation, immunocompromised status, and likelihood of being vaccinated. results 45 903 people admitted to hospital with covid-19 (cases) were compared with 213 103 people with covid-like illness who tested negative for SARS-CoV-2 (controls), and 103 287 people admitted to emergency department or urgent care with covid-19 (cases) were compared with 531 168 people with covid-like illness who tested negative for SARS-CoV-2. In the omicron period, vaccine effectiveness against covid-19 requiring admission to hospital was 89% (95% confidence interval 88% to 90%) within two months after dose 3 but waned to 66% (63% to 68%) by four to five months. Vaccine effectiveness of three doses against emergency department or urgent care visits was 83% (82% to 84%) initially but waned to 46% (44% to 49%) by four to five months. Waning was evident in all subgroups, including young adults and individuals who were not immunocompromised; although waning was more noticeable in people who were immunocompromised. Vaccine effectiveness increased among most groups after a fourth dose in whom this booster was recommended. cOnclusiOns Effectiveness of mRNA vaccines against moderate and severe covid-19 waned with time after vaccination. The findings support recommendations for a booster dose after a primary series and consideration of additional booster doses.
IMPORTANCE Postauthorization monitoring of vaccines in a large population may detect rare adverse... more IMPORTANCE Postauthorization monitoring of vaccines in a large population may detect rare adverse events not identified in clinical trials such as Guillain-Barré syndrome (GBS), which has a background rate of 1 to 2 per 100 000 person-years. OBJECTIVE To describe cases and incidence of GBS following COVID-19 vaccination and assess the risk of GBS after vaccination for Ad.26.COV2.S (Janssen) and mRNA vaccines.
This study compared the age-specific incidence, postdiagnostic survival, and mortality for cardio... more This study compared the age-specific incidence, postdiagnostic survival, and mortality for cardiovascular disease (CVD) in two cohorts of people aged 65 years and older. All subjects were members of a large prepaid health maintenance organization. The influence of changes in CVD risk factors on these rutes also wus e&uated. Trends in pre&ence, incidence, postdiagnostic surui~ul, and mortality for CVD were examined in both cohorts in 1971 and 1980. Myocardial infarction (MI), angina pectoris, stroke, and congestive heart failure (CHF) were included as CVD outcomes in this analysis. Nine-year prospeccioe data on these diagnoses were abstracted from medical records and computerized hospitalization records for both cohorts. Age-sex-adjusted cardiovascular mortality was lower for both sexes by +., 20% in the 1980 cohort. Overall survival did not change, whereas cancer mortality increased by 76% in women and 36% in men. With the exception of stroke, there was no increase in age-adjusted or age-specific prevalence. In men, the age-adjusted prevalence of stroke in men was 24% higher in the J 980 cohort. Age-adjusted 9-year incidence of MI, angina pectoris, stroke, and CHF did not change between cohorts in either sex. Postdiagnostic, age-adjusted mortality for men with incident stroke was 24% lower in the 1980 cohort, and Postdiagnostic, age-adjusted mortality for men with incident angina was 35% lower in the 1980 cohort. Adjustment for risk factors measured at or before baseline had little influence on cohort differences in CVD incidence or duration of survival after CVD diagnosis. This study confirms other research showing a decline in CVD mortality over the past 20 years. These findings suggest that prevalent angina pectoris is increasing in men, and that survival with stroke and with angina is improving in men. Later diagnosis of incident CHF in men suggests that prewention and early detection may be postponing the development of more serious disease.
The American Journal of Managed Care, Oct 16, 2020
OBJECTIVES Continuity of patient information across settings can improve transitions after hospit... more OBJECTIVES Continuity of patient information across settings can improve transitions after hospital discharge, but outpatient clinicians often have limited access to complete information from recent hospitalizations. We examined whether providers' timely access to clinical information through shared inpatient-outpatient electronic health records (EHRs) was associated with follow-up visits, return emergency department (ED) visits, or readmissions after hospital discharge in patients with diabetes. STUDY DESIGN Stepped-wedge observational study. METHODS As an integrated delivery system staggered implementation of a shared inpatient-outpatient EHR, we studied 241,510 hospital discharges in patients with diabetes (2005-2011), examining rates of outpatient follow-up office visits, telemedicine (phone visits and asynchronous secure messages), laboratory tests, and return ED visits or readmissions (as adverse events). We used multivariate logistic regression adjusting for time trends, patient characteristics, and medical center and accounting for patient clustering to calculate adjusted follow-up rates. RESULTS For patients with diabetes, provider use of a shared inpatient-outpatient EHR was associated with a statistically significant shift toward follow-up delivered through a combination of telemedicine and outpatient laboratory tests, without a traditional in-person visit (from 22.9% with an outpatient-only EHR to 27.0% with a shared inpatient-outpatient EHR; P < .05). We found no statistically significant differences in 30-day return ED visits (odds ratio, 1.02; 95% CI, 0.96-1.09) or readmissions (odds ratio, 0.98; 95% CI, 0.91-1.06) with the shared EHR compared with the outpatient-only EHR. CONCLUSIONS Real-time clinical information availability during transitions between health care settings, along with robust telemedicine access, may shift the method of care delivery without adversely affecting patient health outcomes. Efforts to expand interoperability and information exchange may support follow-up care efficiency.
Background Childhood bacterial pneumonia and empyema rates have reportedly increased in recent ye... more Background Childhood bacterial pneumonia and empyema rates have reportedly increased in recent years in Europe. In September 2006 the seven-valent pneumococcal conjugate vaccination (PCV7) was introduced to the childhood national immunisation programme in England following a successful PCV7 campaign in the USA. The aim of this study was to report national time trends in hospital admissions for childhood bacterial pneumonia and empyema in England before and after the introduction of PCV7. Methods A population-based time-trend analysis of Hospital Episode Statistics data of children aged <15 years admitted to all NHS hospitals in England, with a primary diagnosis of bacterial pneumonia and empyema from 1997 to 2008 was performed. Annual crude and age-sex standardised hospital admission rates for bacterial pneumonia and empyema were calculated. Results Admission rates for bacterial pneumonia and empyema increased from 1997 to 2006, then declined to 2008. Bacterial pneumonia rates decreased to 1079 (95% CI 1059 to 1099) per million children and empyema rates decreased to 14 (95% CI 11 to 16) per million children. The RR for bacterial pneumonia admissions
INTRODUCTION Despite high vaccination coverage among children and adolescents, pertussis remains ... more INTRODUCTION Despite high vaccination coverage among children and adolescents, pertussis remains a public health problem, with large outbreaks occurring periodically in the US and other developed countries. AREAS COVERED We examined lessons learned more than 20 years after implementation of programs which use only acellular pertussis vaccines and proposed avenues for possible effective use of acellular pertussis vaccine to prevent large outbreaks. EXPERT OPINION Acellular pertussis vaccines were introduced more than 20 years ago, yet the incidence of pertussis has been increasing the past decade, with periodic large outbreaks marked by notable shifts in disease burden from infants and young children towards fully vaccinated adolescents and young adults. This age shift is mainly driven by waning of vaccine immunity. To better protect adolescents against pertussis, modification of the current acellular pertussis vaccination schedule or adoption of new vaccination strategies should be considered. For infants not yet eligible to be vaccinated, maternal vaccination against pertussis during pregnancy is an effective way to protect infants from infection, severe disease and death. Implementation of maternal vaccination programs should be encouraged in countries without one or efforts to improve coverage should be supported in countries with existing program.
Background. Clostridioides difficile infection (CDI) is a major cause of severe diarrhea. In this... more Background. Clostridioides difficile infection (CDI) is a major cause of severe diarrhea. In this retrospective study, we identified CDI risk factors by comparing demographic and clinical characteristics for Kaiser Permanente Northern California members ≥18 years old with and without laboratory-confirmed incident CDI. Methods. We included these risk factors in logistic regression models to develop 2 risk scores that predict future CDI after an Index Date for Risk Score Assessment (IDRSA), marking the beginning of a period for which we estimated CDI risk. Results. During May 2011 to July 2014, we included 9986 CDI cases and 2 230 354 members without CDI. The CDI cases tended to be older, female, white race, and have more hospitalizations, emergency department and office visits, skilled nursing facility stays, antibiotic and proton pump inhibitor use, and specific comorbidities. Using hospital discharge as the IDRSA, our risk score model yielded excellent performance in predicting the likelihood of developing CDI in the subsequent 31-365 days (C-statistic of 0.848). Using a random date as the IDRSA, our model also predicted CDI risk in the subsequent 31-365 days reasonably well (C-statistic 0.722). Conclusions. These results can be used to identify high-risk populations for enrollment in C difficile vaccine trials and facilitate study feasibility regarding sample size and time to completion.
There is some concern that thiazolidinediones (TZDs) may be associated with an increased risk of ... more There is some concern that thiazolidinediones (TZDs) may be associated with an increased risk of heart failure. This study compares risk of heart failure in patients initiated on TZDs or metformin in a Medicaid Managed Care Organization (MCO). METHODS: Retrospective cohort study using prescription and medical claims of Medicaid MCO patients. The
Weinberg ( v e r y q u i e t l y ) : "I 'm n o t prepared." Murphy:"Areyou aware t h a t by n o t... more Weinberg ( v e r y q u i e t l y ) : "I 'm n o t prepared." Murphy:"Areyou aware t h a t by n o t doing s o you a r e subj e c t i n g y o u r s e l f t o probable d i s c i p l i n a r y a c t i o n ? " Weinberg ( s t i l l more q u i e t l y ) : "I--uh--I 'm aware t h a t y o u ' r e going t o do what y o u ' l l t r y t o do." Murphy: " A l l r i g h t . W i l l you--uh--identify y o u r s e l f ? " Weinberg : "No. " Murphy ( i n a dead-pan v o i c e , almost as i f h e were reading a s c r i p t i n s t e a d of t a l k i n g t o a p a r t i c u l a r person) : "I
routine use in the United States for 5 years. Prior U.S. cost-effectiveness analyses have not tak... more routine use in the United States for 5 years. Prior U.S. cost-effectiveness analyses have not taken into account the effect of the vaccine on nonvaccinated persons. Methods: We revised a previously published model to simulate the effects of PCV on children vaccinated between 2000 and 2004, and to incorporate the effect of the vaccine in reducing invasive pneu-mococcal disease (IPD) in nonvaccinated persons during those years. Data from the Active Bacterial Core Surveillance of the Centers for Disease Control and Prevention (2000–2004) were used to estimate changes in the burden of IPD in nonvaccinated adults since the introduction of PCV (compared with the baseline years 1997–1999). Results combined the simulated effects of the vaccine on the vaccinated and nonvaccinated populations. Results: Before incorporating herd effects in the model, the PCV was estimated to have averted 38,000 cases of IPD during its first 5 years of use at a cost of $112,000 per life-year saved. After incorp...
The Kaiser Permanente Medical Care Program in Northern California, like other health care provide... more The Kaiser Permanente Medical Care Program in Northern California, like other health care providers during the current period of rising medical costs, has a pressing need to manage its hospital utilization while maintaining a high quality of medical care. Small Area Analysis (SM), which applies population-based statistical methods to compare hospitalization rates across hospital service areas, can be helpful in identifying high-variability medical diagnoses and procedures where utilization management may be effective. The SAS System application described here produces detailed graphical reports for comparing hospital utilization rates for many diagnoses and procedures across different hospaals, time periods and populations. SASjGRAPH· was chosen for the production of these reports because of its ability to produce a sequence of high quality customized graphs under. control of the macro language.
Vaccine effectiveness studies are subject to biases due to depletion-of-persons at risk of infect... more Vaccine effectiveness studies are subject to biases due to depletion-of-persons at risk of infection, or at especially high risk of infection, at different rates from different groups (depletionof-susceptibles bias), a problem that can also lead to biased estimates of waning effectiveness, including spurious inference of waning when none exists. An alternative study design to identify waning is to study only vaccinated persons, and compare for each day the incidence in persons with earlier or later dates of vaccination to assess waning in vaccine protection as a function of vaccination time (namely whether earlier vaccination would result in lower subsequent protection compared to later vaccination). Prior studies suggested under what conditions this alternative would yield correct estimates of waning. Here we define the depletion-ofsusceptibles process formally and show mathematically that for influenza vaccine waning studies, a randomised trial or corresponding observational study that compares incidence at a specific calendar time among individuals vaccinated at different times before the influenza season begins will not be vulnerable to depletion-of-susceptibles bias in its inference of waning as a function of vaccination time under the null hypothesis that none exists, and willif waning does actually occurunderestimate the extent of waning. Such a design is thus robust in the sense that a finding of waning in that inference framework reflects actual waning of vaccine-induced immunity. We recommend such a design for future studies of waning, whether observational or randomised. Recent studies on influenza vaccine effectiveness (VE) have suggested that effectiveness declines over the course of one season [1-3]. However, these results have been called into question because inferences of waning may be biased. When there is no waning, some study designs (including the classic test-negative observational design [4, 5] and randomised controlled trials ) may nonetheless infer waningmeasured as a decline in VE as the season progresses. This biased inference is predicted to occur when the vaccine offers 'leaky' protection, reducing the probability of infection on exposure by some proportion less than 100%, and either or both of the following conditions holds and is unaccounted for in the analysis[9]: (i) some infections occur unobserved in the study population, such that individuals are infected and (for the season) immune to further infection unbeknownst to the researchers ; or (ii) heterogeneity in the population exists and is unaccounted for, such that certain persons are at higher risk of becoming exposed or, if they are exposed, of becoming infected upon exposure for reasons other than their vaccine status, for example due to age, past-season history of infection or vaccination or occupation . If either or both of these conditions hold, then over the course of the season, there will be unobserved reductions in the population at risk (or, for the second, at high risk) in each arm of the trial, and these reductions will be greater in any group that receives less vaccine protection, more moderate in a group that is more protected. In a classic comparison of vaccinated vs. unvaccinated persons, this 'depletion-of-susceptibles' will reduce the pool of susceptible individuals (and especially of highly susceptible individuals) in the unvaccinated group more than in the vaccinated group, reducing the influenza incidence rate in the unvaccinated group relative to the vaccinated group as time progresses; equivalently, the benefit of the vaccine will appear to wane. Recently, a novel, cohort variant of the test-negative design (TND), was proposed and implemented that sought to circumvent these sources of bias. This design [3] considered only persons who received influenza vaccine and were subsequently tested for influenza infection. As in the classic TND the vaccine history was compared between those testing positive vs. negative for influenza infection, but unlike a classic TND, the time from vaccination to influenza test was the exposure of interest (as the study was limited to those who had received .
Morbidity and Mortality Weekly Report, May 26, 2023
† Medical events with a discharge code consistent with COVID-19-like illness were included. COVID... more † Medical events with a discharge code consistent with COVID-19-like illness were included. COVID-19-like illness diagnoses were obtained from ICD-10 discharge codes. The specific codes used were COVID-19 pneumonia: J12.
Objective To estimate the effectiveness of mRNA vaccines against moderate and severe covid-19 in ... more Objective To estimate the effectiveness of mRNA vaccines against moderate and severe covid-19 in adults by time since second, third, or fourth doses, and by age and immunocompromised status. Design Test negative case-control study. setting Hospitals, emergency departments, and urgent care clinics in 10 US states, 17 January 2021 to 12 July 2022. ParticiPants 893 461 adults (≥18 years) admitted to one of 261 hospitals or to one of 272 emergency department or 119 urgent care centers for covid-like illness tested for SARS-CoV-2. Main OutcOMe Measures The main outcome was waning of vaccine effectiveness with BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna) vaccine during the omicron and delta periods, and the period before delta was dominant using logistic regression conditioned on calendar week and geographic area while adjusting for age, race, ethnicity, local virus circulation, immunocompromised status, and likelihood of being vaccinated. results 45 903 people admitted to hospital with covid-19 (cases) were compared with 213 103 people with covid-like illness who tested negative for SARS-CoV-2 (controls), and 103 287 people admitted to emergency department or urgent care with covid-19 (cases) were compared with 531 168 people with covid-like illness who tested negative for SARS-CoV-2. In the omicron period, vaccine effectiveness against covid-19 requiring admission to hospital was 89% (95% confidence interval 88% to 90%) within two months after dose 3 but waned to 66% (63% to 68%) by four to five months. Vaccine effectiveness of three doses against emergency department or urgent care visits was 83% (82% to 84%) initially but waned to 46% (44% to 49%) by four to five months. Waning was evident in all subgroups, including young adults and individuals who were not immunocompromised; although waning was more noticeable in people who were immunocompromised. Vaccine effectiveness increased among most groups after a fourth dose in whom this booster was recommended. cOnclusiOns Effectiveness of mRNA vaccines against moderate and severe covid-19 waned with time after vaccination. The findings support recommendations for a booster dose after a primary series and consideration of additional booster doses.
IMPORTANCE Postauthorization monitoring of vaccines in a large population may detect rare adverse... more IMPORTANCE Postauthorization monitoring of vaccines in a large population may detect rare adverse events not identified in clinical trials such as Guillain-Barré syndrome (GBS), which has a background rate of 1 to 2 per 100 000 person-years. OBJECTIVE To describe cases and incidence of GBS following COVID-19 vaccination and assess the risk of GBS after vaccination for Ad.26.COV2.S (Janssen) and mRNA vaccines.
This study compared the age-specific incidence, postdiagnostic survival, and mortality for cardio... more This study compared the age-specific incidence, postdiagnostic survival, and mortality for cardiovascular disease (CVD) in two cohorts of people aged 65 years and older. All subjects were members of a large prepaid health maintenance organization. The influence of changes in CVD risk factors on these rutes also wus e&uated. Trends in pre&ence, incidence, postdiagnostic surui~ul, and mortality for CVD were examined in both cohorts in 1971 and 1980. Myocardial infarction (MI), angina pectoris, stroke, and congestive heart failure (CHF) were included as CVD outcomes in this analysis. Nine-year prospeccioe data on these diagnoses were abstracted from medical records and computerized hospitalization records for both cohorts. Age-sex-adjusted cardiovascular mortality was lower for both sexes by +., 20% in the 1980 cohort. Overall survival did not change, whereas cancer mortality increased by 76% in women and 36% in men. With the exception of stroke, there was no increase in age-adjusted or age-specific prevalence. In men, the age-adjusted prevalence of stroke in men was 24% higher in the J 980 cohort. Age-adjusted 9-year incidence of MI, angina pectoris, stroke, and CHF did not change between cohorts in either sex. Postdiagnostic, age-adjusted mortality for men with incident stroke was 24% lower in the 1980 cohort, and Postdiagnostic, age-adjusted mortality for men with incident angina was 35% lower in the 1980 cohort. Adjustment for risk factors measured at or before baseline had little influence on cohort differences in CVD incidence or duration of survival after CVD diagnosis. This study confirms other research showing a decline in CVD mortality over the past 20 years. These findings suggest that prevalent angina pectoris is increasing in men, and that survival with stroke and with angina is improving in men. Later diagnosis of incident CHF in men suggests that prewention and early detection may be postponing the development of more serious disease.
The American Journal of Managed Care, Oct 16, 2020
OBJECTIVES Continuity of patient information across settings can improve transitions after hospit... more OBJECTIVES Continuity of patient information across settings can improve transitions after hospital discharge, but outpatient clinicians often have limited access to complete information from recent hospitalizations. We examined whether providers' timely access to clinical information through shared inpatient-outpatient electronic health records (EHRs) was associated with follow-up visits, return emergency department (ED) visits, or readmissions after hospital discharge in patients with diabetes. STUDY DESIGN Stepped-wedge observational study. METHODS As an integrated delivery system staggered implementation of a shared inpatient-outpatient EHR, we studied 241,510 hospital discharges in patients with diabetes (2005-2011), examining rates of outpatient follow-up office visits, telemedicine (phone visits and asynchronous secure messages), laboratory tests, and return ED visits or readmissions (as adverse events). We used multivariate logistic regression adjusting for time trends, patient characteristics, and medical center and accounting for patient clustering to calculate adjusted follow-up rates. RESULTS For patients with diabetes, provider use of a shared inpatient-outpatient EHR was associated with a statistically significant shift toward follow-up delivered through a combination of telemedicine and outpatient laboratory tests, without a traditional in-person visit (from 22.9% with an outpatient-only EHR to 27.0% with a shared inpatient-outpatient EHR; P < .05). We found no statistically significant differences in 30-day return ED visits (odds ratio, 1.02; 95% CI, 0.96-1.09) or readmissions (odds ratio, 0.98; 95% CI, 0.91-1.06) with the shared EHR compared with the outpatient-only EHR. CONCLUSIONS Real-time clinical information availability during transitions between health care settings, along with robust telemedicine access, may shift the method of care delivery without adversely affecting patient health outcomes. Efforts to expand interoperability and information exchange may support follow-up care efficiency.
Background Childhood bacterial pneumonia and empyema rates have reportedly increased in recent ye... more Background Childhood bacterial pneumonia and empyema rates have reportedly increased in recent years in Europe. In September 2006 the seven-valent pneumococcal conjugate vaccination (PCV7) was introduced to the childhood national immunisation programme in England following a successful PCV7 campaign in the USA. The aim of this study was to report national time trends in hospital admissions for childhood bacterial pneumonia and empyema in England before and after the introduction of PCV7. Methods A population-based time-trend analysis of Hospital Episode Statistics data of children aged <15 years admitted to all NHS hospitals in England, with a primary diagnosis of bacterial pneumonia and empyema from 1997 to 2008 was performed. Annual crude and age-sex standardised hospital admission rates for bacterial pneumonia and empyema were calculated. Results Admission rates for bacterial pneumonia and empyema increased from 1997 to 2006, then declined to 2008. Bacterial pneumonia rates decreased to 1079 (95% CI 1059 to 1099) per million children and empyema rates decreased to 14 (95% CI 11 to 16) per million children. The RR for bacterial pneumonia admissions
INTRODUCTION Despite high vaccination coverage among children and adolescents, pertussis remains ... more INTRODUCTION Despite high vaccination coverage among children and adolescents, pertussis remains a public health problem, with large outbreaks occurring periodically in the US and other developed countries. AREAS COVERED We examined lessons learned more than 20 years after implementation of programs which use only acellular pertussis vaccines and proposed avenues for possible effective use of acellular pertussis vaccine to prevent large outbreaks. EXPERT OPINION Acellular pertussis vaccines were introduced more than 20 years ago, yet the incidence of pertussis has been increasing the past decade, with periodic large outbreaks marked by notable shifts in disease burden from infants and young children towards fully vaccinated adolescents and young adults. This age shift is mainly driven by waning of vaccine immunity. To better protect adolescents against pertussis, modification of the current acellular pertussis vaccination schedule or adoption of new vaccination strategies should be considered. For infants not yet eligible to be vaccinated, maternal vaccination against pertussis during pregnancy is an effective way to protect infants from infection, severe disease and death. Implementation of maternal vaccination programs should be encouraged in countries without one or efforts to improve coverage should be supported in countries with existing program.
Background. Clostridioides difficile infection (CDI) is a major cause of severe diarrhea. In this... more Background. Clostridioides difficile infection (CDI) is a major cause of severe diarrhea. In this retrospective study, we identified CDI risk factors by comparing demographic and clinical characteristics for Kaiser Permanente Northern California members ≥18 years old with and without laboratory-confirmed incident CDI. Methods. We included these risk factors in logistic regression models to develop 2 risk scores that predict future CDI after an Index Date for Risk Score Assessment (IDRSA), marking the beginning of a period for which we estimated CDI risk. Results. During May 2011 to July 2014, we included 9986 CDI cases and 2 230 354 members without CDI. The CDI cases tended to be older, female, white race, and have more hospitalizations, emergency department and office visits, skilled nursing facility stays, antibiotic and proton pump inhibitor use, and specific comorbidities. Using hospital discharge as the IDRSA, our risk score model yielded excellent performance in predicting the likelihood of developing CDI in the subsequent 31-365 days (C-statistic of 0.848). Using a random date as the IDRSA, our model also predicted CDI risk in the subsequent 31-365 days reasonably well (C-statistic 0.722). Conclusions. These results can be used to identify high-risk populations for enrollment in C difficile vaccine trials and facilitate study feasibility regarding sample size and time to completion.
There is some concern that thiazolidinediones (TZDs) may be associated with an increased risk of ... more There is some concern that thiazolidinediones (TZDs) may be associated with an increased risk of heart failure. This study compares risk of heart failure in patients initiated on TZDs or metformin in a Medicaid Managed Care Organization (MCO). METHODS: Retrospective cohort study using prescription and medical claims of Medicaid MCO patients. The
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Papers by Bruce Fireman