Recently revised vaccination recommendations for US adults, aged 65 years and older, include both 23‐valent pneumococcal polysaccharide vaccine (PPSV23) and 13‐valent pneumococcal conjugate vaccine (PCV13), with PCV13 now recommended for immunocompetent older people based on shared decision making. The public health impact and cost‐effectiveness of this recommendation or of pneumococcal vaccine uptake improvement interventions are unclear.
Markov decision analysis.
SETTING AND PARTICIPANTS
Hypothetical 65‐year‐old general and black population cohorts.
Current pneumococcal vaccination recommendations for US older people, an alternative policy omitting PCV13 in immunocompetent older people, and vaccine uptake improvement programs.
The current pneumococcal vaccination recommendation was the most effective strategy, but afforded slight public health benefits compared to an alternative (PPSV23 for all older people plus PCV13 for the immunocompromised) and cost greater than $750 000 per quality‐adjusted life‐year (QALY) gained in either population group with a vaccine uptake improvement program (absolute uptake increase = 12.3%; cost = $1.78/eligible patient) in place. The alternative strategy was more economically favorable, but cost greater than $100 000/QALY in either population, with or without an uptake intervention. Results were robust in sensitivity analyses; however, in black older people, the alternative strategy with an uptake program was most likely to be favored in probabilistic sensitivity analyses at a $150 000/QALY gained threshold.
Current pneumococcal vaccination recommendations for US older people are economically unfavorable compared to an alternative strategy omitting PCV13 in the immunocompetent. The alternative recommendation with an uptake improvement program may be economically reasonable in black population analyses and could be worth considering as a population‐wide recommendation if mitigating racial disparities is a priority.
Scores of students at the University of Mississippi Medical Center have learned a life-saving measure meant to curb the deadly impact of a nationwide scourge.
Learners from several UMMC schools received hands-on instruction Friday in the administering of naloxone, brand name NARCAN®, a nasal spray that can force the dangers of an opioid overdose into retreat.
The interprofessional naloxone training, conducted in groups by students from the School of Pharmacy and held in the School of Medicine, is part of a cluster of recent or upcoming activities planned by the 37-member Opioid Task Force, established in 2018 by Dr. LouAnn Woodward, vice chancellor for health affairs and dean of the School of Medicine.
While the stated mission of the group is to help health care providers take a more considered approach to prescribing opioids for pain, its work also involves dosing health care workers and the public with information about opioid treatment – including the reversing effects of naloxone.
“It has saved lives and will continue to save lives,” said Dr. Rob Rockhold, professor of health sciences and deputy chief academic officer. “It’s been such a hot topic; we want to cast as wide a net as possible.”
The net was also cast over UMMC Grenada on January 29, when physicians and other health care workers heard an update on Mississippi Prescribing Guidelines and Diversion Prevention from Dr. Jessica Lavender, assistant professor of internal medicine, and Dr. Anthony Cloy, associate professor of medicine.
On February 12, during the annual Jackson Public Schools symposium, Youth Health Matters, the task force reached out to JPS 10th and 11th graders with lessons on administering naloxone. The teachers were mostly pharmacy students, and several medical students, led by Dr. Leigh Ann Ross, associate dean of the UMMC School of Pharmacy and director of the Center for Clinical and Translational Science.
Earlier this week in Tallahatchie County was the site of several events hosted by the School of Pharmacy’s CCTS and the University of Mississippi’s M Partner Initiative. First responders in the Charleston area embraced naloxone training from pharmacy students and Dr. Lauren Bloodworth, associate professor of pharmacy practice and the CCTS community population director.
Also in Charleston, at the Kennedy Wellness Center, area physicians, nurses, nurse practitioners and social workers were invited to a three-hour, opioid-abuse continuing education program featuring a discussion led by Cloy, Lavender and Dr. Ann Kemp, professor of medicine and task force chair.
And, for the residents of Charleston, the School of Pharmacy led a community-wide seminar on opioid abuse – an epidemic that, in 2017, the Department of Health and Human Services declared a public health emergency.
In a one-year period that ended in February 2019, an estimated 69,029 Americans died of a drug overdose, as reported by the National Center for Health Statistics. Almost seven out of 10 of those deaths are attributed to opioids, highly-addictive killers of pain that, when used wrong, can also kill the user.
Opioids include heroin, pain relievers such as oxycodone and hydrocodone, with brand names OxyContin® and Vicodin®, respectively, and synthetic concoctions such as the extremely potent fentanyl.
More than 200 suspected overdose deaths were reported to the Mississippi Bureau of Narcotics between 2017 and 2018. The number of opioid prescriptions dispensed in Mississippi in 2017 alone surpassed 3.3 million.
The majority of opioid addiction cases started with a legal prescription, Lt. John Harless of the MBN told students during last week’s naloxone session, which offered participants digital certification for their newly-acquired skills.
To better manage opioid abuse, Harless urged even closer cooperation between professionals in health care and law enforcement.
“Lt. Harless gave us a great perspective – from someone who’s working in the law enforcement field,” said Conner Ball of Madison, a first-year medical student.
“And [pharmacy student Douglas Dertien] did a good job in letting our groups be interactive and showing us how to use NARCAN the right way. I feel confident in using it now.”
NARCAN was patented in 1961 and approved for opioid overdose treatment by the Food and Drug Administration in 1971. “But until relatively recently, it was available by prescription only to qualified medical personnel,” Rockhold said.
Now, the overdose treatment is more readily obtainable for the public. “It’s available without a specific prescription,” Kemp said. “You can walk into a pharmacy and request it if you have concerns about yourself or someone in your family.
“This has been made possible because of a standing order from the Mississippi State Department of Health.”
Of course, it is important to get instructions on how to use it. This can come from the pharmacist who dispenses the product or at a session like this one, Kemp said.
“There are any number of reports of police officers, family members, and acquaintances providing naloxone in the home or in the field in emergencies andsaving people’s lives,” Rockhold said.
Saving a life can depend on recognizing the signs of an overdose, as described by fourth-year pharmacy student Mary Reagan Richardson to the assorted students attending Friday’s naloxone training activity: blue lips or nails, pale pallor, dizziness, confusion, drowsiness, choking and more.
As Richardson noted, naloxone is administered in more than one way, including by a hand-held auto-injector, Evzio®.
“Evzio comes with voice guidance – it tells you what to do. But the nasal spray is also easy to use and is less expensive, at least for now,” Kemp said. For the public, Evzio can cost several thousand dollars for two injectors, although there will be a generic injector in the future, Kemp said.
“NARCAN nasal spray is available at about $130 or $140,” said Dr. Justin J. Sherman, associate professor of pharmacy practice.
A generic nasal spray will be coming out soon, Kemp said. Its cost is estimated, but not confirmed, at $35.
Across the state, more than 9,000 law enforcement officers and first responders have been trained to administer NARCAN, said Mae Slay, outreach coordinator for a statewide initiative to end the opioid crisis: Stand Up, Mississippi, a partner of the task force and the Associated Student Body for Friday’s session.
For physicians worried that some patients are abusing opioid prescriptions, Dr. Patrick Kyle and Dr. William Gusa, assistant professor of anesthesiology and task force vice chair, are among the authors who collectively published recommendations for testing compliance.
Their article, published on pages 331-336 of the October 2019 issue of the Journal of the Mississippi State Medical Association, offers a vivid account of how some patients try to fake urine tests.
“Although many patients prescribed controlled substances use them responsibly and as directed by their providers, some do not,” said Kyle, assistant professor of pathology.
“Some patients are known to mix potentially harmful illicit drugs with prescribed opioids. But it’s not only illicit drugs that can be potentially dangerous when mixed with opioids.
“There is also a large black market for these drugs. Some people complaining of, say, chronic back pain, may actually be trying to obtain prescription medications they can sell on the street. Drug diversion can be very lucrative.
“We have patients coming into our hospital who have been prescribed those drugs and who know they are going to be tested in order to keep their prescriptions.”
In their JMSMA article, Kyle and his colleagues lay out urine specimen collecting guidelines meant to foil attempts to dilute or otherwise sully test results.
And, in particular, they describe the effectiveness of mass spectrometry testing – the “gold standard of techniques” which are more comprehensive and specific than many hospital’s traditional, and routine, drug screens, Kyle said.
Students and employees of Medical Center hospitals have the opportunity to learn more about drug diversion on February 25 during the ASB/Schwartz Center Rounds event, “This is Us: Shedding Light on Who is at Risk of Substance Use Disorder and Resources for Recovery.”
Scheduled for noon until 1 p.m. in the School of Medicine, room SM122, the presentation is “geared toward health care students, but is also open to providers,” said Reginald Funches, diversion control officer.
“They will also learn about the science behind drug addiction and where employees with an addiction can go to find resources for help.” The forum will feature a case study of a substance-addicted employee who diverted drugs.
More projects are on the way or in the works, such as an update of the task force website – “to house in one place helpful information for UMMC folks,” Kemp said – as well as this spring’s Interprofessional Education seminar on pain management, which will home in on opioids.
Beginning in March, Prescribing Series Continuing Education Sessions will be held from noon until 1 p.m. in the amphitheater, R153, and are listed under “Save the Date” on the task force website.
“With these activities, I hope we are succeeding in getting the message out, to our providers and learners,” Kemp said.
“This issue is broad, but we’ve tried to keep it consistent. All of this is centered on our continued goal to encourage balance and responsible opioid prescribing with individualized patient care.”
To determine for each basic, instrumental, and mobility activity after hospitalization for acute medical illness: (1) disability prevalence immediately before and monthly for 6 months after hospitalization; (2) disability incidence 1 month after hospitalization; and (3) recovery time from incident disability during months 2 to 6 after hospitalization.
Prospective cohort study.
New Haven, Connecticut.
A total of 515 community‐living persons, mean age 82.7 years, hospitalized for acute noncritical medical illness and alive within 1 month of hospital discharge.
Disability was defined monthly for each basic (bathing, dressing, walking, transferring), instrumental (shopping, housework, meal preparation, taking medications, managing finances), and mobility activity (walking a quarter mile, climbing flight of stairs, lifting/carrying 10 pounds, driving) if help was needed to perform the activity or if a car was not driven in the prior month.
Disability was common 1 and 6 months after hospitalization for activities frequently involved in leaving the home to access care including walking a quarter mile (prevalence 65% and 53%, respectively) and driving (65% and 61%). Disability was also common for activities involved in self‐managing chronic health conditions including meal preparation (53% and 41%) and taking medications (41% and 31%). New disability was common and often prolonged. For example, 43% had new disability walking a quarter mile, and 30% had new disability taking medications, with mean recovery time of 1.9 months and 1.7 months, respectively. Findings were similar for the subgroup of persons residing at home (ie, not in a nursing home) at the first monthly follow‐up interview after hospitalization.
Disability in specific functional activities important to leaving home to access care and self‐managing health conditions is common, often new, and present for prolonged time periods after hospitalization for acute medical illness. Post‐discharge care should support patients through extended periods of vulnerability beyond the immediate transitional period.
In 2012, 36 Mississippi counties were faced with having no coverage options of the health insurance marketplace. Heidi Margulis and her team at Humana saw an opportunity to “Do well by doing good” by serving the population and learning new ways to deliver care.
Margulis came back to the state last week, visiting the University of Mississippi Medical Center as the inaugural Executive in Residence for the John D. Bower School of Population Health.
Executive in Residence programs are common at business schools, said Dr. Bettina Beech, dean of the School of Population Health, but they also bring great value to other schools.
“These programs allow academic institutions to develop meaningful engagement with retired or semi-retired senior leaders from a range of industries to lecture, coach, and mentor students, and to link schools to industry,” Beech said. “They bring energy and perspective to campuses that augment classes and research projects and can launch long-term relationships between executives and the school, and these connections can translate into professional opportunities and summer internships for students.”
Margulis, chief corporate affairs officer at Humana until 2019 and now a senior advisor for the company and its Foundation, spent the week meeting with faculty and students talking about her experiences in the business and the real-world applications of population health.
“I was really impressed with the caliber of commitment, compassion and clinical expertise,” Margulis said. “If you have a true commitment to better health, you can’t make that kind of change in a region that ranks at the top of the most-healthy lists.”
A native of Louisville, Kentucky, Margulis says her state and Mississippi face some of the same health challenges. To bring coverage to Mississippi, the company pitched their health insurance plans as a research and development project, learning how to provide the best coverage possible.
One lesson Margulis and her team learned was what does and doesn’t work in encourage preventive care. The company’s insurance plan offered enrollees assistance in finding a primary care physician and a free wellness visit.
“There was about zero uptake,” Margulis said. “What we learned is that it is important to find influencer in the community that others can trust.”
Faith-based institutions and leaders were able to help bridge the gap and help parishioners make healthy choice in their everyday lives.
“There was a pastor in DeSoto County who substituted out the congregation’s fried chicken luncheon with a healthier baked option,” Margulis said.
Prior to 2012, the company’s involvement in Mississippi’s health insurance landscape was primarily through contracts with Department of Defense and Medicare. Insuring civilians and those under 65 wasn’t part of their portfolio. They offered insurance on the exchange for two years, which incentivized other companies to come in and offer insurance.
At the national level, Margulis is also one of the architects of Humana’s population health program the “Bold Goal,” which aims to improve the health of communities they serve by 20 percent – measured by healthy days – by 2020 and beyond. Humana and its non-for-profit arm decided to focus on to social determinants of health: food security and social isolation.
For instance, Margulis said, “the Foundation funds projects that test different solutions to food security or food-banking models, whether that be mobile apps that help people locate food or gardening classes.”
One program that worked well for decreasing social isolation was OATS, or Older Adults Technology Services. These classes teach seniors citizens not just how to use email and social media, but also how manage their finances and health information online.
Through her career, Margulis learned that “health care is one size fits none. You have to tailor the coverage to the people and communities you serve.”
The same goes for the company’s approach to their Bold Goal communities. Starting with clinical town halls, they transition into health advisory boards co-led by a community member and a company representative. Each city or county board identifies its own focus. In Louisville, they focus on asthma. In Baton Rouge, its obesity. In Tampa Bay, its substance use disorders.
During her time at UMMC, Margulis asked each faculty member she met with how they saw her residence fitting in with their lesson plans. Dr. Charles Chima, assistant professor of population health science, put it best, she said.
“He told me that it’s the faculty’s job to teach the principals of population health to students, while my role was to teach the applications of these principals in the marketplace.”
“In the 34 years she spent at Humana, she was integral in building their population health portfolio, including the Bold Goal initiative led by the Humana Foundation,” Beech said. “Her wealth of knowledge and experience has been an invaluable contribution to the education of the students and faculty in the School of Population Health.”
Dr. Roy Beveridge, former chief medical officer for Humana, will be the SOPH’s next Executive in Residence later this spring.
Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]).
Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments.
A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission.
We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7‐day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90‐day cumulative incidence of deintensification.
More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0‐7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50‐.66). Compared with non‐sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31‐1.88), except for basal insulin (aRR = .59; 95% CI = .52‐.66). The only resident factor associated with increased likelihood of deintensification was documented end‐of‐life status (aRR = 1.12; 95% CI = 1.01‐1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75‐.96), obesity (aRR = .88; 95% CI = .78‐.99), and peripheral vascular disease (aRR = .90; 95% CI = .81‐.99) were associated with decreased likelihood of deintensification.
Deintensification of treatment regimens occurred in less than one‐half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics.
A consensus paper from the AARP and the Global Council on Brain Health echoes what University of Mississippi Medical Center experts have said for years: “What’s good for your heart is also good for your brain.”
A Medical Center expert on brain aging and dementia helped prepare “The Brain-Heart Connection.” Dr. Tom Mosley, Robbie and Dudley Hughes Distinguished Chair and director of The MIND Center, was one of the 11 experts selected worldwide to review research and prepare guidance for people over 50 and health care providers.
Published Feb. 10, the report summarizes the importance of managing blood pressure, blood sugar, weight and other cardiovascular risk factors in preventing dementia.
“Dementia is a major cause of disability in older adults, affecting more than 50 million people globally. It is an enormous public health problem,” said Mosley, who studies Alzheimer’s disease and other forms of cognitive decline. “However, even in the absence of cures, we see that certain risk factors, if controlled, may lessen the risk of cognitive decline and dementia in older adults.”
These risk factors include high blood pressure, high cholesterol, diabetes, smoking, sedentary lifestyle, obesity, high salt intake, poor sleep quality and irregular heartbeat. Each can raise the risk of heart disease, stroke and different forms of dementia.
“We know that cardiovascular risk factors can lead to stroke and vascular dementia, but we’ve also found that the same factors increase risk for other types of dementia, most notably Alzheimer’s disease,” Mosley said.
Mosley said it was an honor to be included on the report’s expert panel, saying it underscores the research achievements made by The MIND Center.
The MIND, or Memory Impairment and Neurodegenerative Dementia, Center at UMMC leads research on and provides clinical care for patients with Alzheimer’s disease and other forms of dementia. Studies at The MIND Center include the multisite Atherosclerosis Risk in Communities Neurocognitive Study, or ARIC NCS, Study, which has studied cardiovascular disease and brain aging in 16,000 people, including approximately 4,000 African-Americans from the Jackson metropolitan area.
For example, Mosley said, The MIND Center has “found that even in the absence of brain changes related to clinical stroke, controlling high blood pressure and diabetes may decrease the risk of dementia later in life.”
This finding extends to people with “high normal” measurements, such as pre-hypertension and pre-diabetes, during middle age.
In the absence of stroke, Mosley considers hypertension, diabetes and smoking to be the most influential dementia risk factors outlined in the report, based on their prevalence and their outsized effect on brain and heart health.
“However, if an individual has atrial fibrillation or a history of excessive alcohol use or another risk factor, that could be the most influential risk factor for them,” Mosley said. “It’s never too late to start taking steps to lessen your risk for dementia, and the earlier in life you start, the larger the risk reduction will be.”
The report also highlights where experts still don’t know enough. Mosley said we are still unsure of the causal mechanisms that link brain and heart health.
“What is it about damage, often subtle, to blood vessels that damages the brain, beyond the known effects of a stroke?” Mosley asked. One possibility is that blood vessel damage produces chronic inflammation and immune responses that promote brain aging and cognitive decline, but more work is needed to understand the underlying mechanisms.
The MIND Center’s ongoing research includes a collaboration with Johns Hopkins University studying cardiovascular risk factors and amyloid plaques in the brain, a marker for Alzheimer’s disease. They are also part of the UMMC MIND Center-Mayo Clinic Study of Aging, studying geographic and racial differences in risk and burden of dementia.
“We want to elucidate the factors that explain why cognitive decline and dementia are more prevalent in our region and in African-Americans,” Mosley said.
“The Brain-Heart Connection” has received the seal of approval from multiple health-related associations.
“The American Heart Association endorses this report and commends AARP for focusing on the heart-brain connection. Despite growing science about this relationship, most people are not aware of it,” said Dr. Mitchell Elkind, president-elect of the American Heart Association.
Mosley said it is an important publication because there is “a lot of false and misleading information” on the Internet about unproven remedies and prevention strategies for dementia. This report gives people evidence-based recommendations on how to preserve brain health as they age.
“People are understandably very worried about demenita,” Mosley said. “The AARP and the Global Council on Brain Health have done important work in getting this information out to the public.”
To download a copy of “The Brain-Heart Connection,” click here.
To evaluate the prevalence and factors associated with statin pharmacotherapy in long‐stay nursing home residents with life‐limiting illness.
US Medicare‐ and Medicaid‐certified nursing home facilities.
Long‐stay nursing home resident Medicare fee‐for‐service beneficiaries aged 65 years or older with life‐limiting illness (n = 424 212).
Prevalent statin use was estimated as any low‐moderate intensity (daily dose low‐density lipoprotein‐cholesterol [LDL‐C] reduction <30%‐50%) and high‐intensity (daily dose LDL‐C reduction >50%) use via Medicare Part D claims for a prescription supply on September 30, 2016, with a 90‐day look‐back period. Life‐limiting illness was operationally defined to capture those near the end of life using evidence‐based criteria to identify progressive terminal conditions or limited prognoses (<6 mo). Poisson models provided estimates of adjusted prevalence ratios and 95% confidence intervals for resident factors.
A total of 34% of residents with life‐limiting illness were prescribed statins (65‐75 y = 44.0%, high intensity = 11.1%; >75 y = 31.1%, high intensity = 5.4%). Prevalence of statins varied by life‐limiting illness definition. Of those with a prognosis of less than 6 months, 23% of the 65 to 75 and 12% of the older than 75 age groups were on statins. Factors positively associated with statin use included minority race or ethnicity, use of more than five concurrent medications, and atherosclerotic cardiovascular disease or risk factors.
Despite having a life‐limiting illness, more than one‐third of clinically compromised long‐stay nursing home residents remain on statins. Although recent national guidelines have expanded indications for statins, the benefit of continued therapy in an advanced age population near the end of life is questionable. Efforts to deprescribe statins in the nursing home setting may be warranted.