Mary Patricia Nowalk

Sensitivity and specificity of patient self-report of influenza and pneumococcal polysaccharide vaccinations among elderly outpatients in diverse patient care strata

National surveys of adult vaccination indicate moderate self-reported immunization rates in the US, with limited validity data. We compared self-report with medical record abstraction for 820 persons aged > or =66 years from inner-city health centers, Veterans Affairs (VA) outpatient clinics, rural and suburban practices. For influenza vaccine, sensitivity was 98% (95% CI: 96-99%); specificity was 38% (95% CI: 33-43%). For pneumococcal polysaccharide vaccine, sensitivity was 85% (95% CI: 82-89%) and specificity was 46% (95% CI: 42-50%). The VA had the highest sensitivity and lowest specificity for both vaccines while the converse was true in inner-city centers. High negative predictive values indicate that clinicians can confidently vaccinate based on negative patient self-report.

A Randomized Trial of Exercise Programs Among Older Individuals Living in Two Long-Term Care Facilities: The FallsFREE Program

OBJECTIVE: To use two different exercise programs over a 2‐year period to reduce falls and their sequelae among residents of two long‐term care facilities.

Exercise in a behavioural weight control programme for obese patients with Type 2 (non-insulin-dependent) diabetes

SummaryTwo studies were conducted to determine whether adding exercise to a diet programme promotes weight loss or glycaemic control in Type 2 (non-insulin-dependent) diabetic subjects. In Study 1, 25 subjects were randomly assigned to diet plus moderate exercise or diet plus placebo exercise. All subjects exercised twice a week as a group and once a week on their own; the diet plus moderate exercise group walked a 3-mile route at each session while the diet plus placebo exercise group did very low intensity exercises such as stretching and light calisthenics. All subjects followed a calorie-counting diet and were taught behaviour modification strategies. Weight losses and improvements in glycaemic control did not differ significantly between the two treatment groups at the end of the 10-week treatment or at 1-year follow-up. In Study 2, more extreme conditions were compared: a diet only group and a diet plus exercise group. The diet plus exercise group walked a 3-mile route with the group 3 times/week and once a week on their own, while the diet only group was instructed to maintain their current low level of activity. Both groups received comparable diet and behaviour modification instruction and therapist contacts. The diet plus exercise group had significantly (p<0.01) better weight losses than the diet only condition at the end of the 10 week programme (−9.3kg vs −5.6kg) and at 1 year follow-up (−7.9kg vs −3.8 kg). Both groups had similar improvements in glycosylated haemoglobin, but reductions in medication were more frequent and greater in magnitude in the diet plus exercise group. Finally, analyses were conducted collapsing across studies and across treatment groups and comparing subjects who reported low, medium, or high levels of exercise at 1 year. Self-reported exercise was related to weight loss and to improvements in glycosylated haemoglobin, even after adjusting for weight loss. These data suggest that the combination of diet and exercise improves weight loss and glycaemic control compared to diet only in Type 2 diabetic patients.

What affects influenza vaccination rates among older patients? An analysis from inner-city, suburban, rural, and veterans affairs practices

BACKGROUND Despite strong evidence of the effectiveness of influenza vaccination, immunization rates have reached a plateau that is below the 2010 national goals. Our objective was to identify facilitators of, and barriers to, vaccination in diverse groups of older patients. METHODS A survey was conducted in 2000 by computer-assisted telephone interviewing of patients from inner-city health centers, Veterans Affairs (VA) outpatient clinics, rural practices, and suburban practices. The inclusion criteria were age > or =66 years and an office visit after September 30, 1998. RESULTS Overall, 1007 (73%) interviews were completed among 1383 patients. Influenza vaccination rates were 91% at VA clinics, 79% at rural practices, 79% at suburban practices, and 67% at inner-city health centers. There was substantial variability in vaccination rates among practices, except at the VA. Nearly all persons who were vaccinated reported that their physicians recommended influenza vaccinations, compared with 63% of unvaccinated patients (P <0.001). Thirty-eight percent of unvaccinated patients were concerned that they would get influenza from the vaccine, compared with only 6% of vaccinated persons (P <0.001). Sixty-three percent of those vaccinated, in contrast with 22% of unvaccinated persons, thought that an unvaccinated person would probably contract influenza (P <0.001). CONCLUSION Older patients need intentional messages from physicians that recommend vaccination. Furthermore, more patient education is needed to counter myths about adverse reactions.

Influenza Vaccine Effectiveness in the United States During 2012–2013: Variable Protection by Age and Virus Type

Background. During the 2012–2013 influenza season, there was cocirculation of influenza A(H3N2) and 2 influenza B lineage viruses in the United States. Methods. Patients with acute cough illness for ≤7 days were prospectively enrolled and had swab samples obtained at outpatient clinics in 5 states. Influenza vaccination dates were confirmed by medical records. The vaccine effectiveness (VE) was estimated as [100% × (1 − adjusted odds ratio)] for vaccination in cases versus test-negative controls. Results. Influenza was detected in 2307 of 6452 patients (36%); 1292 (56%) had influenza A(H3N2), 582 (25%) had influenza B/Yamagata, and 303 (13%) had influenza B/Victoria. VE was 49% (95% confidence interval [CI], 43%–55%) overall, 39% (95% CI, 29%–47%) against influenza A(H3N2), 66% (95% CI, 58%–73%) against influenza B/Yamagata (vaccine lineage), and 51% (95% CI, 36%–63%) against influenza B/Victoria. VE against influenza A(H3N2) was highest among persons aged 50–64 years (52%; 95% CI, 33%–65%) and persons aged 6 months–8 years (51%; 95% CI, 32%–64%) and lowest among persons aged ≥65 years (11%; 95% CI, −41% to 43%). In younger age groups, there was evidence of residual protection from receipt of the 2011–2012 vaccine 1 year earlier. Conclusions. The 2012–2013 vaccines were moderately effective in most age groups. Cross-lineage protection and residual effects from prior vaccination were observed and warrant further investigation.

Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type II diabetes?

Self-monitoring of blood glucose levels is currently being recommended for obese patients with type II diabetes to improve weight loss and glycemic control. To determine whether self-monitoring of blood glucose levels improves dietary compliance in these patients, 50 obese patients with type II diabetes were randomly assigned either to a standard behavioral weight control program or to a weight control program that included self-monitoring of blood glucose levels and focused on the weight-blood glucose relationship. Both groups lost significant amounts of weight and maintained their losses for at least one year; reductions in medication could be made for 70 percent of patients. These data suggest that the behavioral weight control used in this study may be of benefit to patients with type II diabetes. However, there was no evidence that the addition of self-monitoring of blood glucose levels to the treatment program improved the outcome in terms of weight loss, reduction in medication, dietary compliance, or mood state.

Cost-effectiveness of Adult Vaccination Strategies Using Pneumococcal Conjugate Vaccine Compared With Pneumococcal Polysaccharide Vaccine

CONTEXT The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear. OBJECTIVE To estimate the cost-effectiveness of PCV13 vaccination strategies in adults. DESIGN, SETTING, AND PARTICIPANTS A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included Centers for Disease Control and Prevention Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey. MAIN OUTCOME MEASURES Pneumococcal disease cases prevented and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS In the base case scenario, administration of PCV13 as a substitute for PPSV23 in current recommendations (ie, vaccination at age 65 years and at younger ages if comorbidities are present) cost

Barriers to pneumococcal and influenza vaccination in older community-dwelling adults (2000-2001)

28,900 per QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost

subclinical Eating Disorders and Glycemic Control in Adolescents with Type I Diabetes

45,100 per QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 years to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing

Influenza Vaccine Effectiveness Against 2009 Pandemic Influenza A(H1N1) Virus Differed by Vaccine Type During 2013–2014 in the United States

496,000 per QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored. CONCLUSION Overall, PCV13 vaccination was favored compared with PPSV23, but the analysis was sensitive to assumptions about PCV13 effectiveness against nonbacteremic pneumococcal pneumonia and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution.