Access to Health Care Improves COVID-19 Vaccination and Mitigates Health Disparities Among Medicare Beneficiaries.

BACKGROUND: COVID-19 disproportionately impacts the elderly, particularly racial/ethnic minorities and those with low socioeconomic status (SES). These latter groups may also have higher vaccine hesitancy. We aim to evaluate if access to care improves COVID-19 vaccination rates and improves health disparities. METHODS: We conducted a retrospective cohort study of Medicare patients receiving care in a high-touch capitated network across ten states. We collected type and date of COVID-19 vaccine and demographic and clinical data from the inpatient and outpatient electronic health records and socioeconomic status from the US census. Our primary outcome was completing vaccination using logistic regression. RESULTS: Our cohort included 93,224 patients enrolled in the network during the study period. Sixty nine percent of all enrolled patients completed full vaccination. Those who completed vaccination did it with Pfizer (46%), Moderna (49%), and Jannsen (4.6%) vaccines. In adjusted models, we found that the following characteristics increased the odds of being vaccinated: being male, increasing age, BMI, and comorbidities, being Black or Hispanic, having had the flu vaccine in 2020, and increasing number of office primary care visits. Living in a neighborhood with higher social deprivation and having dual Medicaid/Medicare enrollment decreased the odds of completing full vaccination. CONCLUSIONS: Increasing office visit in a high-touch primary care model is associated with higher vaccination rates among elderly populations who belong to racial/ethnic minorities or have low socioeconomic status. However, lower SES and Medicaid populations continue to have difficulty in completing vaccination. KEY POINTS: • High COVID-19 vaccination rates of minorities enrolled in Medicare can be achieved. • Lower socioeconomic status is associated with completing vaccination. • Increasing office visits can lead to higher vaccination rates.

Erratum to "Prior cardiovascular risk and screening echocardiograms predict hospitalization and severity of coronavirus infection among elderly Medicare patients" [American Journal of Preventive Cardiology 3C (2020) 100090].

[This corrects the article DOI: 10.1016/j.ajpc.2020.100090.].

Metformin is associated with lower hospitalizations, mortality and severe coronavirus infection among elderly medicare minority patients in 8 states in USA.

BACKGROUND AND AIMS: Metformin has antiviral and anti-inflammatory effects and several cohort studies have shown that metformin lower mortality in the COVID population in a majority white population. There is no data documenting the effect of metformin taken as an outpatient on COVID-19 related hospitalizations. Our aim was to evaluate if metformin decreases hospitalization and severe COVID-19 among minority Medicare patients who acquired the SARS-CoV2 virus. METHODS: We conducted a retrospective cohort study including elderly minority Medicare COVID-19 patients across eight states. We collected data from the inpatient and outpatient electronic health records, demographic data, as well as clinical and echocardiographic data. We classified those using metformin as those patients who had a pharmacy claim for metformin and non-metformin users as those who were diabetics and did not use metformin as well as non-diabetic patients. Our primary outcome was hospitalization. Our secondary outcomes were mortality and acute respiratory distress syndrome (ARDS). RESULTS: We identified 1139 COVID-19 positive patients of whom 392 were metformin users. Metformin users had a higher comorbidity score than non-metformin users (p < 0.01). The adjusted relative hazard (RH) of those hospitalized for metformin users was 0.71; 95% CI 0.52-0.86. The RH of death for metformin users was 0.34; 95% CI 0.19-0.59. The RH of ARDS for metformin users was 0.32; 95% CI 0.22-0.45. Metformin users on 1000 mg daily had lower mortality, but similar hospitalization and ARDS rates when compared to those on 500-850 mg of metformin daily. CONCLUSIONS: Metformin is associated with lower hospitalization, mortality and ARDS among a minority COVID-19 population. Future randomized trials should confirm this finding and evaluate for a causative effect of the drug preventing disease.

Prior cardiovascular risk and screening echocardiograms predict hospitalization and severity of coronavirus infection among elderly medicare patients.

BACKGROUND: The COVID-19 pandemic has disproportionally impacted the elderly. In the United States and Europe the mortality rate of elderly patients with COVID-19 is greater than 30%. Our aim is to determine predictors of COVID-19 related hospitalization and severity of disease among elderly Medicare patients in the United States. METHODS: We conducted a retrospective cohort study including elderly Medicare COVID-19 patients across eight states. We collected data from the inpatient and outpatient electronic health record, demographic, clinical and echocardiographic predictors. Our primary outcomes were hospitalization and adult respiratory distress syndrome (ARDS). Our secondary outcome was mortality. RESULTS: We identified 400 COVID-19 positive patients (incidence 5.2; (95% CI 4.7-5.7) per 1000 patients). The mean age of our patients was 72 â€‹± â€‹8, 60% were female, 82% were minorities and had a mean Charlson score of 2.9 â€‹± â€‹1.4. Two-hundred and forty-four patients were hospitalized due to COVID-19 (63%) and the mortality rate was 18%; 95% CI 14-22 with 1 patient still in the hospital. Age, socioeconomic status, Charlson score, systolic blood pressure, body mass index, grade 2 or 3 diastolic dysfunction, moderate or severe left ventricular hypertrophy were significant predictors of hospitalization and ARDS (p â€‹< â€‹0.05). CONCLUSIONS: Our study reports a lower incidence on a COVID-19 cohort than previously reported. Predictors of poor outcomes included socio-economic, cardiovascular risk and echocardiographic measures. High touch care with early cardiovascular risk factor modification could explain the low risk of events in our population.

Celiac Disease and Gluten Sensitivity.

Celiac disease is an immune-mediated enteropathy triggered by gluten that affects genetically predisposed individuals, typically causing intestinal symptoms and malabsorption. Diagnosis requires stepwise evaluation with anti-tissue transglutaminase IgA and histologic analysis of the small bowel. Strict adherence to a gluten-free diet is the primary treatment. Patients with symptoms thought to be related to gluten but without evidence of celiac disease are difficult to diagnose and treat. Consider first advising general nutritional improvements. If symptoms persist, involve a trained dietitian for restrictive diets and consider evaluation for small intestinal bacterial overgrowth or other treatments for irritable bowel syndrome.

Cerumen impaction.

Cerumen is a naturally occurring, normally extruded product of the external auditory canal. It is usually asymptomatic, but when it becomes impacted it can cause complications such as hearing loss, pain, or dizziness. It also can interfere with examination of the tympanic membrane. Depending on available equipment, physician skill, and patient circumstances, treatment options for cerumen impaction include watchful waiting, manual removal, the use of ceruminolytic agents, and irrigation with or without ceruminolytic pretreatment. The overall quality of the evidence on treatment is limited. Referral to an otolaryngologist for further evaluation is indicated if treatment with a ceruminolytic agent followed by irrigation is ineffective, if manual removal is not possible, if the patient develops severe pain or has vertigo during irrigation, or if hearing loss is still present after cerumen has been removed. The use of cotton swabs and ear candles should be avoided.

Childhood asthma: treatment update.

The prevalence of childhood asthma has risen significantly over the past four decades. A family history of atopic disease is associated with an increased likelihood of developing asthma, and environmental triggers such as tobacco smoke significantly increase the severity of daily asthma symptoms and the frequency of acute exacerbations. The goal of asthma therapy is to control symptoms, optimize lung function, and minimize days lost from school. Acute care of an asthma exacerbation involves the use of inhaled beta2 agonists delivered by a metered-dose inhaler with a spacer, or a nebulizer, supplemented by anticholinergics in more severe exacerbations. The use of systemic and inhaled corticosteroids early in an asthma attack may decrease the rate of hospitalization. Chronic care focuses on controlling asthma by treating the underlying airway inflammation. Inhaled corticosteroids are the agent of choice in preventive care, but leukotriene inhibitors and nedocromil also can be used as prophylactic therapy. Long-acting beta2 agonists may be added to one of the anti-inflammatory medications to improve control of asthma symptoms. Education programs for caregivers and self-management training for children with asthma improve outcomes. Although the control of allergens has not been demonstrated to work as monotherapy, immunotherapy as an adjunct to standard medical therapy can improve asthma control. Sublingual immunotherapy is a newer, more convenient option than injectable immunotherapy, but it requires further study. Omalizumab, a newer medication for prevention and control of moderate to severe asthma, is an expensive option.