Beneficiary characteristics and vaccinations in the end-stage renal disease Medicare beneficiary population, an analysis of claims data 2006–2015
Introduction
Chronic kidney disease is a progressive loss of kidney function over a period of time, months or years, leading in some cases to end-stage renal disease (ESRD), the most severe stage of chronic kidney disease. At this stage of chronic kidney disease, patients require renal replacement therapy in the form of dialysis or kidney transplant. Dialysis treatment is used primarily as an artificial replacement for lost kidney function and requires treatments three times a week. ESRD patients are inherently immunocompromised from the uremic toxicity that characterizes their disease. These patients represent a high-risk group for developing infectious diseases [1]. Infection is common and is the second leading cause of death and contributor to hospitalizations in this population. [1], [2], [3], [4]. Co-morbidities such as diabetes mellitus and the inherent process of dialysis, where patients are frequently exposed to multiple pathogenic agents and potential cross-contamination from dialysis equipment in the health care environment, adds to the susceptibility of this population [5], [6].
The Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) routinely recommends three vaccines – inactivated influenza, hepatitis B, and pneumococcal vaccines – for patients with ESRD [1]. Previous studies and recent outbreaks indicate low compliance to these specific recommendations, particularly among non-white patients [7], [8], [9]. Moreover, Healthy People targets for immunization seek to increase vaccine utilization across the lifespan and in special and vulnerable populations while eliminating health disparities. Healthy People are a set of science-based, 10-year national objectives with the goal of improving the health of Americans [10].
ACIP recommends a routine annual influenza vaccination with no preference indicated for any influenza product. One influenza product is licensed with four-fold increased antigen, designed for older adults (age 65 years and older) with weaker immune systems, and not specified for the ESRD population. ACIP also recommends a three- or four-dose series of hepatitis B vaccinations for dialysis patients as early as possible and preferably before the patient requires dialysis for a better immune response [1]. The pneumococcal vaccination recommendations involve two different vaccine products: a 13-valent pneumococcal conjugate vaccine (PCV13) and a 23-valent pneumococcal polysaccharide vaccine (PPSV23) [1], [11], [12]. The recommended intervals between PCV13 and PPSV23 differ by age, risk group and the order in which the two different vaccines are given. Adults aged ≥65 years with immunocompromising conditions are recommended to receive PCV13 first, followed by PPSV23 ≥8 weeks later. In June 2014, ACIP also recommended that all adults aged ≥65 years who already received PPSV23 should receive a dose of PCV13 ≥1 year after receipt of PPSV23 [12].
ESRD is a medical condition that confers eligibility to Medicare, a federal health insurance program that provides coverage for over 50 million Americans [13]. Medicare’s ESRD Program was created in 1972 and covers dialysis in addition to all other services related to kidney failure. Medicare Part A enrollment is the hospital insurance coverage a beneficiary receives upon enrollment in Medicare. Medicare Part B is medical insurance that includes coverage for preventive services such as wellness visits, screening tests and vaccinations. The purpose of this population-based study is to describe the ESRD dialysis beneficiary population and explore differences in utilization of ACIP-recommended vaccines.
Section snippets
Database and patient selection
Our study cohort was composed of fee-for-service (FFS) Medicare beneficiaries who received Part B dialysis services at any point from January 1, 2006 through December 31, 2015 (through June 30, 2016 for influenza when the vaccine product expires). To assess influenza rates in a given influenza vaccine season (July - June), we restricted the population to ESRD dialysis beneficiaries who were continuously enrolled in Medicare Parts A and B throughout all twelve months of that season, recognizing
Beneficiary characteristics
In each year from 2006–2015, we found an average of over 350,000 ESRD dialysis beneficiaries who were enrolled in Medicare Parts A and B for at least one month of the year (Table 1). On average, slightly over half of each year’s ESRD population is aged 18–64 years (52%) and male (55%). Whereas whites and African Americans comprise 83% and 10% of the overall Medicare beneficiary population in a given year, respectively, they make up 50% and 36% of the ESRD dialysis subpopulation. In general,
Influenza vaccines
Our findings show steady increases in uptake across the study period, with specific increases in coverage in non-white beneficiaries. While immunogenicity issues and dialysis patients offer an opportunity to utilize high-dose influenza vaccine in chronic disease populations such as the ESRD population, the utilization of high-dose in this study was approximately 3%. While there is no current ACIP-preference for this product in the ESRD population, given the product was designed for individuals
Conclusion
Given the frequent access to services, clear recommendations for vaccination, and first-dollar coverage (no cost-sharing to the patient), adult immunization and ESRD advocates have an opportunity to increase compliance to ACIP recommendations for this high-risk population. With 18 ESRD Network service areas that provide quality oversight of and care to over 6,000 dialysis facilities, monitoring and technical assistance through entities like the ESRD network organizations can help determine if
Funding
This study was performed as a joint effort of the Centers for Medicare & Medicaid Services and the National Vaccine Program Office.
Disclaimer
The opinions expressed in this manuscript are those of the authors and not intended to represent the opinions of the National Vaccine Program Office or the Centers for Medicare & Medicaid Services. The authors have no conflict of interest to declare.
Acknowledgements
The authors would like to thank Joel Andress and Ray Strikas for their critical review of this manuscript.
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