Vax Efficacy Among VA Patients; Opioids and Racial Inequality: It’s TTHealthWatch!


TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include COVID vaccine efficacy in a VA population, a new medicine to treat psychosis in those with dementia, opioid prescribing differences between Blacks and whites, and medical debt.

Program notes:

0:41 COVID vaccine efficacy in a VA population

1:42 Overall 97% efficacy

2:43 Delta variant extremely transmissible

3:40 Medical debt in the U.S.

4:40 About 18% had medical debt

5:40 Social determinants of health

6:40 Need universal access to healthcare

7:02 New treatment for psychosis in dementia

8:02 Affects serotonin receptors

9:02 Alzheimer’s medicines

9:55 Racial inequality in prescription opioids

11:00 Mean annual dose for Blacks 36% lower

12:37 End


Elizabeth Tracey: How much medical debt are we in and how is that impacting our health?

Rick Lange, MD: A new drug class for treating people that have psychosis related to dementia.

Elizabeth: Are there disparities between Black and white patients with regard to opioid prescribing?

Rick: And COVID vaccine effectiveness and a high-risk population in a real-world setting.

Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of the Texas Tech University of Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, how about if we turn to Annals of Internal Medicine first? This is our COVID material and, of course, COVID increasing again, so this is relevant.

Rick: Right. I want to focus on the two mRNA vaccines because they were the first released in the U.S. and in randomized controlled trials showed about 95% efficacy in preventing symptomatic COVID infection. The real question is, how effective is it in the real world, and especially in a high-risk patient?

What population do we have that’s high-risk? Well, in this particular instance, the investigators chose the VA population. People that received healthcare at the VA, they’re usually older age, they have higher burden of comorbidities and also a higher prevalence of what are called social vulnerabilities as well. Therefore, that VA system provides kind of a unique opportunity to study the natural history, the disease outcomes, and the effectiveness of the high-risk population.

It’s a particular study called a test-negative case-control study. I don’t want to go into the details about that; I just want to get to the specifics. In the real-world population, mostly males, because they’re VA, the overall vaccine effectiveness of the two vaccines was about 97%. By the way, that’s 2 weeks after they received the second vaccine. It was even extremely effective for individuals that only received one vaccine. That effectiveness was 85%.

Elizabeth: That is good news, in view of the fact that we’re reporting that today 83% of the cases of COVID that are being reported are due to the Delta variant. Comment for me, if you will, on — and I get that it’s speculation — what these vaccines might do against the Delta variant?

Rick: As you alluded to, they didn’t specifically look for variants in here, but the other real-world settings suggested in fact the vaccine is at least 90% to 95% effective in preventing severe infections and hospitalizations as well.

When you look across the country, at who is being hospitalized, 97% of those individuals are individuals that have not been vaccinated. The message that I would want our listeners to understand is the Delta variant is extremely transmissible, it’s extremely infectious, and the current vaccines we have now can mitigate that substantially.

Elizabeth: The latest statistic I heard on the transmissibility of the Delta variant was 225% more transmissible than the wild-type virus.

Rick: So the wild type, an average person will infect about two or 2.25 individuals. Individuals infected with the Delta variant, they infect five to eight individuals.

Elizabeth: We were talking before we started to record. We both agreed that masking in indoor spaces is probably a good idea for all of us.

Rick: Right. Because we don’t know who has been vaccinated and not. For example, I mentioned in the city of El Paso 80% of individuals have already been vaccinated. In other places, as few as 10% to 20% of individuals — other major metropolitan areas. Until we get more people vaccinated, I think wearing a mask, social distancing, and washing your hands are still effective in helping you prevent the spread.

Elizabeth: Okay. Let’s turn to JAMA. This is a look at medical debt in the U.S. between 2009 and 2020. This segue is probably pretty apt because all those folks who are going to get hospitalized with COVID are probably going to be taking on some medical debt as a result of their hospitalization and rehabilitation, even after hospitalization.

This was, as I said, this data set that was gathered prior to the COVID 19 pandemic. It represents nearly 40 million unique individuals. These data were used to estimate the amount of medical debt nationally and by geographic region and Zip code income to examine the association between Medicaid expansion and medical debt overall and by income groups.

And this is a new metric. This is something that we’ve never really looked at before. The editorialists suggest that among the social determinants of health, this is a pretty powerful one, and I actually agree with that assertion.

In June 2020, an estimated almost 18% of individuals had medical debt and the mean amount was $429. This debt was highest in the South and higher in poor than in rich Zip codes. The other really noteworthy fact is that states that expanded Medicaid had a decline in this debt that was really pretty powerful. So, it seems to demonstrate that we ought to be trying to improve our Medicaid coverage so that we can ameliorate this factor relative to somebody’s health.

Rick: Elizabeth, you mentioned the mean debt, and that is $429 across the population. In this study, about 18% of people are the ones that incurred the debt.

Now, there are two types of debt. They talk about stock of debt — that’s the total amount of unpaid medical debt — and also flow of medical debt; that’s how much appeared on credit reports over the last 12 months. Those 18%, the main debt stock was $2,424 and the mean debt flow was $2,396. That’s over $5,000 for the individuals that had debt.

You mentioned the fact that there are social determinants of health. We’ve talked before about some of these: access to healthy food, high-quality housing, education, and employment. Although they didn’t tie this medical debt to health outcomes, it’s clear that the medical debt influences economic stability.

The interesting thing about this is, in Medicaid and non-Medicaid states, the non-medical debt went down regardless of whether you accepted Medicaid expansion. But the medical debt is what was substantially different. People have more medical debt now than they do non-medical debt. That’s just occurred over the last 15 to 20 years.

Elizabeth: Exactly. There are certainly many studies in the cancer world that point to the debt relative to being treated for cancer as a very powerful factor in somebody’s ability to live with their cancer and recover.

Rick: Right. When you have a large amount of medical debt, you’re less likely to have access to affordable healthcare. You’re less likely to seek it as well. We need to have affordable and accessible healthcare universally.

Elizabeth: I would also, just on that point, note that the editorialist points out that data from the early years of the ACA [Affordable Care Act] implementation does not seem to have produced a noticeable decline in bankruptcies due to medical debt. So the ACA doesn’t go far enough.

Rick: Right. Let’s move on, Elizabeth. Let’s talk about a new treatment for a condition which affects millions of individuals worldwide.

There are over 46 million individuals worldwide that have dementia. Besides a cognitive dysfunction, a significant amount of these individuals will actually develop frank psychosis. By the way, psychosis is not only a feature of Alzheimer’s, but other types of dementia as well: Lewy body dementia, Parkinson’s dementia, vascular dementia, and what’s called frontotemporal dementia. We have medications that can treat it, but they have side effects.

As a result, the American Psychiatric Association first recommended we use non-pharmacologic agents first to try to control psychosis associated with dementia. But if it’s not successful, then they recommend what are called typical and atypical antipsychotics that are routinely available. They’re not always as effective as we’d like, so an opportunity to have a new medication enter the market.

This is a new medication called pimavanserin. It’s unique and it’s called an inverse agonist antagonist. Whoa! That means it affects the serotonin receptors in the brain. There are at least three different types — A, B and C — in one of them, it increases the activity. The other one, it decreases the activity; that’s the inverse agonist. The third one, it has no effect at all.

What they did was they took about 350 patients that they put on pimavanserin to show that, in fact, it was effective. It was effective in 62% of them. They did that over a course of several months. Then in half those individuals they continued the medication to see if it would continue to decrease the psychotic events. In the other half, they took it away, called the discontinuation study.

What they found is those individuals in whom they discontinued pimavanserin, 28% had recurrent psychosis and those that continued it only 13%. By the way, it doesn’t have the side effects of the typical anti-psychotic medications and only 2% of individuals had any side effects — things like headache. A new medication holds promise in a condition that affects not only the individual, but caregivers as well without the side effects.

Elizabeth: This, of course, is a population that’s much in the news recently. That’s the Alzheimer’s population, of course, with dementia and the FDA’s — what shall we call it — turmoil relative to another medicine. Talk to me about this particular one. Where is it with regard to its transition through the whole approval process?

Rick: Well, the medicine we’re talking about, the pimavanserin, is a phase III trial, but the data look pretty firm at this particular point.

Elizabeth: No doubt we’ll be scrutinizing this extremely closely. And this is an oral med?

Rick: It is an oral med. It’s already been studied in Parkinson’s patients and it’s approved for them. Can its indications be extended? By the way, the use of the other anti-psychotics in dementia-related psychosis is off-label right now. It would be nice to have an on-label medication that’s effective.

Elizabeth: Okay. Remaining in the New England Journal and also talking about medicines, we’re going to take a look at a special report and this is “Racial Inequality in Prescription Opioid Receipt — Role of Individual Health Systems.” It seems like a real slice and dice.

Again, we were talking, before we started recording, about my personal exposures to, is there a difference in opioid prescribing among Black and white patients? I think I actually have seen that before.

In this case, they used Medicare data claims from a random national sample and then they also looked at 310 racially diverse systems. They compared the data from that with those in their national sample. They looked at annual opioid measures, any prescription filled, short-term receipt, long-term receipt, and the dose in morphine milligram equivalents.

We were also talking, before we started recording, about sort of this specious way of reporting the data. But they report 2,197,153 “person years.” This person-years metric I always find just a little bit troubling. The upshot of the whole thing is that the mean annual dose of opioids for Black patients was 36% lower than it was among the white patients.

Rick: The unique thing about this particular study is we’ve known, because of national studies, that Black and Hispanic patients are less likely to receive opioid analgesics compared to whites. Not only are they less likely to receive a prescription, but when they do, it’s usually for a lower dose.

The real question is, well, is that a function of the fact that these patient populations are in different health systems or is it something about the provider? By examining this at individual health systems, what they determined was that in 91% of the health systems there was this disparity. So it’s not anything new to the health system. It’s actually new to the prescriber, the provider.

Now what we don’t know is are Hispanics and Blacks receiving less opioids than they need or are Caucasians being overprescribed opioids? But there is something systemically wrong with 91% of health systems; we see this.

Elizabeth: I like it that they say one limitation of their study is they, of course, examined prescriptions that were filled. That doesn’t tell us much about all the rest of the prescribing behavior that’s out there.

Rick: No. There are some limitations to this study, but the fact that it’s so ubiquitous across all health systems implies that this is a real finding.

Elizabeth: Okay. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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