Relationship between smoking status and muscle strength in the United States older adults

OBJECTIVES

Muscle strength in older adults is associated with greater physical ability. Identifying interventions to maintain muscle strength can therefore improve quality of life. The purpose of this study was to evaluate whether current or former smoking status is associated with a decrease in muscle strength in older adults.

METHODS

Data from the Health and Retirement Study from 2012-2014 were analyzed with regard to maximum dominant hand grip strength, maximum overall hand grip strength, and smoking status (current, former, or never). Unadjusted linear regression was conducted. Other factors known to be related to strength were included in the adjusted linear regression analyses.

RESULTS

For maximum grip strength, the regression coefficient was 4.91 for current smoking (standard error [SE], 0.58; p<0.001), 3.58 for former smoking (SE, 0.43; p<0.001), and 28.12 for never smoking (SE, 0.34). Fully adjusted linear regression on the relationship between dominant hand grip strength and smoking did not yield a significant result. The factors significantly associated with dominant hand grip strength were male sex, younger age, a race/ethnicity of non-Hispanic White or non-Hispanic Black, higher income, morbidity of ≤1 condition, no pain, and moderate or vigorous exercise more than once a week.

CONCLUSIONS

Muscle strength in older adults was not associated with smoking status in the adjusted analysis.

Impact of Incident Cancer on Short-Term Coronary Artery Disease-Related Healthcare Expenditures Among Medicare Beneficiaries

Background: Healthcare spending for coronary artery disease (CAD)-related services is higher than for other chronic conditions. Diagnosis of incident cancer may impede management of CAD, thereby increasing the risk of CAD-related complications and associated healthcare expenditures. This study examined the relationship between incident cancer and CAD-related expenditures among elderly Medicare beneficiaries. Patients and Methods: A retrospective longitudinal study was conducted using the SEER-Medicare linked registries and a 5% noncancer random sample of Medicare beneficiaries. Elderly fee-for-service Medicare beneficiaries with preexisting CAD and with incident breast, colorectal, or prostate cancer (N=12,095) or no cancer (N=34,237) were included. CAD-related healthcare expenditures comprised Medicare payments for inpatient, home healthcare, and outpatient services. Expenditures were measured every 120 days during the 1-year preindex and 1-year postindex periods. Adjusted relationship between incident cancer and expenditures was analyzed using the generalized linear mixed models. Results: Overall, CAD-related mean healthcare expenditures in the preindex period accounted for approximately 32.6% to 39.5% of total expenditures among women and 41.5% to 46.8% among men. All incident cancer groups had significantly higher CAD-related expenditures compared with noncancer groups (P<.0001). Men and women with colorectal cancer (CRC) had 166% and 153% higher expenditures, respectively, compared with their noncancer counterparts. Furthermore, men and women with CRC had 57% and 55% higher expenditures compared with those with prostate or breast cancer, respectively. Conclusions: CAD-related expenditures were higher for elderly Medicare beneficiaries with incident cancer, specifically for those with CRC. This warrants the need for effective programs and policies to reduce CAD-related expenditures. Close monitoring of patients with a cancer diagnosis and preexisting CAD may prevent CAD-related events and expenditures.

Human papillomavirus (HPV) vaccine utilization among adults (18-29 years), BRFSS 2015

Human papillomavirus (HPV) vaccination acceptance is hampered by fears and conflicting attitudes about the need for and safety of vaccine. There are also ethical dilemmas associated with vaccinating adolescents for a sexually transmitted disease despite future cancer risk. The purpose of this research was to determine HPV vaccination acceptance/hesitancy among young adults. Behavioral Risk Factor Surveillance System 2015 data were used. During 2015, 83.1% of adults ages 25-29 years did not receive any HPV vaccination; the UOR was 3.47; 95% CI = 2.11, 5.70) compared to adults 18-24 years. There is a need to accelerate public health messaging/campaigns to increase HPV vaccination rates.

Associations of multimorbidity and patient-reported experiences of care with conservative management among elderly patients with localized prostate cancer

Background

Many elderly localized prostate cancer patients could benefit from conservative management (CM). This retrospective cohort study examined the associations of patient‐reported access to care and multimorbidity on CM use patterns among Medicare Fee‐for‐Service (FFS) beneficiaries with localized prostate cancer.

Methods

We used linked Surveillance, Epidemiology, and End Results cancer Registry, Medicare Claims, and the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey files. We identified FFS Medicare Beneficiaries (age ≥ 66; continuous enrollment in Parts A & B) with incident localized prostate cancer from 2003 to 2013 and a completed MCAHPS survey measuring patient‐reported experiences of care within 24 months after diagnosis (n = 496). We used multivariable models to examine MCAHPS measures (getting needed care, timeliness of care, and doctor communication) and multimorbidity on CM use.

Results

Localized prostate cancer patients with multimorbidity were less likely to use CM (adjusted odds ratio (AOR)=0.42 (0.27‐ 0.66), P < .001); those with higher scores on timeliness of care (AOR = 1.21 (1.09, 1.35), P < .001), higher education attainment (3.21 = AOR (1.50,6.89), P = .003), and impaired mental health status (4.32 = AOR (1.86, 10.1) P < .001) were more likely to use CM.

Conclusion(s)

Patient‐reported experience with timely care was significantly and positively associated with CM use. Multimorbidity was significantly and inversely associated with CM use. Addressing specific modifiable barriers to timely care along the cancer continuum for elderly localized prostate cancer patients with limited life expectancy could reduce the adverse effects of overtreatment on health outcomes and costs.

The Association of Beta-Blocker Use to Cognitive Impairment among Adults with Hypertension or Cardiovascular Diseases in the United States

BACKGROUND

Some studies have shown that beta-blocker use is associated with better cognitive impairment. However, these studies did not control for pain. The relationship between pain and cognitive impairment has been exhaustively investigated. The association of beta blockers to cognitive impairment in the presence of chronic pain is still unknown.

OBJECTIVE

To examine the independent association of beta-blocker use to cognitive impairment among adults with hypertension or Cardiovascular Diseases (CVDs).

METHODS

We used a cross-sectional study design. We derived data on 8,279 adults from the 2015 Medical Expenditure Panel Survey (MEPS). Study participants were adults (age > 21 years), with hypertension or CVDs and without intracranial injury, Parkinson, Alzheimer's disease and Related Dementia. Cognitive impairment was measured based on 1) confusion or memory loss; 2) problems making decisions, or 3) supervision for participant's safety. Anti-hypertensive medications were categorized into 1) beta-blockers; 2) other anti-hypertensives; and 3) no antihypertensive medication. We used multivariable survey logistic regressions to examine the association between beta-blockers and cognitive impairment after controlling for biological factors, pain, chronic conditions, socioeconomic status, access to healthcare services, behavioral, socio-cultural and external environmental factors.

RESULTS

Overall, 24.2%, 41.9%, and 33.9% reported using beta-blockers, other antihypertensives, and no antihypertensive medications, respectively; 18.1% participants reported cognitive impairment. After controlling for pain, beta-blocker use was not significantly associated with cognitive impairment (AOR= 1.22, 95%CI= 1.00-1.49). In fully adjusted models, the AOR for beta-blockers use was 1.05 (95%CI = 0.84-1.31).

CONCLUSION

In this first large cross-sectional study, we found that the use of beta-blockers was not associated with cognitive impairment. Future prospective studies that include pain management and blood pressure control are needed to confirm the findings.

Mental Health Conditions and Hospitalizations for Ambulatory Care Sensitive Conditions Among Veterans with Diabetes

BACKGROUND

Veterans with diabetes and mental health conditions have a higher risk for suboptimal care and complications related to their diseases than veterans with diabetes who do not have mental health conditions. We hypothesized that among veterans with diabetes, patients with mental health conditions are more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) than those without mental health conditions.

OBJECTIVES

To examine the association between depression, anxiety, and serious mental illness and hospitalizations for ACSC among veterans with diabetes after controlling for demographics and comorbidities.

METHODS

We used a retrospective cohort design with merged Veterans Health Administration (VHA) and Medicare electronic health records from 2008 to 2010. Andersen's Behavioral Model of Health Services Use was used to select the variables associated with hospitalizations for ACSC (ie, predisposing, enabling and need characteristics, personal health practices, and external environment). We used chi-square tests and logistic regressions for our analyses.

RESULTS

Among the dual VHA/Medicare-enrolled veterans with any hospitalization in 2010, 30% had hospitalizations for ACSC. Veterans with diabetes and co-occurring depression were at increased likelihood to be hospitalized for ACSC, after adjusting for all other covariates (adjusted odds ratio, 1.08; 95% confidence interval, 1.04-1.11). Similar findings were observed for anxiety. Veterans with serious mental illness were as likely as veterans without serious mental illness to be hospitalized for ACSC.

CONCLUSION

Veterans with depression and anxiety were more likely to be hospitalized for any or acute ACSC than veterans without mental health conditions. Patients hospitalized for acute ACSC were more susceptible than patients hospitalized for chronic ACSC to have mental health conditions. As the VHA continues to evolve from care provider to community care payer (per the Veterans Affairs MISSION Act), our results highlight the ongoing importance of care coordination and communication between payers and providers.

Prescription Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Depression among Adults with Inflammatory Chronic Conditions in the United States

The association of prescription NSAIDs to presence of depression among adults with inflammatory chronic conditions in adults with and without depression and seeking care in routine clinical practice remains unknown. We examined the association of prescription NSAIDs to depression among adults with inflammatory chronic conditions in a nationally representative sample of the US non-institutionalized civilian population. We used a retrospective cross-sectional design. Data on 10,713 adults with inflammatory chronic conditions were derived from 2015 Medical Expenditure Panel Survey (MEPS). The dependent variable was the presence or absence of depression and the key independent variable was prescription NSAIDs use. Logistic regression models were used to examine the adjusted associations of prescription NSAIDs to depression. In these regressions, other independent variables (biological, sociocultural, socio-economic, access to healthcare services, medical conditions and treatment factors, behavioural, and environmental factors) that may affect the relationship of prescription NSAIDs to depression were also included. All analyses accounted for the complex survey design of MEPS. Overall, 18.2% reported depression. Almost 21% used prescription NSAIDs. In the unadjusted model, prescription NSAIDs use had higher odds of depression (OR = 1.59;95%CI = [1.40, 1.82]) as compared to those without NSAIDs. In the fully-adjusted logistic regression model, with controls for other independent variables, adults using prescription NSAIDs had no significant association with depression (AOR = 0.97;95%CI = [0.84, 1.13]) compared to those without NSAIDs. In this first real-world study of all adults (with and without depression) in the US, we did not observe a statistically significant association of prescription NSAIDs to the presence of depression.

A Longitudinal Study of the Association of Opioid Use with Change in Pain Interference and Functional Limitations in a Nationally Representative Cohort of Adults with Osteoarthritis in the United States

Introduction

Real-world data are sparse on longitudinal associations of opioid use with pain interference with activities (PIA) and daily function with osteoarthritis (OA) in the USA.

Methods

Data from the 2010–2015 Medical Expenditure Panel Surveys were analyzed for community-dwelling adults with OA. Opioid use patterns were defined as persistent, intermittent, and no use. Evaluated outcomes were a change in PIA and functional limitations (activities of daily living [ADL], instrumental ADL [IADL], social and work activities, and cognitive function). Multivariable regression analyses explored the association of persistent/intermittent versus no opioid use with PIA and functional limitations. Results were weighted for the US population.

Results

Among 4172 patients (66.2% female, 80.8% white, mean age 61.7 years), 62.1% reported no PIA change at follow-up, 17.9% worsened, and 20.0% improved. Although 51.0–93.1% of patients reported no functional limitations, 3.8–13.1% worsened (1.1–11.3% improved). Relative to no opioid use, persistent users had higher odds of severe/extreme PIA (adjusted odds ratio [AOR], 2.91; 95% confidence interval [CI], 1.95–4.32; P < 0.001) and moderate PIA (AOR, 2.04; 95% CI, 1.31–3.20; P < 0.01) at follow-up. For patients with baseline functional limitations, persistent opioid users were more likely to report physical and work limitations at follow-up (both P < 0.05). For patients without baseline functional limitations, persistent opioid users had higher odds than those without use of reporting IADL, physical, social, and cognitive limitations at follow-up (all P < 0.05); intermittent users were more likely to report physical and social limitations (both P < 0.05).

Conclusions

Persistent opioid use for pain in patients with OA appeared to be associated with poorer PIA and functional outcomes, regardless of baseline functional status. These findings highlight the importance of patient-reported outcomes for opioid benefit–risk assessment and suggest the need for alternative analgesic approaches.

Prevalence and factors associated with potentially inappropriate medication use in older medicare beneficiaries with cancer

OBJECTIVE

To assess the factors related to potentially inappropriate medication (PIM) use in elderly patients with cancer, as well as to compare the PIM prevalence in older adults with and without cancer.

METHODS

Data from the Surveillance, Epidemiology, and End Results-Medicare-linked base (2009-2011) were accessed to conduct a retrospective study comparing patients with cancers of the breast, colon/rectum, and prostate against a matched population of subjects without cancer. PIM use was defined based on the 2015 Beers Criteria and was quantified using prescription claims. Multivariable logistic regression models were used to assess the associations between the patients' characteristics, clinical factors, and PIM use in patients with cancer based on Beers criteria. Propensity score matching was applied to compare use of PIM in patients with versus without cancer.

RESULTS

PIM usage rates in patients with colorectal and breast cancers were significantly higher than non-cancer-bearing adults; the difference in PIM usage rate was not significantly different in the prostate cancer-matched cohort. The prevalence of inappropriate medication use in the three types of cancers evaluated was directly correlated with number of medications prescribed, treatment with chemotherapy, and co-morbid medical problems.

CONCLUSION

Patients diagnosed with cancer were more likely to use PIM compared with their non-cancer counterparts. The updated Beers criteria has the potential to serve as an important tool in geriatric oncology practice but it may still need to take into consideration different cancer types and their respective treatments.

Five-year trend in healthcare access and patient-reported health outcomes among women veterans

BACKGROUND

This study aimed to describe the five-year trend in healthcare access, health-related quality of life (HRQoL), and health outcomes in women Veterans.

METHODS

A retrospective, pooled, cross-sectional study design was employed. Five-year trend was assessed using 2013 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) data. Bivariate, multivariable logistic regression, and ordinary least squares regression analyses were conducted.

RESULTS

A total of 6561 women Veterans, aged 18 to 64 years (3534 in 2013 and 3027 in 2017) were included. Compared to 2013, more women Veterans in 2017 reported increased healthcare insurance and decreased cost as a barrier to care. Women Veterans with health insurance were less likely to report cost as a barrier to care. There were no statistically significant differences in HRQoL in bivariate or ordinary least squares regression analyses between BRFSS years.

CONCLUSION

Federal policy and Veterans Health Administration expansion have had an impact on improving healthcare access to women Veterans. However, increased healthcare access alone does not translate into improved HRQoL or health outcomes for women Veterans. Future policies should not only focus on increasing healthcare access, but also improving health outcomes, especially HRQoL. The quality of the healthcare accessed must be a focus for future research and policy.

Asthma, chronic obstructive pulmonary disease, tooth loss, and edentulism among adults in the United States: 2016 Behavioral Risk Factor Surveillance System survey

BACKGROUND

Adults with chronic respiratory conditions, specifically asthma or chronic obstructive pulmonary disease (COPD), may be at risk of experiencing poor oral health due to systemic inflammation, challenges in routine oral health care, and adverse effects of medications used to treat these conditions. The authors examined the association of asthma, COPD, and coexisting asthma and COPD (asthma-COPD overlap syndrome [ACOS]) with tooth loss among US adults.

METHODS

The authors conducted a cross-sectional study using 2016 Behavioral Risk Factor Surveillance System data (N = 387,217). The authors categorized the participants with missing permanent teeth into 4 groups: asthma only (n = 38,817), COPD only (n = 19,819), ACOS (n = 13,494), no asthma, no COPD (n = 315,087). The authors used adjusted multinomial logistic regressions to examine the associations between asthma and COPD categories and tooth loss.

RESULTS

According to the authors, 5.3% of study participants reported they were edentulous; 10.7% reported 6 or fewer missing teeth. Participants with asthma only, COPD only, and ACOS had higher odds of reporting tooth loss (6 or more teeth) than those in the no asthma, no COPD group; adjusted odds ratios were 1.12 (95% confidence interval, 1.00 to 1.26) to 2.04 (95% confidence interval, 1.85 to 2.26). A lower percentage of participants with COPD and ACOS visited dentists in the past year than those with no asthma and no COPD. Interactive associations suggested participants with asthma or COPD with dental visits were less likely to report edentulism than those with neither asthma nor COPD and no dental visits.

CONCLUSIONS

Participants with asthma or COPD had higher odds of tooth loss compared with those with neither asthma nor COPD.

PRACTICAL IMPLICATIONS

People with asthma or COPD should maintain routine dental visits to reduce the risk of experiencing tooth loss.

The association of pain interference and opioid use with healthcare utilization and costs, and wage loss among adults with osteoarthritis in the United States

Aim: To examine associations of opioid use and pain interference with activities (PIA), healthcare resource utilization (HRU) and costs, and wage loss in noninstitutionalized adults with osteoarthritis in the United States (US). Methods: Adults with osteoarthritis identified from the Medical Expenditure Panel Survey for 2011/2013/2015 were stratified by no-opioid use with no/mild PIA, no-opioid use with moderate/severe PIA, opioid use with no/mild PIA, and opioid use with moderate/severe PIA. Outcomes included annualized total HRU, direct healthcare costs, and wage loss. Multivariable regression analyses were used for comparisons versus no-opioid use with no/mild PIA (referent). The counterfactual recycled prediction method estimated incremental costs. Results reflect weighted nationally representative data. Results: Of 4,921 participants (weighted n = 20,785,007), 46.5% had no-opioid use with no/mild PIA; 23.2% had no-opioid use with moderate/severe PIA; 9.6% had opioid use with no/mild PIA; and 20.7% had opioid use with moderate/severe PIA. Moderate/severe PIA and/or opioid use were associated with significantly higher HRU and associated costs, and wage loss. Relative to adults with no/mild PIA, opioid users with moderate/severe PIA were more likely to have hospitalizations, specialist visits, and emergency room visits (all p < .001). Relative to the referent, opioid use with no/mild PIA had higher per-patient incremental annual total healthcare costs ($11,672, 95% confidence interval [CI] = $11,435-$11,909) and wage loss ($1,395, 95% CI = $1,376-$1,414) as did opioid use with moderate/severe PIA ($13,595, 95% CI = $13,319-$13,871; and $2,331, 95% CI = $2,298-$2,363) (all p < .001). Compared with the referent, estimated excess national total healthcare costs/lost wages were $23.3 billion/$1.3 billion for opioid use with no/mild PIA, and $58.5 billion/$2.2 billion for opioid use with moderate/severe PIA. Limitations: Unobservable/unmeasured factors that could not be accounted for. Conclusions: Opioid use with moderate/severe PIA had significantly higher HRU, costs, and wage loss; opioid use was more relevant than PIA to the economic burden. These results suggest unmet needs for alternative pain management strategies.

Clinical, humanistic, and economic burden of osteoarthritis among noninstitutionalized adults in the United States

OBJECTIVE

To estimate the burden of osteoarthritis (OA) among noninstitutionalized adults (≥18 years of age) in the US.

DESIGN

Weighted nationally representative data from the 2015 Medical Expenditure Panel Survey were used to estimate OA prevalence in noninstitutionalized adults and compare adults with OA to those without OA for clinical (pain interference with activities [PIA], functional limitations), humanistic (health-related quality-of-life [HRQoL]) and economic outcomes (healthcare costs, wage loss). Productivity/wage loss was estimated among employed working-age adults (18-64 years). Multivariable regression analyses examined the associations between OA and outcomes.

RESULTS

In 2015, 10.5% (25.6 million) of noninstitutionalized US adults reported having any OA. Regression analyses indicated that adults with OA were significantly more likely than those without OA to report moderate (adjusted odds ratios [AOR] 1.99; 95% confidence interval [CI] 1.65-2.40] or severe PIA (AOR 2.59; 95% CI 2.21-3.04), any functional limitation (AOR 2.51; 95% CI 2.21-2.85), and poorer HRQoL on the SF-12 version 2 Physical Component Summary score (adjusted beta [standard error] -3.88 [0.357]; P < 0.001). Adjusted incremental annual total healthcare costs and lost wages among adults with OA relative to those without OA were $1778 and $189 per person, respectively, resulting in estimated national excess costs of $45 billion and $1.7 billion, respectively.

CONCLUSIONS

OA affects approximately 10% of noninstitutionalized adults in the US, resulting in substantial clinical, humanistic, and economic burdens.

Receipt of Guideline-Concordant Care Among Older Women With Stage I-III Breast Cancer: A Population-Based Study

Background: This study examined receipt of guideline-concordant care (GCC) according to evidence-based treatment guidelines and quality measures and specific types of treatment among older women with breast cancer. Patients and Methods: A total of 142,433 patients aged ≥66 years diagnosed with stage I-III breast cancer between 2007 and 2011 were identified in the SEER-Medicare linked database. Algorithms considering cancer characteristics and the appropriate course of care as per guidelines versus actual care received determined receipt of GCC. Multivariable logistic regression estimated the likelihood of GCC and specific types of treatment for women aged ≥75 versus 66 to 74 years. Results: Overall, 39.7% of patients received GCC. Patients diagnosed at stage II or III, with certain preexisting conditions, and of nonwhite race were less likely to receive GCC. Patients with hormone-negative tumors, higher grade tumors, and greater access to oncology care resources were more likely to receive GCC. Patients aged ≥75 years were approximately 40% less likely to receive GCC or adjuvant endocrine therapy, 78% less likely to have any surgery, 61% less likely to have chemotherapy, and about half as likely to have radiation therapy than those aged 66 to 74 years. Conclusions: Fewer than half of older women with breast cancer received GCC, with the lowest rates observed among the oldest age groups, racial/ethnic minorities, and women with later-stage cancers. However, patients with more aggressive tumor characteristics and greater access to oncology resources were more likely to receive GCC. Considering that older women have the highest incidence of breast cancer and that many are diagnosed at stages requiring more aggressive treatment, efforts to increase rates of earlier stage diagnosis and the development of less toxic treatments could help improve GCC and survival while preserving quality of life.

Facility and state-level factors associated with telemental health (TMH) adoption among mental health facilities in the United States

INTRODUCTION

Telemental health (TMH) is a promising approach to increase access to mental healthcare. This study examined the TMH adoption rates and associations with facility- and state-level factors among US mental health (MH) facilities.

METHODS

This retrospective, cross-sectional study used linked data for 2016 from the National Mental Health Services Survey (N = 11,833), Area Health Resources File, and national reports for broadband access and telehealth policies. The associations of facility and state-level characteristics with TMH adoption were examined with multi-level logistic regressions.

RESULTS

Overall, 25.9% had used TMH. Having veteran affiliation [Adjusted Odds Ratio (AOR) = 18.53, 95% Confidence Interval (95%CI): 10.66-32.21] and greater Information Technology (IT) capacity [AOR(95%CI): 2.89(2.10-3.98)] were the strongest correlates of TMH adoption. Other facility characteristics associated with higher likelihood of TMH adoption were: public ownership, high patient volumes, having comprehensive MH treatments or Quality Improvement practices, having private or non-Medicaid public payers, and treating elderly patients (AORs: 1.16-2.41). TMH adoption was less likely among facilities treating more African Americans or patients with substance abuse disorders. TMH adoption varied substantially across states, with adoption more likely in states issuing special telehealth licences and those with more rural counties.

DISCUSSION

One in four MH facilities adopted TMH in 2016. TMH adoption varied by multiple facility- and state-level factors. Our findings suggest that: legal/regulatory burden and lower facility IT capacity may discourage TMH adoption; significant racial disparities exist in TMH adoption; and there is a need to increase TMH use for substance abuse disorders.

Dipeptidyl Peptidase-4 Inhibitors and Joint Pain: A Retrospective Cohort Study of Older Veterans with Type 2 Diabetes Mellitus

BACKGROUND

In recent years, dipeptidyl peptidase (DPP)-4 inhibitors have been added to the diabetes treatment algorithm. Few published studies have shown that the use of DPP-4 inhibitors is associated with joint pain. To our knowledge, no population-based studies in the United States have studied this association.

OBJECTIVE

To evaluate the association between a new prescription of DPP-4 inhibitors and joint pain within 1 year among older veterans with diabetes.

METHODS

This was a retrospective cohort study of older veterans (aged ≥66 years) who were dually enrolled in Medicare and the Veterans Health Administration (VHA; N = 134,488). Data were derived from linked Medicare claims and VHA electronic health records from 2008 to 2010. Diabetes during the baseline and joint pain during the follow-up period were identified with International Classification of Diseases, Ninth Revision codes. Filled prescriptions for DPP-4 inhibitors during the baseline period were identified from Medicare Part D and VHA pharmacy records. The adjusted associations between DPP-4 inhibitors and joint pain were examined with logistic regressions.

RESULTS

Approximately 8.4% of the 134,488 study patients received at least 1 prescription for DPP-4 inhibitors and 11.7% were diagnosed with joint pain during the follow-up period. An unadjusted analysis showed significant differences in joint pain by DPP-4 inhibitor status (12.9% among users vs 11.6% among nonusers; P <.0001). In a fully adjusted model, having a DPP-4 inhibitor prescription had higher odds of joint pain (adjusted odds ratio, 1.17; 95% confidence interval, 1.10-1.24) compared with no prescription for a DPP-4 inhibitor.

CONCLUSION

In a cohort of older veterans who did not have documented joint pain at baseline, a prescription for DPP-4 inhibitors was significantly associated with a newly documented joint pain.

Health reform under the patient protection and Affordable Care Act: characteristics of exchange-based health insurance enrollees

The Affordable Care Act (ACA) reformed and expanded healthcare coverage with an exchange-based health insurance program. While millions of Americans have benefited from enrollment in ACA marketplace insurance plans, many individuals are likely to be affected by potential future policy changes. Since few studies on the features of marketplace enrollees exist, we adopted a retrospective, cross-sectional study design using 2016 National Health Interview data to identify sociodemographic and health characteristics of enrollees, comparing them to those without insurance. Chi-square tests and logistic regression examined factors associated with enrollees. Adults with multiple chronic diseases (AOR = 1.90, 95% CI = 1.44, 2.50), a history of smoking (AOR = 2.44, 95% CI = 1.82, 3.26), females, married, age 50-64 years, higher educational attainment, and retirees (AOR = 1.86, 95% CI = 1.06, 3.27) were more likely to be enrollees. Since enrollees are largely higher risk individuals with greater healthcare needs, policies that modify the ACA should take these factors into account to reduce potential adverse impacts on enrollees.

The Association of Perceived Memory Loss with Osteoarthritis and Related Joint Pain in a Large Appalachian Population

Objective

Previous studies have documented memory impairment in several chronic pain syndromes. However, the potential link between memory loss and osteoarthritis (OA), the second most common cause of chronic pain, remains little explored. In this cross-sectional study, we examine the association of perceived memory loss to OA and assess the potential mediating influence of sleep and mood disturbance in a large Appalachian population.

Design

Cross-sectional.

Setting

US Ohio Valley.

Subjects

A total of 21,982 Appalachian adults age 40 years or older drawn from the C8 Health Project (N = 19,004 adults without and 2,478 adults with OA). All participants completed a comprehensive health survey between 2005 and 2006. Medical history, including physician diagnosis of OA, lifestyle factors, short- and long-term memory loss, sleep quality, and mood were assessed via self-report.

Results

After adjustment for demographic, lifestyle, health-related, and other factors, participants with OA were almost three times as likely to report frequent memory loss (adjusted odds ratios [ORs] for short- and long-term memory loss, respectively = 2.7, 95% confidence interval [CI] = 2.2-3.3, and 2.6, 95% CI = 2.0-3.3). The magnitude of these associations increased significantly with rising frequency of reported joint pain (adjusted OR for OA with frequent joint pain vs no OA = 3.3, 95% CI = 2.6-4.1, Ptrend < 0.00001). Including measures of mood and sleep impairment attenuated but did not eliminate these associations (ORs for any memory loss = 2.0, 95% CI = 1.6-2.4, and 2.1, 95% CI = 1.7-2.8, adjusted for sleep and mood impairment, respectively; OR = 1.8, 95% CI = 1.4-2.2, adjusted for both factors).

Conclusions

In this large cross-sectional study, OA and related joint pain were strongly associated with perceived memory loss; these associations may be partially mediated by sleep and mood disturbance.

Predictors of Major Bleeding Among Working-Age Adults with Atrial Fibrillation: Evaluating the Effects of Potential Drug-drug Interactions and Switching from Warfarin to Non-vitamin K Oral Anticoagulants

PURPOSE

This study aims to evaluate the associations between switching from warfarin to non-vitamin K oral anticoagulants (NOACs), exposure to potential drug-drug interactions (DDIs), and major bleeding events in working-age adults with atrial fibrillation (AF).

METHODS

We conducted a retrospective cohort study using the claims database of commercially insured working-age adults with AF from 2010 to 2015. Switchers were defined as patients who switched from warfarin to NOAC; non-switchers were defined as those who remained on warfarin. We developed novel methods to calculate the number and proportion of days with potential DDIs with NOAC/warfarin. Multivariate logistic regressions were utilized to evaluate the associations between switching to NOACs, exposure to potential DDIs, and major bleeding events.

RESULTS

Among a total of 4126 patients with AF, we found a significantly lower number of potential DDIs and the average proportion of days with potential DDIs in switchers than non-switchers. The number of potential DDIs (AOR 1.14, 95% CI 1.02-1.27) and the HAS-BLED score (AOR 1.64, 95% CI 1.48-1.82) were significantly and positively associated with the likelihood of a major bleeding event. The proportion of days with potential DDIs was also significantly and positively associated with risk for bleeding (AOR 1.42, 95% CI 1.03, 1.96). We did not find significant associations between switching to NOACs and major bleeding events.

CONCLUSIONS

The number and duration of potential DDIs and patients' comorbidity burden are important factors to consider in the management of bleeding risk in working-age AF adults who take oral anticoagulants.

Tumor Necrosis Factor Inhibitor Therapy and the Risk for Depression Among Working-Age Adults with Rheumatoid Arthritis

BACKGROUND

Individuals with rheumatoid arthritis (RA) are at high risk for depression because of the overall burden of systemic inflammation. Although some evidence suggests that treatment with powerful anti-inflammatory drugs, such as tumor necrosis factor (TNF) inhibitors, may be effective in reducing the risk for depression in patients with RA, it is unclear whether such reduction in risk is dependent on the response to TNF inhibitor therapy.

OBJECTIVE

To evaluate the association between the response to TNF inhibitor therapy and the risk for depression among working-age adults with RA.

METHOD

This retrospective, observational cohort study design was based on data derived from commercial claims data in the QuintilesIMS Real World Data Adjudicated Claims database between October 1, 2009, and September 30, 2015. A total of 4222 working-age adults (18-62 years) with RA who started treatment with TNF inhibitor therapy and were continuously enrolled during the 3 observation periods (ie, 1-year baseline, 1-year treatment, and 1-year follow-up periods) were included in the study. Treatment response to a TNF inhibitor was measured using prescription drug claims based on a published validated algorithm. Multivariable logistic regression was used to examine the association between treatment response to TNF inhibitor therapy and the risk for depression, after controlling for baseline demographic characteristics, clinical characteristics, and RA-related medication use. An inverse probability of treatment weighting technique was used to control for observable differences in TNF inhibitor responders' characteristics versus TNF inhibitor nonresponders.

RESULTS

Overall, 359 (8.5%) patients with RA had depression during the follow-up period and 1679 (39.8%) patients responded to TNF inhibitor treatment during the 1-year treatment period. A significantly lower percentage of TNF inhibitor responders (7.1%, N = 119) had depression than TNF inhibitor nonresponders (9.4%, N = 239). After controlling for other risk factors, responders to TNF inhibitors were 20% less likely to have depression during the follow-up period (adjusted odds ratio, 0.80; 95% confidence interval, 0.64-0.98) than nonresponders to TNF inhibitor therapy.

CONCLUSION

The risk for depression was significantly reduced among patients with RA who responded to TNF inhibitor therapy compared with those who did not respond to such therapy. To determine whether the lower rate of depression observed with TNF inhibition is a direct effect of treatment with a TNF inhibitor, or whether it could be attributed to improvement in RA disease secondary to treatment, future studies need to also incorporate a control population of patients with RA who receive other antirheumatic regimens, such as disease-modifying antirheumatic drugs.

The Association of Joint Pain and Dipeptidyl Peptidase-4 Inhibitor Use Among U.S. Adults With Type-2 Diabetes Mellitus

The purpose of this study was to examine the association of dipeptidyl peptidase-4 inhibitors (DPP4Is) with joint pain in adults with type 2 diabetes mellitus (T2DM). This was a retrospective cross-sectional study design, pooling data from the 2012 and 2014 Medical Expenditure Panel Survey. The sample consisted of 4,559 T2DM patients older than 40 years with (n = 3,224) or without joint pain (n = 1,335). Chi-square test and logistic regression were used to describe association of DPP4I use with joint pain. Among adults with T2DM, 70.7% reported physician-diagnosed joint pain. There were no significant differences in DPP4I use among those with and without joint pain (7.8% vs 6.3%). Even after adjusting for other factors that may affect DPP4I use, there was not a statistically significant difference in DPP4I use among adults with T2DM with and without joint pain (AOR = 1.04; 95% CI, 0.74-1.48). Adults with public health insurance (AOR = 1.76; 95% CI, 1.01-3.04), with prescription insurance (AOR = 1.76; 95% CI, 1.02-3.03), and with a heart disease (AOR = 1.59; 95% CI, 1.18-2.15). DPP4I use was not affected by the presence of joint pain.

Tobacco Use among Adult Muslims in the United States

BACKGROUND

Compared with the general United States (US) population, Muslims in the US exhibit elevated rates of tobacco use. As a result, they might be at a higher risk for preventive disease and premature death as compared with the general US population.

OBJECTIVE

This study investigated the Social Cognitive Theory (SCT) factors that are associated with tobacco use among a sample of adult Muslims in the US.

METHODS

Data were collected (November 2016-March 2017) using a cross-sectional, on-line survey from a convenience sample of adult (≥ 18 years) US Muslims. Participants with a lung cancer history were excluded. Associations between SCT factors and tobacco use were investigated with bivariate analyses and multinomial logistic regression models.

RESULTS

Eligible participants (n = 271) from 30 states completed the survey; 52.8% reported current tobacco use. A higher rate of current tobacco use was reported by men (62.8%) as compared to women (41.3%), x²(1, N = 271) = 12.49, p < .001. In terms of cognitive factors, individuals who (1) expected more personal consequences for tobacco use on health, and (2) had more confidence regarding ability to abstain from tobacco use, were less likely to report current tobacco use. In terms of environmental factors, individuals whose family members did not use tobacco were less likely to report current tobacco use.

CONCLUSION

The study findings suggest that family-oriented interventions emphasizing self-efficacy and personal consequences to prevent tobacco use can potentially be effective in reducing tobacco use rates in the adult US Muslim population.

Impact of diffuse large B-cell lymphoma on visits to different provider specialties among elderly Medicare beneficiaries: challenges for care coordination

Newly diagnosed diffuse large B-cell lymphoma (DLBCL) can pose significant challenges to care coordination. We utilized a social-ecological model to understand the impact of DLBCL diagnosis on visits to primary care providers (PCPs) and specialists, a key component of care coordination, over a 3-year period of cancer diagnosis and treatment. We used hurdle models and multivariable logistic regression with the Surveillance Epidemiology and End Result-Medicare linked dataset to analyze visits to PCPs and specialists by DLBCL patients (n = 5,455) compared with noncancer patients (n = 14,770). DLBCL patients were more likely to visit PCPs (adjusted odds ratio, AOR [95% confidence interval, CI]: 1.25 [1.18, 1.31]) and had greater number of visits to PCPs (β, SE: 0.384, -0.014) than noncancer patients. Further, DLBCL patients were more likely to have any visit to cardiologists (AOR [95% CI]: 1.40 [1.32, 1.47]), endocrinologists (1.43, [1.21, 1.70]), and pulmonologists (1.51 [1.36, 1.67]) than noncancer patients. Among DLBCL patients, the number of PCP visits markedly increased during the treatment period compared with the baseline period (β, SE: 0.491, -0.028) and then decreased to baseline levels (-0.464, -0.022). Visits to PCPs and specialists were much more frequent for DLBCL patients than noncancer patients, which drastically increased during the DLBCL treatment period for chronic care. More chronic conditions, treatment side effects, and frequent testing may have increased visits to PCPs and specialists. Interventions to improve care coordination may need to target the DLBCL treatment period, when patients are most vulnerable to poor care coordination.