Confirmation of administrative claims-identified opportunistic infections and other serious potential adverse events associated with tumor necrosis factor alpha antagonists and disease-modifying antirheumatic drugs

Validity of ICD-10-CM diagnoses to identify hospitalizations for serious infections among patients treated with biologic therapies

PURPOSE

Identifying hospitalizations for serious infections among patients dispensed biologic therapies within healthcare databases is important for post-marketing surveillance of these drugs. We determined the positive predictive value (PPV) of an ICD-10-CM-based diagnostic coding algorithm to identify hospitalization for serious infection among patients dispensed biologic therapy within the FDA's Sentinel Distributed Database.

METHODS

We identified health plan members who met the following algorithm criteria: (1) hospital ICD-10-CM discharge diagnosis of serious infection between July 1, 2016 and August 31, 2018; (2) either outpatient/emergency department infection diagnosis or outpatient antimicrobial treatment within 7 days prior to hospitalization; (3) inflammatory bowel disease, psoriasis, or rheumatological diagnosis within 1 year prior to hospitalization, and (4) were dispensed outpatient biologic therapy within 90 days prior to admission. Medical records were reviewed by infectious disease clinicians to adjudicate hospitalizations for serious infection. The PPV (95% confidence interval [CI]) for confirmed events was determined after further weighting by the prevalence of the type of serious infection in the database.

RESULTS

Among 223 selected health plan members who met the algorithm, 209 (93.7% [95% CI, 90.1%-96.9%]) were confirmed to have a hospitalization for serious infection. After weighting by the prevalence of the type of serious infection, the PPV of the ICD-10-CM algorithm identifying a hospitalization for serious infection was 80.2% (95% CI, 75.3%-84.7%).

CONCLUSIONS

The ICD-10-CM-based algorithm for hospitalization for serious infection among patients dispensed biologic therapies within the Sentinel Distributed Database had 80% PPV for confirmed events and could be considered for use within pharmacoepidemiologic studies.

Propensity score trimming mitigates bias due to covariate measurement error in inverse probability of treatment weighted analyses: A plasmode simulation

BACKGROUND

Inverse probability of treatment weighting (IPTW) may be biased by influential observations, which can occur from misclassification of strong exposure predictors.

METHODS

We evaluated bias and precision of IPTW estimators in the presence of a misclassified confounder and assessed the effect of propensity score (PS) trimming. We generated 1000 plasmode cohorts of size N = 10 000, sampled with replacement from 6063 NHANES respondents (1999-2014) age 40 to 79 with labs and no statin use. We simulated statin exposure as a function of demographics and CVD risk factors; and outcomes as a function of 10-year CVD risk score and statin exposure (rate ratio [RR] = 0.5). For 5% of the people in selected populations (eg, all patients, exposed, those with outcomes), we randomly misclassified a confounder that strongly predicted exposure. We fit PS models and estimated RRs using IPTW and 1:1 PS matching, with and without asymmetric trimming.

RESULTS

IPTW bias was substantial when misclassification was differential by outcome (RR range: 0.38-0.63) and otherwise minimal (RR range: 0.51-0.53). However, trimming reduced bias for IPTW, nearly eliminating it at 5% trimming (RR range: 0.49-0.52). In one scenario, when the confounder was misclassified for 5% of those with outcomes (0.3% of cohort), untrimmed IPTW was more biased and less precise (RR = 0.37 [SE(logRR) = 0.21]) than matching (RR = 0.50 [SE(logRR) = 0.13]). After 1% trimming, IPTW estimates were unbiased and more precise (RR = 0.49 [SE(logRR) = 0.12]) than matching (RR = 0.51 [SE(logRR) = 0.14]).

CONCLUSIONS

Differential misclassification of a strong predictor of exposure resulted in biased and imprecise IPTW estimates. Asymmetric trimming reduced bias, with more precise estimates than matching.

The importance of inhibition of a catabolic pathway of methotrexate metabolism in its efficacy for rheumatoid arthritis

Methotrexate (MTX), an antifolate, is the anchor drug for the treatment of rheumatoid arthritis (RA). It is inexpensive, effective, and generally safe. When clinical response is inadequate, biological therapies are commonly used in combination with MTX. However, biological agents have safety concerns (i.e. infections, malignancy) and the addition of a biologic agent is expensive, making strategies to improve MTX efficacy important. Inhibition of pathways of folate metabolism involving purine metabolism by MTX, have been traditionally emphasized as important in MTX efficacy. However, inhibition MTX catabolism may also be important. MTX is irreversibly hydroxylated to form 7-hydroxy methotrexate (7-OH-MTX) by aldehyde oxidase (EC 1.2.3.1) (AOX). Catabolism of MTX to 7-OH-MTX is the first metabolic process imposed on an oral dose of MTX and will alter subsequent interactions of MTX with other enzymes. 7-OH-MTX is less potent than MTX in the treatment of rat adjuvant arthritis. RA patients with a low capacity to catabolize MTX to 7-OH-MTX do better clinically than individuals who are rapid formers of 7-OH-MTX. Therefore, altering the catabolism of MTX may be an innovative way to improve MTX efficacy. Raloxifene is a FDA-approved therapy for postmenopausal osteoporosis and for the reduction of invasive breast cancers but has no known activity in RA. Raloxifene is a potent inhibitor of human liver AOX. Postmenopausal women with RA frequently have low bone mineral density and would be candidates for raloxifene and MTX combination therapy. The effect of raloxifene on MTX metabolism has never been studied. Our hypothesis is that in postmenopausal women with RA and osteoporosis treated with MTX and raloxifene, the inhibition of AOX with resultant decreased formation of 7-OH MTX; will increase MTX levels and improve MTX efficacy. This hypothesis could be studied in an open-label, proof of concept clinical study in individuals before and after the addition of raloxifene. Red blood cell MTX and 7-OH-MTX levels and RA disease activity (DAS28) would be measured. In possible future studies, there are dietary substances, as supplements, (e.g. epigallocatechin gallate in green tea and resveratrol) which inhibit human liver AOX which could be evaluated.

Comparative Risk of Hospitalized Infection Associated With Biologic Agents in Rheumatoid Arthritis Patients Enrolled in Medicare

OBJECTIVE

The risks of hospitalized infection associated with biologic agents used to treat rheumatoid arthritis (RA) are unclear. The aim of this study was to determine whether the associated risk of hospitalized infections differed between specific biologic agents used to treat RA.

METHODS

In a retrospective cohort study using Medicare data from 2006-2011 for all enrolled patients with RA, new episodes of treatment with etanercept, adalimumab, certolizumab, golimumab, infliximab, abatacept, rituximab, and tocilizumab were identified. Patients were required to have received another biologic agent previously and to have been continuously enrolled in Medicare medical and pharmacy plans during the baseline period and throughout followup. Followup started on the date of initiation of treatment with the new biologic agent (after previous treatment with a different biologic agent) and ended on the date of the earliest hospitalized infection, at 12 months, after an exposure gap of >30 days, or at the time of death or loss of Medicare coverage. Cox regression analysis was used to calculate the adjusted hazard ratio (HR) for hospitalized infection, adjusting for an infection risk score and other confounders.

RESULTS

Of 31,801 new biologic treatment episodes in patients who had previously received another biologic agent, 12.0% were with etanercept, 15.2% with adalimumab, 5.9% with certolizumab, 4.4% with golimumab, 12.4% with infliximab, 28.9% with abatacept, 14.8% with rituximab, and 6.3% with tocilizumab. During followup, we identified 2,530 hospitalized infections; incidence rates ranged from 13.1 per 100 person-years (abatacept) to 18.7 per 100 person-years (rituximab). After adjustment, etanercept (HR 1.24, 95% confidence interval [95% CI] 1.07-1.45), infliximab (HR 1.39, 95% CI 1.21-1.60), and rituximab (HR 1.36, 95% CI 1.21-1.53) had significantly higher HRs for hospitalized infection compared with abatacept.

CONCLUSION

In RA patients with prior exposure to a biologic agent, exposure to etanercept, infliximab, or rituximab was associated with a greater 1-year risk of hospitalized infection compared with the risk associated with exposure to abatacept.

Risk of hospitalized bacterial infections associated with biologic treatment among US veterans with rheumatoid arthritis

OBJECTIVE

The comparative risk of infection associated with non-anti-tumor necrosis factor (anti-TNF) biologic agents is not well established. Our objective was to compare risk for hospitalized infections between anti-TNF and non-anti-TNF biologic agents in US veterans with rheumatoid arthritis (RA).

METHODS

Using 1998-2011 data from the US Veterans Health Administration, we studied RA patients initiating rituximab, abatacept, or anti-TNF therapy. Exposure was based upon days supplied (injections) or usual dosing intervals (infusions). Treatment episodes were defined as new biologic agent use. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for hospitalization for a bacterial infection were estimated from Cox proportional hazards models, adjusting for potential confounders.

RESULTS

Among 3,152 unique RA patients contributing 4,158 biologic treatment episodes to rituximab (n = 596), abatacept (n = 451), and anti-TNF agents (n = 3,111), the patient mean age was 60 years and 87% were male. The most common infections were pneumonia (37%), skin/soft tissue (22%), urinary tract (9%), and bacteremia/sepsis (7%). Hospitalized infection rates per 100 person-years were 4.4 (95% CI 3.1-6.4) for rituximab, 2.8 (95% CI 1.7-4.7) for abatacept, and 3.0 (95% CI 2.5-3.5) for anti-TNF. Compared to etanercept, the adjusted rate of hospitalized infection was not different for adalimumab (HR 1.4, 95% CI 0.9-2.2), abatacept (HR 1.1, 95% CI 0.6-2.1), or rituximab (HR 1.4, 0.8-2.6), although it was increased for infliximab (HR 2.3, 95% CI 1.3-4.0). Infection risk was greater for those taking prednisone >7.5 mg/day (HR 1.8, 95% CI 1.3-2.7) and in the highest quartile of C-reactive protein (HR 2.3, 95% CI 1.4-3.8) and erythrocyte sedimentation rate (HR 4.1, 95% CI 2.3-7.2) compared to the lowest quartile.

CONCLUSION

In older, predominantly male US veterans with RA, the risk of hospitalized bacterial infections associated with rituximab or abatacept was similar to etanercept.

A systematic review of validated methods for identifying patients with rheumatoid arthritis using administrative or claims data

PURPOSE

To review the evidence supporting the validity of billing, procedural, or diagnosis code, or pharmacy claim-based algorithms used to identify patients with rheumatoid arthritis (RA) in administrative and claim databases.

METHODS

We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to RA and reference lists of included studies were searched. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria and extracted the data. Data collected included participant and algorithm characteristics.

RESULTS

Nine studies reported validation of computer algorithms based on International Classification of Diseases (ICD) codes with or without free-text, medication use, laboratory data and the need for a diagnosis by a rheumatologist. These studies yielded positive predictive values (PPV) ranging from 34 to 97% to identify patients with RA. Higher PPVs were obtained with the use of at least two ICD and/or procedure codes (ICD-9 code 714 and others), the requirement of a prescription of a medication used to treat RA, or requirement of participation of a rheumatologist in patient care. For example, the PPV increased from 66 to 97% when the use of disease-modifying antirheumatic drugs and the presence of a positive rheumatoid factor were required.

CONCLUSIONS

There have been substantial efforts to propose and validate algorithms to identify patients with RA in automated databases. Algorithms that include more than one code and incorporate medications or laboratory data and/or required a diagnosis by a rheumatologist may increase the PPV.

Understanding the burden of tuberculosis among American Indians/Alaska Natives in the U.S.: a validation study

OBJECTIVE

We validated cases of active tuberculosis (TB) recorded in the Indian Health Service (IHS) National Patient Information Reporting System (NPIRS) and evaluated the completeness of TB case reporting from IHS facilities to state health departments.

METHODS

We reviewed the medical records of American Indian/Alaska Native (AI/AN) patients at IHS health facilities who were classified as having active TB using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes from 2006 to 2009 for clinical and laboratory evidence of TB disease. Individuals were reclassified as having active TB disease; recent latent TB infection (LTBI); past positive tuberculin skin test (TST) only; or as having no evidence of TB, LTBI, or a past positive TST. We compared validated active TB cases with corresponding state records to determine if they were reported.

RESULTS

The study included 596 patients with active TB as per ICD-9-CM codes. Based on chart review, 111 (18.6%) had active TB; 156 (26.2%) had LTBI; 104 (17.4%) had a past positive TST; and 221 (37.1%) had no evidence of TB disease, LTBI, or a past positive TST. Of the 111 confirmed cases of active TB, 89 (80.2%) resided in participating states; 81 of 89 (91.2%) were verified as reported TB cases.

CONCLUSIONS

ICD-9-CM codes for active TB disease in the IHS NPIRS do not accurately reflect the burden of TB among AI/ANs. Most confirmed active TB cases in the IHS health system were reported to the state; the national TB surveillance system may accurately represent the burden of TB in the AI/AN population.

Risk of hospitalised infection in rheumatoid arthritis patients receiving biologics following a previous infection while on treatment with anti-TNF therapy

BACKGROUND

The risk of subsequent infections in rheumatoid arthritis (RA) patients who receive biologic therapy after a serious infection is unclear.

OBJECTIVE

To compare the subsequent risk of hospitalised infections associated with specific biologic agents among RA patients previously hospitalised for infection while receiving anti-tumour necrosis factor (anti-TNF) therapy.

METHODS

Using 2006-2010 Medicare data for 100% of beneficiaries with RA enrolled in Medicare, we identified patients hospitalised with an infection while on anti-TNF agents. Follow-up began 61 days after hospital discharge and ended at the earliest of: next infection, loss of Medicare coverage or 18 months after start of follow-up. We calculated the incidence rate of subsequent hospitalised infection for each biologic and used Cox regression to control for potential confounders.

RESULTS

10 794 eligible hospitalised infections among 10183 unique RA patients who contributed at least 1 day of biologic exposure during follow-up. We identified 7807 person-years of exposure to selected biologics--333 abatacept, 133 rituximab and 7341 anti-TNFs (1797 etanercept, 1405 adalimumab, 4139 infliximab)--and 2666 associated infections. Mean age across biologic exposure cohorts was 64-69 years. The crude incidence rate of subsequent hospitalised infection ranged from 27.1 to 34.6 per 100 person-years. After multivariable adjustment, abatacept (HR: 0.80, 95% CI 0.64 to 0.99) and etanercept (HR: 0.83, 95% CI 0.72 to 0.96) users had significantly lower risks of subsequent infection compared to infliximab users.

CONCLUSIONS

Among RA patients who experienced a hospitalised infection while on anti-TNF therapy, abatacept and etanercept were associated with the lowest risk of subsequent infection compared to other biologic therapies.

Systematic review of validation studies of the use of administrative data to identify serious infections

OBJECTIVE

To conduct a systematic review of the literature on the validation of algorithms identifying infections in administrative data for future use in populations with rheumatic diseases.

METHODS

Medline and EMBase were searched using the themes "administrative data" and "infection" between 1950 and October 2012. Inclusion criteria consisted of validation studies of administrative data identifying infections in adult populations. Article quality was assessed using a validated tool.

RESULTS

A total of 5,941 articles were identified, 90 articles underwent detailed review, and 24 studies were included. The majority (17 of 24) examined bacterial infections and 9 examined opportunistic infections. Eighteen studies were from the US and all but 4 studies used International Classification of Diseases, Ninth Revision codes. Rheumatoid arthritis patients were studied in 6 of 24 articles. The studies on bacterial infections in general reported highly variable sensitivity and positive predictive value (PPV) for the diagnosis of infections using administrative data (sensitivity range 4.4-100%, PPV range 21.7-100%). Algorithms to identify opportunistic infections similarly had a highly variable sensitivity (range 20-100%) and PPV (range 1.3-100%). Thirteen studies compared the diagnostic accuracy of different algorithms, which revealed that strategies including a comprehensive algorithm using a greater number of diagnostic codes or codes in any position had the highest sensitivity for the diagnosis of infection. Algorithms that incorporated microbiologic or pharmacy data in combination with diagnostic codes had improved PPV for identification of tuberculosis.

CONCLUSION

Algorithms for identifying infections using administrative data should be selected based on the purpose of the study, with careful consideration as to whether a high sensitivity or PPV is required.

Incidence density of serious infection, opportunistic infection, and tuberculosis associated with biologic treatment in patients with rheumatoid arthritis - a systematic evaluation of the literature

Summary data on the incidence density (ie, incidence per person-year [PY]) of serious infection, opportunistic infection, and tuberculosis associated with each of the nine biologic therapies currently indicated in rheumatoid arthritis patients are not available. To summarize these data, a systematic review was conducted with searches on PubMed and Embase of literature ranging from January 1998 to November 2011. Incidence density was extracted and reported using the definitions from the respective publications. If the incidence density was not reported, estimation was made using available information. A total of 72 published studies met the inclusion criteria and were reviewed, including 44 clinical trials, open-label extension studies, or meta-analyses, and 28 observational studies. Additional calculation of the incidence density was performed in 12 studies for serious infection and in 13 studies for opportunistic infection or tuberculosis. The incidence of serious infection was consistent across studies and biologic therapies, ranging from 0 to 11/100 PY but mainly clustered from 2 to 6/100 PY. Fewer incidence data were available for opportunistic infection and tuberculosis. The incidence of opportunistic infection and tuberculosis ranged widely, from 0.01 to 3.0/100 PY and 0.01 to 2.6/100 PY, respectively. The data on serious infection may be used to evaluate the public health risk and benefit of biologic treatment. They may also serve as a point of reference for future studies. The limited data on opportunistic infection and the lack of a consistent definition of opportunistic infection invite caution for a benchmark rate for opportunistic infection as a composite category.

Geographic distribution of endemic fungal infections among older persons, United States

TOC summary: Incidence was highest for histoplasmosis and blastomycosis in the Midwest and for coccidioidomycosis in the West.

To investigate the epidemiology and geographic distribution of histoplasmosis, coccidioidomycosis, and blastomycosis in older persons in the United States, we evaluated a random 5% sample of national Medicare data from 1999 through 2008. We calculated national, regional, and state-based incidence rates and determined 90-day postdiagnosis mortality rates. We identified 776 cases (357 histoplasmosis, 345 coccidioidomycosis, 74 blastomycosis). Patient mean age was 75.7 years; 55% were male. Histoplasmosis and blastomycosis incidence was highest in the Midwest (6.1 and 1.0 cases/100,000 person-years, respectively); coccidioidomycosis incidence rate was highest in the West (15.2). On the basis of available data, for 86 (11.1%) cases, there was no patient exposure to a traditional disease-endemic area. Knowledge of areas where endemic mycosis incidence is increased may affect diagnostic or prevention measures for older adults at risk.

Initiation of tumor necrosis factor-α antagonists and the risk of hospitalization for infection in patients with autoimmune diseases

CONTEXT

Although tumor necrosis factor (TNF)-α antagonists are increasingly used in place of nonbiologic comparator medications, their safety profile remains incomplete.

OBJECTIVES

To determine whether initiation of TNF-α antagonists compared with nonbiologic comparators is associated with an increased risk of serious infections requiring hospitalization.

DESIGN, SETTING, AND PATIENTS

Within a US multi-institutional collaboration, we assembled retrospective cohorts (1998-2007) of patients with rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and psoriasis, psoriatic arthritis, or ankylosing spondylitis (psoriasis and spondyloarthropathies) combining data from Kaiser Permanente Northern California, New Jersey and Pennsylvania Pharmaceutical Assistance programs, Tennessee Medicaid, and national Medicaid/Medicare. TNF-α antagonists and nonbiologic regimens were compared in disease-specific propensity score (PS)-matched cohorts using Cox regression models with nonbiologics as the reference. Baseline glucocorticoid use was evaluated as a separate covariate.

MAIN OUTCOME MEASURE

Infections requiring hospitalization (serious infections) during the first 12 months after initiation of TNF-α antagonists or nonbiologic regimens.

RESULTS

Study cohorts included 10,484 RA, 2323 IBD, and 3215 psoriasis and spondyloarthropathies matched pairs using TNF-α antagonists and comparator medications. Overall, we identified 1172 serious infections, most of which (53%) were pneumonia and skin and soft tissue infections. Among patients with RA, serious infection hospitalization rates were 8.16 (TNF-α antagonists) and 7.78 (comparator regimens) per 100 person-years (adjusted hazard ratio [aHR], 1.05 [95% CI, 0.91-1.21]). Among patients with IBD, rates were 10.91 (TNF-α antagonists) and 9.60 (comparator) per 100 person-years (aHR, 1.10 [95% CI, 0.83-1.46]). Among patients with psoriasis and spondyloarthropathies, rates were 5.41 (TNF-α antagonists) and 5.37 (comparator) per 100 person-years (aHR, 1.05 [95% CI, 0.76-1.45]). Among patients with RA, infliximab was associated with a significant increase in serious infections compared with etanercept (aHR, 1.26 [95% CI, 1.07-1.47]) and adalimumab (aHR, 1.23 [95% CI, 1.02-1.48]). Baseline glucocorticoid use was associated with a dose-dependent increase in infections.

CONCLUSION

Among patients with autoimmune diseases, compared with treatment with nonbiologic regimens, initiation of TNF-α antagonists was not associated with an increased risk of hospitalizations for serious infections.

Validity of self-report of infections in a longitudinal cohort of patients with rheumatoid arthritis differs by source of report and infection severity

OBJECTIVE

We evaluated and compared the validity of patients' and rheumatologists' reports of infection with those confirmed by medical record review.

STUDY DESIGN AND SETTING

Reports of infections in 961 patients with rheumatoid arthritis from the Brigham and Women's Rheumatoid Arthritis Sequential Study (BRASS) were included over a 2-year period. BRASS is a longitudinal prospective cohort that collects detailed questionnaire data from patients semiannually and their treating rheumatologists every year.

RESULTS

Rheumatologist report of infection was more likely to be confirmed by medical record review than patient self-report (57.1% vs. 34.3% for definite or possible infections). Confirmation rates varied based on whether the participant received her primary care from the same network of health care providers. For participants with primary care "out of network," between 7.0% and 23.1% of patient or rheumatologist reports were confirmed by medical record review vs. between 16.1% and 41.7% for those with primary care "in network."

CONCLUSION

The present study shows that relying strictly on patient or rheumatologist report of infection for a confirmed endpoint is not ideal but useful in case finding. The confirmation rate is affected by a number of factors including severity and definition of the infection and limited by data availability.

Clinical and economic impact of infusion reactions in patients with colorectal cancer treated with cetuximab

Background: Systemic agents in cancer treatment were often associated with possible infusion reactions (IRs). This study estimated the incidence of IRs requiring medical intervention and assessed the clinical and economic impacts of IRs in patients with colorectal cancer (CRC) treated with cetuximab.

Patients and methods: Details on patients with CRC receiving cetuximab in 2004–2006 were extracted from a large USA administrative claims database. IRs were identified based on the occurrence of outpatient treatment, emergency room (ER) visit, and/or hospitalization for hypersensitivity and allergic reactions. Multivariate regressions were used to examine potential risk factors and quantify the economic impact of IRs.

Results: A total of 1122 CRC patients receiving cetuximab were identified. The incidence of IRs requiring medical intervention was 8.4%. Sixty-eight percent of the patients had treatment disruptions and 34% discontinued cetuximab treatment. Mean adjusted costs were $13 863 for cetuximab administrations with an IR requiring ER visit or hospitalization and $6280 for those with an IR requiring outpatient treatment, compared with $4555 for those without an IR.

Conclusions: The incidence rate of cetuximab-related IRs requiring medical intervention in clinical practice was found to be higher than rates reported in the product label and clinical trials. The clinical and economic impacts of these IRs are substantial.

Adverse events associated with common therapy regimens for moderate-to-severe Crohn's disease

OBJECTIVES

We sought to determine whether treatment with steroids, immunosuppressives (ISs), and anti-tumor necrosis factor (TNF) agents is associated with an increased risk of adverse events in patients with Crohn's disease (CD).

METHODS

This study analyzed claims from patients with CD and controls without CD from the United States with private insurance (2002-2005). Patients were classified by treatment with steroids, ISs, anti-TNF agents, combinations of two or three, and none of these medications. Follow-up adverse events in patients with CD and controls were compared across different treatment categories and are presented as hazard ratios (HRs) and 95% confidence intervals (CIs). Within the CD patients, a subset analysis examined the relationship between therapies and outcomes.

RESULTS

A total of 22,310 patients with CD (8,581 longitudinal cohort cases) and 111,550 controls were identified. Compared with the controls, CD patients had higher rate ratios for all pre-specified events. Within the CD patient population subgroup, monotherapy with steroids, ISs, or anti-TNF agents was associated with an increased risk of tuberculosis (TB) (HR 2.7; 95% CI, 1.0-7.3), candidiasis (HR 2.7; 95% CI, 1.8-4.0), herpes zoster (HR 1.7; 95% CI, 1.0-2.7), sepsis (HR 1.3; 95% CI, 1.1-1.5), demyelinating conditions (HR 3.2; 95% CI, 1.5-6.9), and cervical dysplasia (HR 1.5; 95% CI, 1.2-2.0) as compared with patients not receiving these medications. The use of two or three of these medications further increased these risks: TB (HR 7.4; 95% CI, 2.1-26.3), candidiasis (HR 3.8; 95% CI, 2.0-7.6), herpes zoster (HR 3.7; 95% CI, 1.8-7.5), sepsis (HR 1.6; 95% CI, 1.2-2.1), and cervical dysplasia (HR 1.8; 95% CI, 1.1-3.0).

CONCLUSIONS

Treatment with steroids, ISs, or anti-TNF agents singly and in combination in patients with CD is associated with increased risks of infection, demyelinating disorders, and cervical dysplasia.

Validity of physician-reported hospitalized infections in a US arthritis registry

OBJECTIVE

In safety studies, events reported as infections may be misclassified and, therefore, affect the validity of estimated risks associated with biologic agents. Using data from the Consortium of Rheumatology Researchers of North America (CORRONA), we evaluated hospitalized infection reports contributed by rheumatologists to establish their validity.

METHODS

All patients hospitalized with infections from 2002 to 2007 reported to CORRONA were examined and compared with information from hospital discharge summaries and other confirmatory data. Infectious episodes were classified by two physicians as confirmed, empirically treated, possible or unlikely.

RESULTS

Of 562 reported hospitalized infectious episodes, 9% were classified as unlikely and had minimal or no supporting evidence for infection, leaving 509 hospitalized infectious episodes. Of these, 53% of the infectious episodes were classified as confirmed, 15% empirically treated and 32% possible. The confirmation status of infectious episodes for younger or biologic-exposed participants was similar to older and biologic-unexposed participants.

CONCLUSION

More than two-thirds of hospitalized infections reported by rheumatologists were confirmed or had evidence that the physician was treating an infection. In almost all cases, there was at least modest evidence for an infection. Future studies should consider case definitions for infections or sensitivity analyses, or both, regarding the certainty of an infection to account for possible misclassification and reduce bias.

Computerized definitions showed high positive predictive values for identifying hospitalizations for congestive heart failure and selected infections in Medicaid enrollees with rheumatoid arthritis

PURPOSE

Computerized definitions are used to identify serious infections and congestive heart failure leading to hospitalizations in studies of medication safety. However, information on their accuracy is limited. We evaluated the ability of computerized definitions to identify these conditions as the reason for admission among patients diagnosed with rheumatoid arthritis (RA).

METHODS

Medical charts were randomly selected from a systematic sample of hospitalizations for selected conditions in a cohort of Medicaid patients with RA. We calculated positive predictive values (PPVs) for computerized definitions for community-acquired pneumonia, invasive pneumococcal disease, sepsis, opportunistic mycoses, and congestive heart failure using charts reviews as gold standard and computed inter-reviewer agreement statistics.

RESULTS

From 2667 hospitalizations, 336 (13%) records were selected for review. A total of 277 charts (82%) were available. Based on any discharge diagnosis, PPVs for hospitalizations due to community-acquired pneumonia, invasive pneumococcal disease, sepsis, and opportunistic mycoses were 84, 100, 80, and 62%, respectively. Restricting definitions to principal diagnoses yielded higher PPVs, 95% for pneumonia and 100% for other diagnoses. The PPV of a principal diagnosis for congestive heart failure was 100%. Inter-reviewer agreement was at least 77% for all outcomes.

CONCLUSION

These findings suggest that computerized definitions can identify congestive heart failure and selected infections leading to hospitalization in Medicaid patients with RA.