Drug, Alcohol Deaths in Those Over 65; Medicare Advantage and Heart Attacks

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, 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 benefits of 13 valent pneumococcal vaccine, a new therapy for advanced melanoma, is there any advantage to Medicare Advantage plans, and alcohol and drug overdose deaths in those over 65 years of age.

Program notes:

0:38 Medicare Advantage and outcomes from heart attacks

1:35 No difference in mortality

2:35 If you want to pick your own physician

2:40 Alcohol and drug overdose deaths in those 65 and older

3:40 Higher for non-Hispanic black men

4:40 Dramatic increase in things like fentanyl

5:30 Tumor infiltrating lymphocytes and melanoma

6:30 Progression free survival doubled

7:30 Use earlier in disease course

7:40 13 valent pneumococcal vaccine and pneumonia hospitalizations

8:40 Varying types of pneumonia

9:40 Don’t get vaccine very often

10:35 Vaccine helps in high-risk individuals

11:40 End

Transcript:

Elizabeth: If you’re an older adult, should you get a pneumococcal vaccine?

Rick: Is there a health advantage to having Medicare Advantage?

Elizabeth: And speaking of older adults, gosh, more deaths from alcohol and substance use.

Rick: Using our own immune system to fight advanced melanoma.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, 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 Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, I’m going to let you choose this week. No COVID, so which one do you like the best?

Rick: Elizabeth, let’s talk about Medicare Advantage. Private Medicare Advantage programs have really increased substantially over the last 10 to 15 years. Back in 2009 of all Medicare beneficiaries, about 24% were enrolled in Medicare Advantage programs. Now it’s 41% and is projected to be up to 70% over the next 7 or 8 years.

Medicare Advantage are third-party payers and they oftentimes offer additional services, preventive services, but conversely they narrow the number of physicians that the individual may see. Do these extra services provide health advantages to older individuals?

These investigators took routine heart attacks and asked a simple question: for individuals that are on Medicare Advantage, do they have a better outcome after they have had a heart attack?

There were over 2 million participants. These individuals were in their late 70s and what they discovered was there was no difference in mortality regardless of whether someone received Medicare Advantage versus those that receive Medicare. There were modestly lower rates of readmissions for ICU use, but overall no significant benefit of Medicare Advantage. Now, this is an issue because we are really overpaying for Medicare Advantage. We are paying more, we’re not getting really any better healthcare.

Elizabeth: That’s a really important message because people are really being sold on purchasing these plans. I was under the understanding — this, of course, is in JAMA — that there was an initial advantage at the beginning of this study, but that that disappeared.

Rick: In 2009, it looked like there was an advantage, but more recently, in 2018, there was not.

Elizabeth: I know this is outside of your purview. But for right now, if you were talking with somebody who is contemplating the purchase of such a plan, what would you say?

Rick: My mother and mother-in-law are faced with this issue. I said, “Listen, if you want to be able to pick your own physician, then I’d recommend you use Medicare rather than Medicare Advantage.”

Elizabeth: OK. Let’s turn now to the National Center for Health Statistics, which released two reports this week that are pretty daunting. One of them deals with drug overdose deaths in adults aged 65 and older — and that was between the years of 2000 and 2020 — and the other one looks at alcohol-induced deaths in adults in this same population in 2019 and 2020. Both of them report that there are increases in these and that these deaths have increased in the past two decades.

It’s the rate of increase, of course, that’s the most concerning, rather than the absolute number. Men, of course, experiencing more of this than women in this time period. Regarding substance use, their drug overdose deaths increased by 14% annually on average. Those rates of drug overdose deaths for men were 1.2 times higher than for women at the beginning, and 2.1 times higher in 2020. For men 75 and older, these drug overdose deaths were higher for non-Hispanic Black men in comparison with their Hispanic and non-Hispanic white counterparts.

As far as women go, the non-Hispanic Black women in that 65 to 74 age group had the highest drug overdose death rates. If we turn to alcohol, we find that again, there is this trend that’s increasing since 2011. It rose by 18.2% from 2019 to 2020. Men who are experiencing this big increase — that’s the American Indian and Alaska natives who are experiencing the highest rate of death from alcohol. These are some rather daunting trends I think.

Rick: Less than 1% of all deaths in this age group is due to alcohol or to drug overdose. The percentage increases are substantial and I want to talk specifically about the drug overdose deaths. Because when you look at major categories, we’re talking about just over the last year from 2019 to 2020, there was really no significant increase in deaths due to heroin or to semi-synthetic opioids — things like oxycodone.

But where the dramatic increase took place — a 53% increase in deaths related to synthetic opioids. That’s things like fentanyl, fentanyl analogs, and tramadol. These deaths were accidental.

Elizabeth: This issue of fentanyl is also something that caught my attention, because where would somebody get fentanyl? I mean, tramadol is something that is prescribed. I can understand that.

Rick: The incidence of fentanyl deaths has increased substantially in younger individuals, but until recently we’ve not really looked in the older age group.

Elizabeth: Right. I guess I’m interested in the penetration of these drugs that are not obtained from the local pharmacy into older populations.

Rick: This particular document doesn’t say where they came from, but it’s still an issue we need to address.

Elizabeth: No question. Let’s move on then and now we’re going to go to the New England Journal.

Rick: I have teed this up as using our own immune cells to fight advanced melanoma. Over the last decade, we have developed a new class of medication — it’s called immune checkpoint inhibitors — and other targeted therapies that have dramatically improved the outcomes of people with advanced melanoma. Unfortunately, even though many of these individuals respond, about half don’t have a durable benefit.

There is another therapy that one can prescribe where you actually take a portion of the tumor and you grind it up. You isolate immune cells, lymphocytes, that are present in the tumor and you inject them back into the individual. It’s called tumor-infiltrating lymphocyte therapy.

In this Phase 3 multicenter trial, they took 168 patients, about 86% of which had had routine therapy and then had recurrence of their melanoma, and they treated them either with a second targeted therapy, a routine chemotherapy, or they used tumor-infiltrating lymphocyte therapy.

When they looked at progression-free survival in those that received the routine chemotherapy or immunotherapy, it was 3.1 months. But those that received the tumor-infiltrating lymphocyte therapy, it was double that. Overall survival was about 26 months with the tumor-infiltrating lymphocyte therapy and only 19 months with the routine therapy.

Elizabeth: Let’s talk about the side effects of tumor-infiltrating lymphocytes.

Rick: Essentially, everybody with tumor-infiltrating lymphocytes therapy has some side effects because you’re giving chemotherapy to knock down the person’s own immune system. It’s transient. It’s not very severe. Even with that, the outcome is better with this than it is with routine therapy.

Elizabeth: I wonder how much this is going to cost to generate these kinds of individually tailored cells for each patient.

Rick: There is some cost associated with it. This particular study encourages us to do a cost-benefit analysis to see what that is. As this becomes more mainstream, then the cost goes down.

Elizabeth: I also guess that if this therapy gets moved earlier in the course of disease it’s probably going to have a whole lot more impact.

Rick: The editorial says it’s great for second-line therapy, but should we move it up further? I think additional studies will provide insight into that.

Elizabeth: Finally, let’s turn to JAMA Internal Medicine and this is taking a look at the 13-valent pneumococcal conjugate vaccine and its association with pneumonia hospitalization in older adults, especially in those with underlying medical conditions.

They took a look at Medicare beneficiaries — gosh, we’re talking a lot about Medicare beneficiaries this week, aren’t we? These folks were resident in all of the states or the District of Columbia. They followed these folks through December 31^st, 2017. Over 24 million beneficiaries initially included in this cohort, and among them, just 20.5% had received this particular pneumococcal vaccine while almost 80% had not. More than half of the beneficiaries in this cohort were younger than 75 years of age. They were white and had either immune-compromising or chronic medical conditions.

Well, if you got this vaccine, did you end up hospitalized with pneumonias of varying types? The upshot of the study suggests that using this pneumococcal vaccine, the 13-valent vaccine, was associated with reduced pneumonia hospitalization in these folks, many of whom had underlying medical conditions.

Rick: The virtue of this study is, it takes older individuals with chronic medical conditions and shows that one of the early pneumococcal vaccines could be helpful in reducing all-cause pneumonia, hospitalizations from community-acquired pneumonia, and lobar pneumonia. The 13-valent pneumococcal vaccine would have averted about 35,000 hospitalizations. This is an early vaccine. We have a 15-valent and a 23-valent polysaccharide vaccine. It’s recommended that these be administered in that order to individuals that are over the age of 65.

Elizabeth: Questions that really remain quite active for me regarding this are appropriate intervals for vaccination because I believe that the recommendations now are you don’t get it very often.

Rick: This is true. There is no evidence that one needs to get recurrent doses of the pneumococcal vaccine. It’s recommended that kind of a 2-dose stage — that is, the 15 followed by an interval and then the 23.

Elizabeth: The other thing that I think is interesting is, we have reported before about the association of having had a flu vaccine with better outcomes when people have cardiovascular disease, for example, and have a heart attack. I’m wondering about just the stimulation of the immune system in general and then its ability to subsequently fight off these different types of pneumonia.

Rick: As you mentioned in this age group, 6 out of 10 individuals have severe comorbid conditions, heart disease being among them. It’s nice to know that this vaccine is helpful not only in low-risk individuals, but more importantly even in high-risk individuals and immunocompromised individuals. In terms of absolute percentage, they are the ones that are more likely to suffer complications from flu or from pneumococcal pneumonia, hence most likely to receive the benefit.

Elizabeth: I would like to just end with the fact that I saw this morning that only 12.5% of the eligible population for the bivalent COVID vaccine has actually stepped up and taken it and that we’re also seeing a paucity of people who have had flu vaccination, especially pregnant women and children younger than 5 years of age. I think it behooves all of us to get our vaccines.

Rick: Elizabeth, I could not have said it any better. For listeners, it’s time to review your vaccine status and ask, “Does it need to be updated?”

Elizabeth: 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.