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Yetmar ZA, Khodadadi RB, Chesdachai S, McHugh JW, Challener DW, Wengenack NL, Bosch W, Seville MT, Beam E. Epidemiology, Timing, and Secondary Prophylaxis of Recurrent Nocardiosis. Open Forum Infect Dis 2024; 11:ofae122. [PMID: 38560606 PMCID: PMC10977627 DOI: 10.1093/ofid/ofae122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Background Nocardia tends to cause infection in immunocompromised patients or those with chronic pulmonary disease. Nocardia is known to recur, prompting the practice of secondary prophylaxis in patients perceived at high risk. However, few data exist regarding the epidemiology of recurrent nocardiosis or the effectiveness of secondary prophylaxis. Methods We performed a multicenter, retrospective cohort study of adults diagnosed with nocardiosis from November 2011 to April 2022, including patients who completed primary treatment and had at least 30 days of posttreatment follow-up. Propensity score matching was used to analyze the effect of secondary prophylaxis on Nocardia recurrence. Results Fifteen of 303 (5.0%) patients developed recurrent nocardiosis after primary treatment. Most recurrences were diagnosed either within 60 days (N = 6/15, 40.0%) or between 2 to 3 years (N = 4/15, 26.7%). Patients with primary disseminated infection tended to recur within 1 year, whereas later recurrences were often nondisseminated pulmonary infection. Seventy-eight (25.7%) patients were prescribed secondary prophylaxis, mostly trimethoprim-sulfamethoxazole (N = 67/78). After propensity-matching, secondary prophylaxis was not associated with reduced risk of recurrence (hazard ratio, 0.96; 95% confidence interval, .24-3.83), including in multiple subgroups. Eight (53.3%) patients with recurrent nocardiosis required hospitalization and no patients died from recurrent infection. Conclusions Recurrent nocardiosis tends to occur either within months because of the same Nocardia species or after several years with a new species. Although we did not find evidence for the effectiveness of secondary prophylaxis, the confidence intervals were wide. However, outcomes of recurrent nocardiosis are generally favorable and may not justify long-term antibiotic prophylaxis for this indication alone.
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Affiliation(s)
- Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ryan B Khodadadi
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack W McHugh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas W Challener
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nancy L Wengenack
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Elena Beam
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Dong YH, Wang JL, Chang CH, Lin JW, Chen YA, Chen CY, Toh S. Association Between Use of Fluoroquinolones and Risk of Mitral or Aortic Valve Regurgitation: A Nationwide Cohort Study. Clin Pharmacol Ther 2024; 115:147-157. [PMID: 37926942 DOI: 10.1002/cpt.3084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Abstract
Biological plausibility suggests that fluoroquinolones may lead to mitral valve regurgitation or aortic valve regurgitation (MR/AR) through a collagen degradation pathway. However, available real-world studies were limited and yielded inconsistent findings. We estimated the risk of MR/AR associated with fluoroquinolones compared with other antibiotics with similar indications in a population-based cohort study. We identified adult patients who initiated fluoroquinolones or comparison antibiotics from the nationwide Taiwanese claims database. Patients were followed for up to 60 days after cohort entry. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of MR/AR comparing fluoroquinolones to comparison antibiotics after 1:1 propensity score (PS) matching. All analyses were conducted by type of fluoroquinolone (fluoroquinolones as a class, respiratory fluoroquinolones, and non-respiratory fluoroquinolones) and comparison antibiotic (amoxicillin/clavulanate or ampicillin/sulbactam, extended-spectrum cephalosporins). Among 6,649,284 eligible patients, the crude incidence rates of MR/AR ranged from 1.44 to 4.99 per 1,000 person-years across different types of fluoroquinolones and comparison antibiotics. However, fluoroquinolone use was not associated with an increased risk in each pairwise PS-matched comparison. HRs were 1.00 (95% CI, 0.89-1.11) for fluoroquinolones as a class, 0.96 (95% CI, 0.83-1.12) for respiratory fluoroquinolones, and 0.87 (95% CI, 0.75-1.01) for non-respiratory fluoroquinolones, compared with amoxicillin/clavulanate or ampicillin/sulbactam. Results were similar when fluoroquinolones were compared with extended-spectrum cephalosporins (HRs of 0.96, 95% CI, 0.82-1.12, HR, 1.05, 95% CI, 0.86-1.28, and HR, 0.88, 95% CI, 0.75-1.03, respectively). This large-scale cohort study did not find a higher risk of MR/AR with different types of fluoroquinolones in the adult population.
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Affiliation(s)
- Yaa-Hui Dong
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiun-Ling Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Jou-Wei Lin
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Douliou City, Yunlin County, Taiwan
- Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Douliou City, Yunlin County, Taiwan
| | - Yu-An Chen
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Yu Chen
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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Htoo PT, Glynn RJ, Wang S, Paik JM, Schneeweiss S, Walker AM, Patorno E. Stratified analysis in comparative effectiveness studies that emulate randomized trials. Pharmacoepidemiol Drug Saf 2024; 33:e5716. [PMID: 37876341 DOI: 10.1002/pds.5716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE For observational cohort studies that employ matching by propensity scores (PS), preliminary stratification by consequential predictors of outcome better emulates stratified randomization and potentially reduces variance and bias through relaxed dependence on modeling assumptions. We assessed the impact of pre-stratification in two real-life examples. For both, prior evidence from placebo-controlled randomized clinical trials (RCTs) suggested small or no risk reduction, but observational analysis suggested protection, presumably the result of confounding bias. STUDY DESIGN AND SETTING The study populations consisted of Medicare beneficiaries (2014-18) with type 2 diabetes initiating either (i) empagliflozin versus dipeptidyl peptidase-4 inhibitors (DPP-4i) or (ii) empagliflozin versus glucagon-like peptide-1 receptor agonists (GLP-1RA). The outcome was myocardial infarction or stroke. We estimated hazard ratios (HR) and rate differences (RD) after controlling for 143 pre-exposure covariates via 1:1 PS matching after (1) PS estimation in the total cohort (total-cohort PS-matching) and (2) PS estimation separately by baseline cardiovascular disease (stratified PS matching). RESULTS Stratified PS matching resulted in HRs that exceeded those from total-cohort PS-matching by 13% and 9%, respectively, for the comparisons of empagliflozin to DPP-4i and GLP-1RA. Against both comparators, HRs and RDs after stratified PS matching were closer to the null, with slightly higher variances (2%-3%) than those after total-cohort PS matching. CONCLUSION Stratified PS matching produced effect estimates closer to the expected trial findings than total-cohort PS matching. The price paid in increased variance was minimal.
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Affiliation(s)
- Phyo T Htoo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shirley Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander M Walker
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Chatelet F, Verillaud B, Chevret S. How to perform prespecified subgroup analyses when using propensity score methods in the case of imbalanced subgroups. BMC Med Res Methodol 2023; 23:255. [PMID: 37907863 PMCID: PMC10617117 DOI: 10.1186/s12874-023-02071-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Looking for treatment-by-subset interaction on a right-censored outcome based on observational data using propensity-score (PS) modeling is of interest. However, there are still issues regarding its implementation, notably when the subsets are very imbalanced in terms of prognostic features and treatment prevalence. METHODS We conducted a simulation study to compare two main PS estimation strategies, performed either once on the whole sample ("across subset") or in each subset separately ("within subsets"). Several PS models and estimands are also investigated. We then illustrated those approaches on the motivating example, namely, evaluating the benefits of facial nerve resection in patients with parotid cancer in contact with the nerve, according to pretreatment facial palsy. RESULTS Our simulation study demonstrated that both strategies provide close results in terms of bias and variance of the estimated treatment effect, with a slight advantage for the "across subsets" strategy in very small samples, provided that interaction terms between the subset variable and other covariates influencing the choice of treatment are incorporated. PS matching without replacement resulted in biased estimates and should be avoided in the case of very imbalanced subsets. CONCLUSIONS When assessing heterogeneity in the treatment effect in small samples, the "across subsets" strategy of PS estimation is preferred. Then, either a PS matching with replacement or a weighting method must be used to estimate the average treatment effect in the treated or in the overlap population. In contrast, PS matching without replacement should be avoided in this setting.
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Affiliation(s)
- Florian Chatelet
- ECSTRRA Team, INSERM U1153, Université Paris Cité, 1 avenue Claude Vellefaux, 75010, Paris, France.
- ENT and head and neck surgery department, Lariboisiere hospital, 2 rue Ambroise Paré, 75010, Paris, France.
| | - Benjamin Verillaud
- ENT and head and neck surgery department, Lariboisiere hospital, 2 rue Ambroise Paré, 75010, Paris, France
- INSERM U1141 "NeuroDiderot", Université Paris Cité, 75010, Paris, France
| | - Sylvie Chevret
- ECSTRRA Team, INSERM U1153, Université Paris Cité, 1 avenue Claude Vellefaux, 75010, Paris, France
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Chen CY, Pan SW, Hsu CC, Liu JJ, Kumamaru H, Dong YH. Comparative cardiovascular safety of LABA/LAMA FDC versus LABA/ICS FDC in patients with chronic obstructive pulmonary disease: a population-based cohort study with a target trial emulation framework. Respir Res 2023; 24:239. [PMID: 37775734 PMCID: PMC10543303 DOI: 10.1186/s12931-023-02545-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/21/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Use of combinations of long-acting β2 agonists/long-acting muscarinic antagonists (LABA/LAMA) in patients with chronic obstructive pulmonary disease (COPD) is increasing. Nevertheless, existing evidence on cardiovascular risk associated with LABA/LAMA versus another dual combination, LABA/inhaled corticosteroids (ICS), was limited and discrepant. AIM The present cohort study aimed to examine comparative cardiovascular safety of LABA/LAMA and LABA/ICS with a target trial emulation framework, focusing on dual fixed-dose combination (FDC) therapies. METHODS We identified patients with COPD who initiated LABA/LAMA FDC or LABA/ICS FDC from a nationwide Taiwanese database during 2017-2020. The outcome of interest was a hospitalized composite cardiovascular events of acute myocardial infarction, unstable angina, heart failure, cardiac dysrhythmia, and ischemic stroke. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for composite and individual cardiovascular events after matching up to five LABA/LAMA FDC initiators to one LABA/ICS FDC initiator using propensity scores (PS). RESULTS Among 75,926 PS-matched patients, use of LABA/LAMA FDC did not show a higher cardiovascular risk compared to use of LABA/ICS FDC, with a HR of 0.89 (95% CI, 0.78-1.01) for the composite events, 0.80 (95% CI, 0.61-1.05) for acute myocardial infarction, 1.48 (95% CI, 0.68-3.25) for unstable angina, 1.00 (95% CI, 0.80-1.24) for congestive heart failure, 0.62 (95% CI, 0.37-1.05) for cardiac dysrhythmia, and 0.82 (95% CI, 0.66-1.02) for ischemic stroke. The results did not vary substantially in several pre-specified sensitivity and subgroup analyses. CONCLUSION Our findings provide important reassurance about comparative cardiovascular safety of LABA/LAMA FDC treatment among patients with COPD.
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Affiliation(s)
- Chun-Yu Chen
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sheng-Wei Pan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chen Hsu
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jason J Liu
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yaa-Hui Dong
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Kranzler HR, Leong SH, Naps M, Hartwell EE, Fiellin DA, Rentsch CT. Association of topiramate prescribed for any indication with reduced alcohol consumption in electronic health record data. Addiction 2022; 117:2826-2836. [PMID: 35768956 PMCID: PMC10317468 DOI: 10.1111/add.15980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 06/02/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Topiramate is a medication that is widely prescribed to treat a variety of conditions, including alcohol use disorder (AUD). We used electronic health record (EHR) data to measure topiramate's effects on drinking in individuals differentiated by a history of AUD. DESIGN Parallel-groups comparison of patients prescribed topiramate and a propensity score-matched comparison group. SETTING A large US integrated health-care system. PARTICIPANTS Patients with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scores prior to and after a minimum of 180 days of topiramate prescription for any indication and a propensity score-matched group. The sample included 5918 patients with an electronic health record diagnosis of alcohol use disorder at any time (AUD-hx-pos) (1738 topiramate-exposed and 4180 controls) and 23 614 patients with no EHR diagnosis of AUD (AUD-hx-neg) (6324 topiramate-exposed and 17 290 controls). MEASUREMENTS Regression analyses compared difference-in-difference (DiD) estimates, separately by AUD history. DiD estimates represent exposure-group (i.e. topiramate versus control) differences on the pre-post difference in AUDIT-C score. Effects of baseline AUDIT-C score and daily topiramate dosage were also tested. FINDINGS AUD-hx-neg patients who received topiramate had a greater reduction in AUDIT-C score (-0.11) than matched controls (-0.04). This yielded a DiD score of -0.07 [95% confidence interval (CI) = -0.11,-0.03; P = 0.002], with the greatest effect among AUD-hx-neg patients with a baseline AUDIT-C score of 4+ (DiD = -0.35, 95% CI = -0.49, -0.21; P < 0.0001) and those prescribed > 150 mg/day of the medication (DiD = -0.15, 95%CI = -0.23, -0.07; P < 0.001). DISCUSSION Among individuals with no history of alcohol use disorder, topiramate appears to be associated with reduced drinking. This small effect is most evident among patients with higher baseline drinking levels and at a higher average daily topiramate dosage.
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Affiliation(s)
- Henry R. Kranzler
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104
| | - Shirley H. Leong
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104
| | - Michelle Naps
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104
| | - Emily E. Hartwell
- Mental Illness Research, Education and Clinical Center, Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104
| | - David A. Fiellin
- Department of Medicine, Yale School of Medicine, New Haven, CT 06510
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT 06510
| | - Christopher T. Rentsch
- Department of Medicine, Yale School of Medicine, New Haven, CT 06510
- CT VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven, CT 06516
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
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Simoneau G, Pellegrini F, Debray TPA, Rouette J, Muñoz J, Platt RW, Petkau J, Bohn J, Shen C, de Moor C, Karim ME. Recommendations for the use of propensity score methods in multiple sclerosis research. Mult Scler 2022; 28:1467-1480. [PMID: 35387508 PMCID: PMC9260471 DOI: 10.1177/13524585221085733] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/03/2022] [Accepted: 02/17/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND With many disease-modifying therapies currently approved for the management of multiple sclerosis, there is a growing need to evaluate the comparative effectiveness and safety of those therapies from real-world data sources. Propensity score methods have recently gained popularity in multiple sclerosis research to generate real-world evidence. Recent evidence suggests, however, that the conduct and reporting of propensity score analyses are often suboptimal in multiple sclerosis studies. OBJECTIVES To provide practical guidance to clinicians and researchers on the use of propensity score methods within the context of multiple sclerosis research. METHODS We summarize recommendations on the use of propensity score matching and weighting based on the current methodological literature, and provide examples of good practice. RESULTS Step-by-step recommendations are presented, starting with covariate selection and propensity score estimation, followed by guidance on the assessment of covariate balance and implementation of propensity score matching and weighting. Finally, we focus on treatment effect estimation and sensitivity analyses. CONCLUSION This comprehensive set of recommendations highlights key elements that require careful attention when using propensity score methods.
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Affiliation(s)
| | | | | | - Julie Rouette
- Department of Epidemiology, Biostatistics and
Occupational Health, McGill University, Montreal, QC, Canada/Centre for
Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital,
Montreal, QC, Canada
| | - Johanna Muñoz
- University Medical Center Utrecht, Utretch, The
Netherlands
| | - Robert W. Platt
- Department of Pediatrics, McGill University,
Montreal, QC, Canada/Department of Epidemiology, Biostatistics and
Occupational Health, McGill University, Montreal, QC, Canada/Centre for
Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital,
Montreal, QC, Canada
| | - John Petkau
- Department of Statistics, The University of
British Columbia, Vancouver, BC, Canada
| | | | | | | | - Mohammad Ehsanul Karim
- School of Population and Public Health, The
University of British Columbia, Vancouver, BC, Canada/Centre for Health
Evaluation and Outcome Sciences, The University of British Columbia,
Vancouver, BC, Canada
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Dong YH, Chang CH, Lin JW, Yang WS, Wu LC, Toh S. Comparative cardiovascular effectiveness of glucagon-like peptide-1 receptor agonists versus sodium-glucose cotransporter-2 inhibitors in patients with type 2 diabetes: A population-based cohort study. Diabetes Obes Metab 2022; 24:1623-1637. [PMID: 35491533 DOI: 10.1111/dom.14741] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 04/15/2022] [Accepted: 04/28/2022] [Indexed: 12/12/2022]
Abstract
AIMS To examine the comparative effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors for select cardiovascular outcomes and to examine whether the relative risks varied across different patient subgroups in patients with type 2 diabetes. MATERIALS AND METHODS We conducted a nationwide cohort study of patients with type 2 diabetes who initiated GLP-1RAs or SGLT2 inhibitors between 2012 and 2018 in Taiwan. The study outcomes included myocardial infarction and total stroke, further classified into ischaemic or haemorrhagic stroke. We estimated the hazard ratios (HRs) and 95% confidence intervals (CIs) for each outcome, comparing GLP-1RAs with SGLT2 inhibitors using Cox proportional hazards models after 1:1 propensity-score (PS) matching. We also examined if there was effect modification by age, underlying chronic kidney disease, or coexisting cardiovascular disease in prespecified subgroup analyses. RESULTS Among 26 032 PS-matched patients, GLP-1RA initiators and SGLT2 inhibitor initiators showed similar risks of myocardial infarction (HR 0.99, 95% CI 0.65-1.52), total stroke (HR 0.90, 95% CI 0.69-1.17), ischaemic stroke (HR 0.86, 95% CI 0.65-1.14) and haemorrhagic stroke (HR 0.88, 95% CI 0.63-1.25). However, GLP-1RA treatment was associated with an increased risk of total stroke (HR 1.76, 95% CI 1.06-2.94) and ischaemic stroke (HR 1.88, 95% CI 1.09-3.23) among patients with chronic kidney disease, but not among patients without chronic kidney disease. GLP-1RA therapy seemed to have a lower risk of haemorrhagic stroke among patients with cardiovascular disease (HR 0.64, 95% CI 0.43-0.97), but not in patients without cardiovascular disease. CONCLUSIONS Glucagon-like peptide-1 receptor agonists and SGLT2 inhibitors appeared to have comparable effectiveness with regard to several cardiovascular outcomes overall, but their comparative effectiveness may vary in certain patient subgroups.
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Affiliation(s)
- Yaa-Hui Dong
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Jou-Wei Lin
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Douliou City, Taiwan
- Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Douliou City, Taiwan
| | - Wei-Shun Yang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
- The Graduate Institute of Medical Genomics and Proteomics, National Taiwan University, Taipei, Taiwan
| | - Li-Chiu Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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Abstract
Randomized controlled trials (RCTs) are the gold standard design to establish the efficacy of new drugs and to support regulatory decision making. However, a marked increase in the submission of single-arm trials (SATs) has been observed in recent years, especially in the field of oncology due to the trend towards precision medicine contributing to the rise of new therapeutic interventions for rare diseases. SATs lack results for control patients, and information from external sources can be compiled to provide context for better interpretability of study results. External comparator arm (ECA) studies are defined as a clinical trial (most commonly a SAT) and an ECA of a comparable cohort of patients-commonly derived from real-world settings including registries, natural history studies, or medical records of routine care. This publication aims to provide a methodological overview, to sketch emergent best practice recommendations and to identify future methodological research topics. Specifically, existing scientific and regulatory guidance for ECA studies is reviewed and appropriate causal inference methods are discussed. Further topics include sample size considerations, use of estimands, handling of different data sources regarding differential baseline covariate definitions, differential endpoint measurements and timings. In addition, unique features of ECA studies are highlighted, specifically the opportunity to address bias caused by unmeasured ECA covariates, which are available in the SAT.
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10
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Dong YH, Wu JH, Chang CH, Lin JW, Wu LC, Toh S. Association between glucagon-like peptide-1 receptor agonists and biliary-related diseases in patients with type 2 diabetes: A nationwide cohort study. Pharmacotherapy 2022; 42:483-494. [PMID: 35508702 DOI: 10.1002/phar.2688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE Clinical trials have suggested that glucagon-like peptide-1 receptor agonists (GLP-1RAs) may be associated with a higher risk of biliary-related diseases in patients with type 2 diabetes. Limited real-world studies have examined the comparative biliary safety of GLP-1RAs versus other antihyperglycemic drugs. We aimed to estimate the comparative risk of biliary-related diseases between GLP-1RAs and sodium glucose cotransporter 2 inhibitors (SGLT2is), which are indicated for patients with similar diabetes severity in Taiwan. DESIGN Retrospective cohort study. DATA SOURCE Taiwan National Health Insurance Database during 2011 to 2018. PATIENTS Patients with type 2 diabetes who initiated GLP-1RAs or SGLT2is. INTERVENTION GLP-1RAs versus SGLT2is. MEASUREMENTS AND MAIN RESULTS We used an on-treatment approach to examine the effect of continuous use and an intention-to-treat approach to assess the effect of initiation of GLP-1RAs versus SGLT2is. We used Coxregression models to estimate the hazard ratios (HRs) and 95% confidenceintervals (CIs) for the composite hospitalized biliary-related diseases, including acute cholecystitis or cholecystectomy, choledocholithiasis, and acute cholangitis, after matching each GLP-1RA initiator to up to 10 SGLT2iinitiators using propensity scores (PSs). Among 78,253 PS-matched patients, GLP-1RA use was associated with a numerically higher risk of biliary-related diseases versus SGLT2i use in the on-treatment analysis, with an HR of 1.20 (95% CI, 0.93-1.56) for the composite outcome, an HR of 1.22 (95% CI, 0.92-1.62) for acute cholecystitis or cholecystectomy, an HR of 1.20 (95% CI, 0.69-2.07) for choledocholithiasis, and an HR of 1.14 (95% CI,0.82-2.42) for acute cholangitis. The HRs were more pronounced in theintention-to-treat analysis (1.27 [95% CI, 1.05-1.53] for the composite outcome, 1.29 [95% CI, 1.04-1.58] foracute cholecystitis or cholecystectomy, 1.74 [95% CI, 1.23-2.46] for choledocholithiasis, and 1.31 [95% CI, 0.89-1.94] for acute cholangitis). The increased risk of the composite outcome associated with GLP-1RAs was more evident in patients aged 〉60 years, women, and 120 days after treatment initiation. Liraglutide, but not dulaglutide, was associated with an elevated risk. CONCLUSIONS GLP-1RAs might be associated with an elevated risk of biliary-related diseases compared to SGLT2is in Asian patients with type 2 diabetes.
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Affiliation(s)
- Yaa-Hui Dong
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Hsuan Wu
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, Hamilton Glaucoma Center, University of California, San Diego, California, USA
| | - Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Jou-Wei Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Douliou City, Taiwan.,Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Douliou City, Taiwan
| | - Li-Chiu Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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11
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Zhao Y, Yu Y, Wang H, Li Y, Deng Y, Jiang G, Luo Y. Machine Learning in Causal Inference: Application in Pharmacovigilance. Drug Saf 2022; 45:459-476. [PMID: 35579811 PMCID: PMC9114053 DOI: 10.1007/s40264-022-01155-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 01/28/2023]
Abstract
Monitoring adverse drug events or pharmacovigilance has been promoted by the World Health Organization to assure the safety of medicines through a timely and reliable information exchange regarding drug safety issues. We aim to discuss the application of machine learning methods as well as causal inference paradigms in pharmacovigilance. We first reviewed data sources for pharmacovigilance. Then, we examined traditional causal inference paradigms, their applications in pharmacovigilance, and how machine learning methods and causal inference paradigms were integrated to enhance the performance of traditional causal inference paradigms. Finally, we summarized issues with currently mainstream correlation-based machine learning models and how the machine learning community has tried to address these issues by incorporating causal inference paradigms. Our literature search revealed that most existing data sources and tasks for pharmacovigilance were not designed for causal inference. Additionally, pharmacovigilance was lagging in adopting machine learning-causal inference integrated models. We highlight several currently trending directions or gaps to integrate causal inference with machine learning in pharmacovigilance research. Finally, our literature search revealed that the adoption of causal paradigms can mitigate known issues with machine learning models. We foresee that the pharmacovigilance domain can benefit from the progress in the machine learning field.
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Affiliation(s)
- Yiqing Zhao
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, Room 11-189, Chicago, IL, 60611, USA
| | - Yue Yu
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, 55902, USA
| | - Hanyin Wang
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, Room 11-189, Chicago, IL, 60611, USA
| | - Yikuan Li
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, Room 11-189, Chicago, IL, 60611, USA
| | - Yu Deng
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, Room 11-189, Chicago, IL, 60611, USA
| | - Guoqian Jiang
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, 55902, USA
| | - Yuan Luo
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, Room 11-189, Chicago, IL, 60611, USA.
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12
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Marsden AM, Dixon WG, Dunn G, Emsley R. The impact of moderator by confounder interactions in the assessment of treatment effect modification: a simulation study. BMC Med Res Methodol 2022; 22:88. [PMID: 35369866 PMCID: PMC8978434 DOI: 10.1186/s12874-022-01519-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/11/2022] [Indexed: 12/22/2022] Open
Abstract
Background When performed in an observational setting, treatment effect modification analyses should account for all confounding, where possible. Often, such studies only consider confounding between the exposure and outcome. However, there is scope for misspecification of the confounding adjustment when estimating moderation as the effects of the confounders may themselves be influenced by the moderator. The aim of this study was to investigate bias in estimates of treatment effect modification resulting from failure to account for an interaction between a binary moderator and a confounder on either treatment receipt or the outcome, and to assess the performance of different approaches to account for such interactions. Methods The theory behind the reason for bias and factors that impact the magnitude of bias is explained. Monte Carlo simulations were used to assess the performance of different propensity scores adjustment methods and regression adjustment where the adjustment 1) did not account for any moderator-confounder interactions, 2) included moderator-confounder interactions, and 3) was estimated separately in each moderator subgroup. A real-world observational dataset was used to demonstrate this issue. Results Regression adjustment and propensity score covariate adjustment were sensitive to the presence of moderator-confounder interactions on outcome, whilst propensity score weighting and matching were more sensitive to the presence of moderator-confounder interactions on treatment receipt. Including the relevant moderator-confounder interactions in the propensity score (for methods using this) or the outcome model (for regression adjustment) rectified this for all methods except propensity score covariate adjustment. For the latter, subgroup-specific propensity scores were required. Analysis of the real-world dataset showed that accounting for a moderator-confounder interaction can change the estimate of effect modification. Conclusions When estimating treatment effect modification whilst adjusting for confounders, moderator-confounder interactions on outcome or treatment receipt should be accounted for. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01519-7.
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13
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Htoo PT, Measer G, Orr R, Bohn J, Sorbello A, Francis H, Dutcher SK, Cosgrove A, Carruth A, Toh S, Cocoros NM. Evaluating Confounding Control in Estimations of Influenza Antiviral Effectiveness in Electronic Health Plan Data. Am J Epidemiol 2022; 191:908-920. [PMID: 35106530 DOI: 10.1093/aje/kwac020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 01/17/2022] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Observational studies of oseltamivir use and influenza complications could suffer from residual confounding. Using negative control risk periods and a negative control outcome, we examined confounding control in a health-insurance-claims-based study of oseltamivir and influenza complications (pneumonia, all-cause hospitalization, and dispensing of an antibiotic). Within the Food and Drug Administration's Sentinel System, we identified individuals aged ≥18 years who initiated oseltamivir use on the influenza diagnosis date versus those who did not, during 3 influenza seasons (2014-2017). We evaluated primary outcomes within the following 1-30 days (the primary risk period) and 61-90 days (the negative control period) and nonvertebral fractures (the negative control outcome) within days 1-30. We estimated propensity-score-matched risk ratios (RRs) per season. During the 2014-2015 influenza season, oseltamivir use was associated with a reduction in the risk of pneumonia (RR = 0.72, 95% confidence interval (CI): 0.70, 0.75) and all-cause hospitalization (RR = 0.54, 95% CI: 0.53, 0.55) in days 1-30. During days 61-90, estimates were near-null for pneumonia (RR = 1.04, 95% CI: 0.95, 1.15) and hospitalization (RR = 0.94, 95% CI: 0.91, 0.98) but slightly increased for antibiotic dispensing (RR = 1.14, 95% CI: 1.08, 1.21). The RR for fractures was near-null (RR = 1.09, 95% CI: 0.99, 1.20). Estimates for the 2016-2017 influenza season were comparable, while the 2015-2016 season had conflicting results. Our study suggests minimal residual confounding for specific outcomes, but results differed by season.
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14
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Sun SH, Chang CH, Zhan ZW, Chang WH, Chen YA, Dong YH. Risk of COPD Exacerbations Associated with Statins versus Fibrates: A New User, Active Comparison, and High-Dimensional Propensity Score Matched Cohort Study. Int J Chron Obstruct Pulmon Dis 2021; 16:2721-2733. [PMID: 34621122 PMCID: PMC8491865 DOI: 10.2147/copd.s323391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/03/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Several observational studies have found that statins may materially decrease the risk of chronic obstructive pulmonary disease (COPD) exacerbations. However, most of these studies used a prevalent user, non-user comparison approach, which may lead to overestimation of the clinical benefits of statins. We aimed to explore the risk of COPD exacerbations associated with statins with a new user, active comparison approach to address potential methodological concerns. We selected fibrates, another class of lipid-lowering agents, as the reference group because no evidence suggests that fibrates have an effect on COPD exacerbations. METHODS We identified patients with COPD who initiated statins or fibrates from a nationwide Taiwanese database. Patients were followed from cohort entry to the earliest of the following: hospitalization for COPD exacerbations, death, end of the data, or 180 days after cohort entry. Stratified Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of COPD exacerbations comparing statins with fibrates after variable-ratio propensity score (PS) matching and high-dimensional PS (hd-PS) matching, respectively. RESULTS We identified a total of 134,909 eligible patients (110,726 initiated statins; 24,183 initiated fibrates); 1979 experienced COPD exacerbations during follow-up. The HRs were 1.10 (95% CI, 0.96 to 1.26) after PS matching and 1.08 (95% CI, 0.94 to 1.24) after hd-PS matching. The results did not differ materially by type of statins and patient characteristic and did not change with longer follow-up durations. CONCLUSION This large-scale, population-based cohort study did not show that use of statins was associated with a reduced risk of acute exacerbations in patients with COPD using state-of-the-art pharmacoepidemiologic approaches. The findings emphasize the importance of applying appropriate methodology in exploring statin effectiveness in real-world settings.
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Affiliation(s)
- Shu-Hui Sun
- Department of Pharmacy, Far Eastern Memorial Hospital, Banciao, New Taipei City, Taiwan
| | - Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Zhe-Wei Zhan
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Hsuan Chang
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-An Chen
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yaa-Hui Dong
- Department of Pharmacy, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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15
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Robertson SE, Leith A, Schmid CH, Dahabreh IJ. Assessing Heterogeneity of Treatment Effects in Observational Studies. Am J Epidemiol 2021; 190:1088-1100. [PMID: 33083822 DOI: 10.1093/aje/kwaa235] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 01/21/2023] Open
Abstract
Here we describe methods for assessing heterogeneity of treatment effects over prespecified subgroups in observational studies, using outcome-model-based (g-formula), inverse probability weighting, doubly robust, and matching estimators of subgroup-specific potential outcome means, conditional average treatment effects, and measures of heterogeneity of treatment effects. We compare the finite-sample performance of different estimators in simulation studies where we vary the total sample size, the relative frequency of each subgroup, the magnitude of treatment effect in each subgroup, and the distribution of baseline covariates, for both continuous and binary outcomes. We find that the estimators' bias and variance vary substantially in finite samples, even when there is no unobserved confounding and no model misspecification. As an illustration, we apply the methods to data from the Coronary Artery Surgery Study (August 1975-December 1996) to compare the effect of surgery plus medical therapy with that of medical therapy alone for chronic coronary artery disease in subgroups defined by previous myocardial infarction or left ventricular ejection fraction.
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16
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Schneeweiss S, Carver PL, Datta K, Galar A, Johnson MD, Letourneau AR, Marty FM, Nagel J, Najdzinowicz M, Saul M, Schuster M, Shoham S, Silveira FP, Varughese C, Wilck M, Weatherby L, Oene JV, Walker AM. Long-term risk of hepatocellular carcinoma mortality in 23220 hospitalized patients treated with micafungin or other parenteral antifungals. J Antimicrob Chemother 2021; 75:221-228. [PMID: 31580432 DOI: 10.1093/jac/dkz396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/06/2019] [Accepted: 08/13/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Liver tumours observed in rats exposed to micafungin led to a black box warning upon approval in Europe in 2008. Micafungin's risk for liver carcinogenicity in humans has not been investigated. We sought to describe the risk of fatal hepatocellular carcinoma (HCC) among persons who received micafungin and other parenteral antifungals (PAFs) with up to 12 years of follow-up. METHODS We assembled a US multicentre cohort of hospitalized patients who received micafungin or other PAFs between 2005 and 2012. We used propensity score (PS) matching on patient characteristics from electronic medical records to compare rates of HCC mortality identified through the National Death Index though to the end of December 2016. We computed HRs and 95% CIs. RESULTS A total of 40110 patients who received a PAF were identified; 6903 micafungin recipients (87% of those identified) were successfully matched to 16317 comparator PAF users. Ten incident HCC deaths, one in the micafungin-exposed group and nine among comparator PAF users, occurred in 71285 person-years of follow-up. The HCC mortality rate was 0.05 per 1000 person-years in micafungin patients and 0.17 per 1000 person-years in comparator PAF patients. The PS-matched HR for micafungin versus comparator PAF was 0.29 (95% CI 0.04-2.24). CONCLUSIONS Both micafungin and comparator PAFs were associated with HCC mortality rates of <0.2 per 1000 person-years. Given the very low event rates, any potential risk for HCC should not play a role in clinical decisions regarding treatment with micafungin or other PAFs investigated in this study.
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Affiliation(s)
- Sebastian Schneeweiss
- WHISCON, Dedham, MA, USA.,Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Peggy L Carver
- University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Kausik Datta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alicia Galar
- Division of Infectious Diseases, Department of Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Melissa D Johnson
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Alyssa R Letourneau
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA
| | - Francisco M Marty
- Division of Infectious Diseases, Department of Medicine, Brigham & Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Jerod Nagel
- University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Maryann Najdzinowicz
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa Saul
- Division of Infectious Diseases, University of Pittsburgh, and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mindy Schuster
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fernanda P Silveira
- Division of Infectious Diseases, University of Pittsburgh, and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christy Varughese
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA
| | - Marissa Wilck
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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17
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Eworuke E, Haug N, Bradley M, Cosgrove A, Zhang T, Dee EC, Adimadhyam S, Petrone A, Lee H, Woodworth T, Toh S. Risk of Nonmelanoma Skin Cancer in Association With Use of Hydrochlorothiazide-Containing Products in the United States. JNCI Cancer Spectr 2021; 5:pkab009. [PMID: 33733052 PMCID: PMC7947823 DOI: 10.1093/jncics/pkab009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/16/2020] [Accepted: 01/28/2021] [Indexed: 12/31/2022] Open
Abstract
Background European studies reported an increased risk of nonmelanoma skin cancer associated with hydrochlorothiazide (HCTZ)-containing products. We examined the risks of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) associated with HCTZ compared with angiotensin-converting enzyme inhibitors (ACEIs) in a US population. Methods We conducted a retrospective cohort study in the US Food and Drug Administration's Sentinel System. From the date of HCTZ or ACEI dispensing, patients were followed until a SCC or BCC diagnosis requiring excision or topical chemotherapy treatment on or within 30 days after the diagnosis date or a censoring event. Using Cox proportional hazards regression models, we estimated the hazard ratios (HRs), overall and separately by age, sex, and race. We also examined site- and age-adjusted incidence rate ratios (IRRs) by cumulative HCTZ dose within the matched cohort. Results Among 5.2 million propensity-score matched HCTZ and ACEI users, the incidence rate (per 1000 person-years) of BCC was 2.78 and 2.82, respectively, and 1.66 and 1.60 for SCC. Overall, there was no difference in risk between HCTZ and ACEIs for BCC (HR = 0.99, 95% confidence interval [CI] = 0.97 to 1.00), but there was an increased risk for SCC (HR = 1.04, 95% CI = 1.02 to 1.06). HCTZ use was associated with higher risks of BCC (HR = 1.09, 95% CI = 1.07 to 1.11) and SCC (HR = 1.15, 95% CI = 1.12 to 1.17) among Caucasians. Cumulative HCTZ dose of 50 000 mg or more was associated with an increased risk of SCC in the overall population (IRR = 1.19, 95% CI = 1.05 to 1.35) and among Caucasians (IRR = 1.27, 95% CI = 1.10 to 1.47). Conclusions Among Caucasians, we identified small increased risks of BCC and SCC with HCTZ compared with ACEI. Appropriate risk mitigation strategies should be taken while using HCTZ.
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Affiliation(s)
- Efe Eworuke
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Nicole Haug
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Marie Bradley
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Austin Cosgrove
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Tancy Zhang
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Elizabeth C Dee
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sruthi Adimadhyam
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Andrew Petrone
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Hana Lee
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Tiffany Woodworth
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
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18
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Lee HL, Kim JT, Lee JS, Kim BJ, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi JC, Kwon JH, Kim WJ, Shin DI, Sohn SI, Hong JH, Park MS, Choi KH, Cho KH, Lee J, Bae HJ. CHA2DS2-VASc score in acute ischemic stroke with atrial fibrillation: results from the Clinical Research Collaboration for Stroke in Korea. Sci Rep 2021; 11:793. [PMID: 33436977 PMCID: PMC7804950 DOI: 10.1038/s41598-020-80874-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/24/2020] [Indexed: 11/09/2022] Open
Abstract
We investigated a multicenter registry to identify estimated event rates according to CHA2DS2-VASc scores in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF). The additional effectiveness of antiplatelets (APs) plus oral anticoagulants (OACs) compared with OACs alone considering the CHA2DS2-VASc scores was also explored. This study retrospectively analyzed a multicenter stroke registry between Jan 2011 and Nov 2017, identifying patients with acute ischemic stroke with AF. The primary outcome event was a composite of recurrent stroke, myocardial infarction, and all-cause mortality within 1 year. A total of 7395 patients (age, 73 ± 10 years; men, 54.2%) were analyzed. The primary outcome events at one year ranged from 5.99% (95% CI 3.21–8.77) for a CHA2DS2-VASc score of 0 points to 30.45% (95% CI 24.93–35.97) for 7 or more points. After adjustments for covariates, 1-point increases in the CHA2DS2-VASc score consistently increased the risk of primary outcome events (aHR 1.10 [1.06–1.15]) at 1-year. Among OAC-treated patients at discharge (n = 5500), those treated with OAC + AP (vs. OAC alone) were more likely to experience vascular events, though among patients with a CHA2DS2-VASc score of 5 or higher, the risk of primary outcome in the OAC + AP group was comparable to that in the OAC alone group (Pint = 0.01). Our study found that there were significant associations of increasing CHA2DS2-VASc scores with the increasing risk of vascular events at 1-year in AIS with AF. Further study would be warranted.
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Affiliation(s)
- Hak-Loh Lee
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea.
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Jong-Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Hong-Kyun Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University College of Medicine, Ulsan, Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University College of Medicine, Ulsan, Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea.
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Assimon MM, Flythe JE. Zolpidem Versus Trazodone Initiation and the Risk of Fall-Related Fractures among Individuals Receiving Maintenance Hemodialysis. Clin J Am Soc Nephrol 2021; 16:88-97. [PMID: 33355192 PMCID: PMC7792650 DOI: 10.2215/cjn.10070620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Zolpidem, a nonbenzodiazepine hypnotic, and trazodone, a sedating antidepressant, are the most common medications used to treat insomnia in the United States. Both drugs have side effect profiles (e.g., drowsiness, dizziness, and cognitive and motor impairment) that can heighten the risk of falls and fractures. Despite widespread zolpidem and trazodone use, little is known about the comparative safety of these medications in patients receiving hemodialysis, a vulnerable population with an exceedingly high fracture rate. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using data from the United States Renal Data System registry (2013-2016), we conducted a retrospective cohort study to investigate the association between the initiation of zolpidem versus trazodone therapy and the 30-day risk of hospitalized fall-related fractures among Medicare-enrolled patients receiving maintenance hemodialysis. We used an active comparator new-user design and estimated 30-day inverse probability of treatment-weighted hazard ratios and risk differences. We treated death as a competing event. RESULTS A total of 31,055 patients were included: 18,941 zolpidem initiators (61%) and 12,114 trazodone initiators (39%). During the 30-day follow-up period, 101 fall-related fractures occurred. Zolpidem versus trazodone initiation was associated with a higher risk of hospitalized fall-related fracture (weighted hazard ratio, 1.71; 95% confidence interval, 1.11 to 2.63; weighted risk difference, 0.17%; 95% confidence interval, 0.07% to 0.29%). This association was more pronounced among individuals prescribed higher zolpidem doses (hazard ratio, 1.85; 95% confidence interval, 1.10 to 3.01; and risk difference, 0.20%; 95% confidence interval, 0.04% to 0.38% for higher-dose zolpidem versus trazodone; and hazard ratio, 1.60; 95% confidence interval, 1.01 to 2.55 and risk difference, 0.14%; 95% confidence interval, 0.03% to 0.27% for lower-dose zolpidem versus trazodone). Sensitivity analyses using longer follow-up durations yielded similar results. CONCLUSIONS Among individuals receiving maintenance hemodialysis, zolpidem initiators had a higher risk of hospitalized fall-related fracture compared with trazodone initiators. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_12_18_CJN10070620_final.mp3.
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Affiliation(s)
- Magdalene M. Assimon
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jennifer E. Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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20
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Blatch C, O'Sullivan K, Goodman-Delahunty J, Willis M, Delaney JJ. Effectiveness of a Domestic Abuse Program for Australian Indigenous Offenders. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2020; 64:1639-1673. [PMID: 32340494 DOI: 10.1177/0306624x19900979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The subject of this study is to assess the effectiveness of a culture-neutral domestic abuse program (DAP) developed for offenders with domestic and family violence histories, when used for Australian Indigenous offenders, serving community-based supervised orders. The study employed a retrospective quasi-experimental research design and intention-to-treat program definition for 953 DAP-treated men and propensity score-matched controls, from diverse cultural, religious, and racial backgrounds, 19% being Indigenous Australians. Outcomes measured were program completion, time to first reconviction, and reconviction rates. Indigenous men completed the program similar to non-Indigenous men (58% vs. 63%; NS), although significantly more dropped out (22% vs. 18%); 63% of Indigenous DAP-treated men, remained reconviction free versus 49% of Indigenous controls. Significant therapeutic benefits required program completion, 73% Indigenous and 74% of non-Indigenous men remained reconviction free. Indigenous DAP participants, relative to controls, took significantly longer to first reconviction. Survival was associated with prior criminal histories, but not with rural or remote domiciles. Reconviction rates were predicted by Level of Service Inventory-Revised actuarial risk scores and by DAP completion, but not by Indigenous status. Program effect size was d = .477, mean reconvictions for Indigenous DAP enrollees being 50% lower than controls. Generic domestic violence interventions utilising evidence-based theoretical principles can be effective for Indigenous offenders, despite an absence of specific Indigenous cultural, or healing content, and delivery by Indigenous facilitators or Elders.
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Affiliation(s)
- Chris Blatch
- NSW Department of Communities and Justice, Sydney, Australia
| | | | | | - Matthew Willis
- Australian Institute of Criminology, Canberra City, Australian Capital Territory, Australia
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Lee HL, Kim JT, Lee JS, Park MS, Choi KH, Cho KH, Kim BJ, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Sun Oh M, Kim DE, Ryu WS, Choi JC, Kwon JH, Kim WJ, Shin DI, Sohn SI, Hong JH, Lee J, Bae HJ. Comparative Effectiveness of Dual Antiplatelet Therapy With Aspirin and Clopidogrel Versus Aspirin Monotherapy in Mild-to-Moderate Acute Ischemic Stroke According to the Risk of Recurrent Stroke: An Analysis of 15 000 Patients From a Nationwide, Multicenter Registry. Circ Cardiovasc Qual Outcomes 2020; 13:e006474. [PMID: 33201737 DOI: 10.1161/circoutcomes.119.006474] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study compared the effectiveness of dual antiplatelet therapy (DAPT) with clopidogrel-aspirin with that of aspirin monotherapy (AM) in mild-to-moderate acute ischemic stroke considering the risk of recurrent stroke using the Stroke Prognosis Instrument II (SPI-II) score. METHODS This study is a retrospective analysis of data from a prospective, nationwide, multicenter stroke registry database between January 2011 and July 2018. We included patients with mild-to-moderate (National Institutes of Health Stroke Scale score ≤10), acute (within 24 hours of onset), noncardioembolic ischemic stroke. The primary outcome was a 3-month composite of stroke (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality. Propensity scores using the inverse probability of treatment weighting method were used to mitigate baseline imbalances between the DAPT and AM groups and within each subgroup considering SPI-II scores. RESULTS Among the 15 430 patients (age, 66±13 years; men, 62.0%), 45.1% (n=6960) received DAPT and 54.9% (n=8470) received AM. Primary outcome events were significantly more frequent in the AM group (16.7%) than in the DAPT group (15.5%; P=0.03). Weighted Cox proportional hazards models showed a reduced risk of 3-month primary vascular events in the DAPT group versus the AM group (hazard ratio, 0.84 [0.78-0.92]; P<0.001), with no interaction between acute treatment type and SPI-II risk subgroups (Pinteraction=0.44). However, among the high-risk patients with SPI-II scores >7, a substantially larger absolute benefit was observed for 3-month composite vascular events in the DAPT group (weighted absolute risk differences, 5.4%), whereas smaller absolute benefits were observed among patients in the low- or medium-risk SPI-II subgroups (1.7% and 2.4%, respectively). CONCLUSIONS Treatment with clopidogrel-aspirin was associated with a reduction in 3-month vascular events compared with AM in mild-to-moderate acute noncardioembolic ischemic stroke patients. Larger magnitudes of the effects of DAPT with clopidogrel-aspirin were observed in the high-risk subgroup by SPI-II risk scores.
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Affiliation(s)
- Hak-Loh Lee
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.-L.L., J.-T.K., M.-S.P., K.-H. Choi, K.-H. Cho)
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.-L.L., J.-T.K., M.-S.P., K.-H. Choi, K.-H. Cho)
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.S.L.)
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.-L.L., J.-T.K., M.-S.P., K.-H. Choi, K.-H. Cho)
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.-L.L., J.-T.K., M.-S.P., K.-H. Choi, K.-H. Cho)
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.-L.L., J.-T.K., M.-S.P., K.-H. Choi, K.-H. Cho)
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (B.J.K., H.-J.B.)
| | - Jong-Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea (J.-M.P., K.K.)
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea (J.-M.P., K.K.)
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea (S.J.L., J.G.K.)
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea (S.J.L., J.G.K.)
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K.)
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K.)
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.)
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Korea (T.H.P., S.-S.P.)
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea (K.B.L.)
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea (J.L.)
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea (K.-S.H., Y.-J.C., H.-K.P.)
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea (K.-S.H., Y.-J.C., H.-K.P.)
| | - Hong-Kyun Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea (K.-S.H., Y.-J.C., H.-K.P.)
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (B.-C.L., K.-H.Y., M.S.O.)
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (B.-C.L., K.-H.Y., M.S.O.)
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (B.-C.L., K.-H.Y., M.S.O.)
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea (D.-E.K., W.-S.R.)
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea (D.-E.K., W.-S.R.)
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Korea (J.C.C.)
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University College of Medicine, Korea (J.-H.K., W.-J.K.)
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University College of Medicine, Korea (J.-H.K., W.-J.K.)
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea (D.-I.S.)
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea (S.I.S., J.-H.H.)
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea (S.I.S., J.-H.H.)
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, BK21FOUR Program in Learning Health Systems, Korea University, Seoul (J.L.)
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (B.J.K., H.-J.B.)
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Lund LC, Kristensen KB, Reilev M, Christensen S, Thomsen RW, Christiansen CF, Støvring H, Johansen NB, Brun NC, Hallas J, Pottegård A. Adverse outcomes and mortality in users of non-steroidal anti-inflammatory drugs who tested positive for SARS-CoV-2: A Danish nationwide cohort study. PLoS Med 2020; 17:e1003308. [PMID: 32898149 PMCID: PMC7478808 DOI: 10.1371/journal.pmed.1003308] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/03/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Concerns over the safety of non-steroidal anti-inflammatory drug (NSAID) use during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been raised. We studied whether use of NSAIDs was associated with adverse outcomes and mortality during SARS-CoV-2 infection. METHODS AND FINDINGS We conducted a population-based cohort study using Danish administrative and health registries. We included individuals who tested positive for SARS-CoV-2 during the period 27 February 2020 to 29 April 2020. NSAID users (defined as individuals having filled a prescription for NSAIDs up to 30 days before the SARS-CoV-2 test) were matched to up to 4 non-users on calendar week of the test date and propensity scores based on age, sex, relevant comorbidities, and use of selected prescription drugs. The main outcome was 30-day mortality, and NSAID users were compared to non-users using risk ratios (RRs) and risk differences (RDs). Secondary outcomes included hospitalization, intensive care unit (ICU) admission, mechanical ventilation, and acute renal replacement therapy. A total of 9,236 SARS-CoV-2 PCR-positive individuals were eligible for inclusion. The median age in the study cohort was 50 years, and 58% were female. Of these, 248 (2.7%) had filled a prescription for NSAIDs, and 535 (5.8%) died within 30 days. In the matched analyses, treatment with NSAIDs was not associated with 30-day mortality (RR 1.02, 95% CI 0.57 to 1.82, p = 0.95; RD 0.1%, 95% CI -3.5% to 3.7%, p = 0.95), risk of hospitalization (RR 1.16, 95% CI 0.87 to 1.53, p = 0.31; RD 3.3%, 95% CI -3.4% to 10%, p = 0.33), ICU admission (RR 1.04, 95% CI 0.54 to 2.02, p = 0.90; RD 0.2%, 95% CI -3.0% to 3.4%, p = 0.90), mechanical ventilation (RR 1.14, 95% CI 0.56 to 2.30, p = 0.72; RD 0.5%, 95% CI -2.5% to 3.6%, p = 0.73), or renal replacement therapy (RR 0.86, 95% CI 0.24 to 3.09, p = 0.81; RD -0.2%, 95% CI -2.0% to 1.6%, p = 0.81). The main limitations of the study are possible exposure misclassification, as not all individuals who fill an NSAID prescription use the drug continuously, and possible residual confounding by indication, as NSAIDs may generally be prescribed to healthier individuals due to their side effects, but on the other hand may also be prescribed for early symptoms of severe COVID-19. CONCLUSIONS Use of NSAIDs was not associated with 30-day mortality, hospitalization, ICU admission, mechanical ventilation, or renal replacement therapy in Danish individuals who tested positive for SARS-CoV-2. TRIAL REGISTRATION The European Union electronic Register of Post-Authorisation Studies EUPAS34734.
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Affiliation(s)
- Lars Christian Lund
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Kasper Bruun Kristensen
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Mette Reilev
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Steffen Christensen
- Department of Anaesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Henrik Støvring
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Biostatistics, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Nanna Borup Johansen
- Department of Medical Evaluation and Biostatistics, Danish Medicines Agency, Copenhagen, Denmark
| | - Nikolai Constantin Brun
- Department of Medical Evaluation and Biostatistics, Danish Medicines Agency, Copenhagen, Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
- * E-mail:
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23
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Kim JT, Lee JS, Kim BJ, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi JC, Kwon JH, Kim WJ, Shin DI, Sohn SI, Hong JH, Park MS, Choi KH, Cho KH, Lee J, Gorelick PB, Bae HJ. Effectiveness of Adding Antiplatelets to Oral Anticoagulants in Patients with Acute Ischemic Stroke with Atrial Fibrillation and Concomitant Large Artery Steno-Occlusion. Transl Stroke Res 2020; 11:1322-1331. [PMID: 32472251 DOI: 10.1007/s12975-020-00822-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/10/2020] [Accepted: 05/13/2020] [Indexed: 01/27/2023]
Abstract
We investigated the effectiveness of adding antiplatelet (AP) to oral anticoagulant (OAC) treatment versus OAC treatment alone in patients with AIS with atrial fibrillation (AF) and significant large artery steno-occlusion (LASO). This study is a retrospective analysis of a nationwide, prospective, multicenter stroke registry between April 2008 and November 2017. Patients with acute (within 48 h of onset) and mild-to-moderate (NIHSS score ≤ 15) stroke with AF and concomitant LASO were identified. Antithrombotic regimens at discharge were categorized into OAC alone or OAC + AP. The primary outcome event was a composite of recurrent stroke, myocardial infarction, and all-cause mortality within 3 months of stroke. Among the 2553 patients (age, 73 ± 10 years; men, 50.4%), 78.8% were treated with OAC alone, and 21.2% were treated with OAC + AP. The primary outcome events were significantly more common in the OAC + AP group (6.7%) than the OAC alone group (4.3%) (p = 0.02). Weighted Cox proportional hazard analysis showed that OAC + AP increased the risk of 3-month primary outcome events compared with OAC alone (HR, 1.62 [1.06 to 2.46]). A potential interaction between the type of LASO and discharge antithrombotics was suggested (Pinteraction = 0.04); unlike in patients with complete occlusion (OAC + AP; HR, 2.00 [1.27-3.15]), OAC + AP was comparable with OAC alone for 3-month primary outcome in patients with moderate-to-severe stenosis (HR, 0.54 [0.17-1.70]). In conclusion, OAC + AP might increase the risk of 3-month outcome events compared with OAC alone in patients with AIS with AF and concomitant LASO. However, the effect of additional AP to OAC might differ according to LASO type.
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Affiliation(s)
- Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea.
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University College of Medicine, Cerebrovascular Center, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Jong-Moo Park
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, South Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, South Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, South Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, South Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | - Hong-Kyun Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym Neurological Institute, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym Neurological Institute, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym Neurological Institute, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, South Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University College of Medicine, Ulsan, South Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University College of Medicine, Ulsan, South Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, South Korea
| | - Philip B Gorelick
- Department of Neurology, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Department of Translational Neuroscience, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University College of Medicine, Cerebrovascular Center, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea.
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Secondary prevention of acute coronary syndrome with antiplatelet agents in real life: A high-dimensional propensity score matched cohort study in the French National claims database. MethodsX 2020; 7:100796. [PMID: 32322541 PMCID: PMC7168760 DOI: 10.1016/j.mex.2020.100796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/17/2020] [Indexed: 12/14/2022] Open
Abstract
Users of newly marketed drugs often differ from the patients included in randomized clinical trials, and from patients prescribed similar drugs. Cohorts of such users may be compared using propensity score adjustment, or similar user cohorts may be built using high-dimensional propensity score matching in large population databases. One such database is SNDS, the French nationwide claims and hospitalization database, which covers 99 % of the French population. It has yet been rarely used. To study the comparative effectiveness and safety in secondary coronary prevention of ticagrelor, compared to clopidogrel or prasugrel, we identified in SNDS patients who were dispensed any of the three antiplatelet agents of interest (± aspirin) within a month after discharge from hospital for acute coronary syndrome (ACS) and followed them one year for recurrence of ACS, stroke, acute bleeding, or death. High-dimensional propensity scores were developed to identify matched cohorts. Drug performances were also compared in the whole population using adjustment on the same parameters. Here we describe the database that was used, and the methods developed for the high-dimensional propensity score matching, resulting in standardized mean differences between the matched populations of less than 2 % for all of the 500+ variables included in the model. This study was done in a newly available large-scale claims database, which may differ from other population databases, by it size and exhaustiveness The methods elaborate on standard high-dimensional propensity scores as adapted to this claims database
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D'Ambrosio L, Touati N, Blay JY, Grignani G, Flippot R, Czarnecka AM, Piperno-Neumann S, Martin-Broto J, Sanfilippo R, Katz D, Duffaud F, Vincenzi B, Stark DP, Mazzeo F, Tuchscherer A, Chevreau C, Sherriff J, Estival A, Litière S, Sents W, Ray-Coquard I, Tolomeo F, Le Cesne A, Rutkowski P, Stacchiotti S, Kasper B, Gelderblom H, Gronchi A. Doxorubicin plus dacarbazine, doxorubicin plus ifosfamide, or doxorubicin alone as a first-line treatment for advanced leiomyosarcoma: A propensity score matching analysis from the European Organization for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group. Cancer 2020; 126:2637-2647. [PMID: 32129883 DOI: 10.1002/cncr.32795] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/05/2020] [Accepted: 01/24/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The optimal treatment for advanced leiomyosarcoma is still debated. Given histotype-specific prospective controlled data lacking, this study retrospectively evaluated doxorubicin plus dacarbazine, doxorubicin plus ifosfamide, and doxorubicin alone as first-line treatments for advanced/metastatic leiomyosarcoma treated at European Organization for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group (EORTC-STBSG) sites. METHODS The inclusion criteria were a confirmed histological diagnosis, treatment between January 2010 and December 2015, measurable disease (Response Evaluation Criteria in Solid Tumors 1.1), an Eastern Cooperative Oncology Group performance status ≤2, and an age ≥ 18 years. The endpoints were progression-free survival (PFS), overall survival (OS), and overall response rate (ORR). PFS was analyzed with methods for interval-censored data. Patients were matched according to their propensity scores, which were estimated with a logistic regression model accounting for histology, grade, age, sex, performance status, tumor site, and tumor extent. RESULTS Three hundred three patients from 18 EORTC-STBSG sites were identified. One hundred seventeen (39%) received doxorubicin plus dacarbazine, 71 (23%) received doxorubicin plus ifosfamide, and 115 (38%) received doxorubicin. In the 2:1:2 propensity score-matched population (205 patients), the estimated median PFS was 9.2 months (95% confidence interval [CI], 5.2-9.7 months), 8.2 months (95% CI, 5.2-10.1 months), and 4.8 months (95% CI, 2.3-6.0 months) with ORRs of 30.9%, 19.5%, and 25.6% for doxorubicin plus dacarbazine, doxorubicin plus ifosfamide, and doxorubicin alone, respectively. PFS was significantly longer with doxorubicin plus dacarbazine versus doxorubicin (hazard ratio [HR], 0.72; 95% CI, 0.52-0.99). Doxorubicin plus dacarbazine was associated with longer OS (median, 36.8 months; 95% CI, 27.9-47.2 months) in comparison with both doxorubicin plus ifosfamide (median, 21.9 months; 95% CI, 16.7-33.4 months; HR, 0.65; 95% CI, 0.40-1.06) and doxorubicin (median, 30.3 months; 95% CI, 21.0-36.3 months; HR, 0.66; 95% CI, 0.43-0.99). Adjusted analyses retained an effect for PFS but not for OS. None of the factors selected for multivariate analysis had a significant interaction with the received treatment for both PFS and OS. CONCLUSIONS This is the largest retrospective study of first-line treatment for advanced leiomyosarcoma. In the propensity score-matched population, doxorubicin and dacarbazine showed favorable activity in terms of both ORR and PFS and warrants further evaluation in prospective trials.
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Affiliation(s)
- Lorenzo D'Ambrosio
- Department of Oncology, University of Turin, Turin, Italy.,Sarcoma Unit, Division of Medical Oncology, Candiolo Cancer Institute-FPO, IRCCS, Candiolo, Italy
| | - Nathan Touati
- European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Jean-Yves Blay
- Leon Berard Center and Claude Bernard Lyon I University, EURACAN, LYRICAN, Lyon, France
| | - Giovanni Grignani
- Sarcoma Unit, Division of Medical Oncology, Candiolo Cancer Institute-FPO, IRCCS, Candiolo, Italy
| | - Ronan Flippot
- Department of Medicine, Gustave Roussy, Villejuif Cedex, France
| | - Anna M Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Institute-Oncology Center, Gliwice, Poland.,Department of Experimental Pharmacology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | | | - Javier Martin-Broto
- Virgen del Rocio University Hospital, Institute of Biomedicine Research/CSIC/University of Seville, Seville, Spain
| | - Roberta Sanfilippo
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Daniela Katz
- Oncology Department, Sharett Institute of Oncology, Hadassah-Hebrew University, Jerusalem, Israel
| | - Florence Duffaud
- Medical Oncology - University Hospital Timone, Aix-Marseille University, Marseille, France
| | - Bruno Vincenzi
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Daniel P Stark
- St James's Institute of Oncology, Leeds Institute of Cancer and Pathology, University of Leeds and Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom
| | - Filomena Mazzeo
- Medical Oncology, Clinique Universitaire Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - Armin Tuchscherer
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Christine Chevreau
- Claudius Regaud Institute, University Cancer Institute of Toulouse, Toulouse, France
| | - Jenny Sherriff
- Cancer Centre, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | - Saskia Litière
- European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Ward Sents
- European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Isabelle Ray-Coquard
- Leon Berard Center and Claude Bernard Lyon I University, EURACAN, LYRICAN, Lyon, France
| | - Francesco Tolomeo
- Sarcoma Unit, Division of Medical Oncology, Candiolo Cancer Institute-FPO, IRCCS, Candiolo, Italy
| | - Axel Le Cesne
- Department of Medicine, Gustave Roussy, Villejuif Cedex, France
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Institute-Oncology Center, Gliwice, Poland.,Department of Experimental Pharmacology, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Silvia Stacchiotti
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Bernd Kasper
- Sarcoma Unit, Interdisciplinary Tumor Center, Mannheim University Medical Center, University of Heidelberg, Mannheim, Germany
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Huybrechts KF, Gopalakrishnan C, Bartels DB, Zint K, Gurusamy VK, Landon J, Schneeweiss S. Safety and Effectiveness of Dabigatran and Other Direct Oral Anticoagulants Compared With Warfarin in Patients With Atrial Fibrillation. Clin Pharmacol Ther 2020; 107:1405-1419. [DOI: 10.1002/cpt.1753] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/22/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics Department of Medicine Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
| | - Chandrasekar Gopalakrishnan
- Division of Pharmacoepidemiology and Pharmacoeconomics Department of Medicine Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
| | - Dorothee B. Bartels
- Global Epidemiology Boehringer Ingelheim International GmbH Ingelheim Germany
- BI X GmbH Ingelheim Germany
- Hannover Medical School Hannover Germany
| | - Kristina Zint
- Global Epidemiology Boehringer Ingelheim International GmbH Ingelheim Germany
| | | | - Joan Landon
- Division of Pharmacoepidemiology and Pharmacoeconomics Department of Medicine Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics Department of Medicine Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
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Carnahan RM, Gagne JJ, Hampp C, Leonard CE, Toh S, Fuller CC, Hennessy S, Hou L, Cocoros NM, Panucci G, Woodworth T, Cosgrove A, Iyer A, Chrischilles EA. Evaluation of the US Food and Drug Administration Sentinel Analysis Tools Using a Comparator with a Different Indication: Comparing the Rates of Gastrointestinal Bleeding in Warfarin and Statin Users. Pharmaceut Med 2020; 33:29-43. [PMID: 31933271 DOI: 10.1007/s40290-018-00265-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The US Food and Drug Administration's Sentinel System was established to monitor safety of regulated medical products. Sentinel investigators identified known associations between drugs and adverse events to test reusable analytic tools developed for Sentinel. This test case used a comparator with a different indication. OBJECTIVE We tested the ability of Sentinel's reusable analytic tools to identify the known association between warfarin and gastrointestinal bleeding (GIB). Statins, expected to have no effect on GIB, were the comparator. We further explored the impact of analytic features, including matching ratio and stratifying Cox regression analyses, on matched pairs. METHODS This evaluation included data from 14 Sentinel Data Partners. New users of warfarin and statins, aged 18 years and older, who had not received other anticoagulants or had recent GIB were matched on propensity score using 1:1 and 1:n variable ratio matching, matching statin users with warfarin users to estimate the average treatment effect in warfarin-treated patients. We compared the risk of GIB using Cox proportional hazards regression, following patients for the duration of their observed continuous treatment or until a GIB. For the 1:1 matched cohort, we conducted analyses with and without stratification on matched pair. The variable ratio matched cohort analysis was stratified on the matched set. RESULTS We identified 141,398 new users of warfarin and 2,275,694 new users of statins. In analyses stratified on matched pair/set, the hazard ratios (HR) for GIB in warfarin users compared with statin users were 2.78 (95% confidence interval [CI] 2.36-3.28) in the 1:1 matched cohort and 3.10 (95% CI 2.76-3.49) in the variable ratio matched cohort. The HR was lower in the analysis of the 1:1 matched cohort not stratified by matched pair (2.22, 95% CI 1.97-2.49), and highest early in treatment. Follow-up for warfarin users tended to be shorter than for statin users. CONCLUSIONS This study identified the expected GIB risk with warfarin compared with statins using an analytic tool developed for Sentinel. Our findings suggest that comparators with different indications may be useful in surveillance in select circumstances. Finally, in the presence of differential censoring, stratification by matched pair may reduce the potential for bias in Cox regression analyses.
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Affiliation(s)
- Ryan M Carnahan
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Dr., S437 CPHB, Iowa City, IA, 52242, USA.
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Christian Hampp
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Charles E Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sengwee Toh
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Candace C Fuller
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura Hou
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Noelle M Cocoros
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Genna Panucci
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Tiffany Woodworth
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Austin Cosgrove
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Aarthi Iyer
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Chrischilles
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Dr., S437 CPHB, Iowa City, IA, 52242, USA
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Schuttevaer R, Alsma J, Brink A, van Dijk W, de Steenwinkel JEM, Lingsma HF, Melles DC, Schuit SCE. Appropriate empirical antibiotic therapy and mortality: Conflicting data explained by residual confounding. PLoS One 2019; 14:e0225478. [PMID: 31743361 PMCID: PMC6863559 DOI: 10.1371/journal.pone.0225478] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/05/2019] [Indexed: 11/18/2022] Open
Abstract
Objective Clinical practice universally assumes that appropriate empirical antibiotic therapy improves survival in patients with bloodstream infection. However, this is not generally supported by previous studies. We examined the association between appropriate therapy and 30-day mortality, while minimizing bias due to confounding by indication. Methods We conducted a retrospective cohort study between 2012 and 2017 at a tertiary university hospital in the Netherlands. Adult patients with bloodstream infection attending the emergency department were included. Based on in vitro susceptibility, antibiotic therapy was scored as appropriate or inappropriate. Primary outcome was 30-day mortality. To control for confounding, we performed conventional multivariable logistic regression and propensity score methods. Additionally, we performed an analysis in a more homogeneous subgroup (i.e. antibiotic monotherapy). Results We included 1.039 patients, 729 (70.2%) received appropriate therapy. Overall 30-day mortality was 10.4%. Appropriately treated patients had more unfavorable characteristics, indicating more severe illness. Despite adjustments, we found no association between appropriate therapy and mortality. For the antibiotic monotherapy subgroup (n = 449), patient characteristics were more homogeneous. Within this subgroup, appropriate therapy was associated with lower mortality (Odds Ratios [95% Confidence Intervals] ranging from: 0.31 [0.14; 0.67] to 0.40 [0.19; 0.85]). Conclusions Comparing heterogeneous treatment groups distorts associations despite use of common methods to prevent bias. Consequently, conclusions of such observational studies should be interpreted with care. If possible, future investigators should use our method of attempting to identify and analyze the most homogeneous treatment groups nested within their study objective, because this minimizes residual confounding.
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Affiliation(s)
- Romy Schuttevaer
- Department of Internal Medicine, Section Acute Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jelmer Alsma
- Department of Internal Medicine, Section Acute Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anniek Brink
- Department of Internal Medicine, Section Acute Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Willian van Dijk
- Department of Internal Medicine, Section Acute Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jurriaan E. M. de Steenwinkel
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Damian C. Melles
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Medical Microbiology and Immunology, Meander MC, Amersfoort, The Netherlands
| | - Stephanie C. E. Schuit
- Department of Internal Medicine, Section Acute Medicine, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- * E-mail:
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Lega IC, Bronskill SE, Campitelli MA, Guan J, Stall NM, Lam K, McCarthy LM, Gruneir A, Rochon PA. Sodium glucose cotransporter 2 inhibitors and risk of genital mycotic and urinary tract infection: A population-based study of older women and men with diabetes. Diabetes Obes Metab 2019; 21:2394-2404. [PMID: 31264755 DOI: 10.1111/dom.13820] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/21/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023]
Abstract
AIMS The objective of the study was to quantify the association between SGLT2 inhibitors and genital mycotic infection and between SGLT2 inhibitors and urinary tract infection (UTI) within 30 days of drug initiation among older women and men. MATERIALS AND METHODS This was a retrospective cohort study using linked administrative databases of women and men with diabetes, aged 66 years or older, in Ontario, Canada. We compared the incidence of genital mycotic infection or UTI within 30 days between new users of an SGLT2 inhibitor and of a dipeptidyl-peptidase-4 (DPP4) inhibitor. RESULTS We identified 21 444 incident users of SGLT2 inhibitor and 22 463 incident users of DPP4 inhibitor. Among SGLT2 inhibitor users, there were 8848 (41%) women and the mean age at index was 71.8 ± 5 (SD) years. After adjusting for propensity score, age, sex and recent UTI, there was a 2.47-fold increased risk of genital mycotic infection with incident use of SGLT2 inhibitors (adjusted hazard ratio (HR), 2.47; 95% confidence interval (CI), 2.08-2.92; P < 0.001) within 30 days compared to incident use of DPP4 inhibitors. For UTI, the adjusted HR was 0.89 (95% CI, 0.78-1.00; P = 0.05). CONCLUSIONS Incident use of SGLT2 inhibitors among older women and men is associated with increased risk of genital mycotic infections within 30 days; there is no associated increased risk of UTI. These findings from a real-world setting provide evidence of the potential harms of SGLT2 inhibitors.
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Affiliation(s)
- Iliana C Lega
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Susan E Bronskill
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Nathan M Stall
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Ontario, Canada
| | - Kenneth Lam
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Lisa M McCarthy
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Andrea Gruneir
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Adimadhyam S, Lee TA, Calip GS, Smith Marsh DE, Layden BT, Schumock GT. Sodium-glucose co-transporter 2 inhibitors and the risk of fractures: A propensity score-matched cohort study. Pharmacoepidemiol Drug Saf 2019; 28:1629-1639. [PMID: 31646732 DOI: 10.1002/pds.4900] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 08/27/2019] [Accepted: 09/01/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE To determine the risk of fractures associated with sodium-glucose co-transporter 2 inhibitors (SGLT2i) compared with dipeptidyl peptidase-4 inhibitors (DPP4i). METHODS We conducted a retrospective cohort study using data from the Truven Health MarketScan (2009-2015) databases. Our cohort included patients newly initiating treatment with SGLT2i or DPP-4i between 1 April 2013 and 31 March 2015 that were matched 1:1 using high dimensional propensity scores. Patients were followed up in an as-treated approach starting from initiation of treatment until the earliest of any fracture, treatment discontinuation, disenrollment, or end of data (31 December 2015). Risk of fractures was determined at any time during the follow-up, early in therapy (1-14 days of the follow-up), and later in therapy (15 days and beyond). Cox proportional hazards models were used to determine hazard ratios and robust 95% confidence intervals (95% CI). RESULTS After matching, our cohort included 30 549 patients in each treatment group. Over a median follow-up of 219 days, there were 745 fractures overall. The most common site for fractures was the foot (32.7%). The effect estimates for fracture risk occurring at any time during follow-up, early in therapy, and later in therapy were HR 1.11 [95% CI 0.96-1.28], HR 1.82 [95% CI 0.99-3.32], and HR 1.07 [95% CI 0.92-1.24], respectively. CONCLUSION There is a possible increase in risk for fractures early in therapy with SGLT2i. Beyond this initial period, SGLT2is had no apparent effect on the incidence of fractures.
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Affiliation(s)
- Sruthi Adimadhyam
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.,Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.,Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Daphne E Smith Marsh
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Brian T Layden
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA.,Jesse Brown Veterans Medical Center, Chicago, IL, USA
| | - Glen T Schumock
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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Ali MS, Prieto-Alhambra D, Lopes LC, Ramos D, Bispo N, Ichihara MY, Pescarini JM, Williamson E, Fiaccone RL, Barreto ML, Smeeth L. Propensity Score Methods in Health Technology Assessment: Principles, Extended Applications, and Recent Advances. Front Pharmacol 2019; 10:973. [PMID: 31619986 PMCID: PMC6760465 DOI: 10.3389/fphar.2019.00973] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/31/2019] [Indexed: 01/29/2023] Open
Abstract
Randomized clinical trials (RCT) are accepted as the gold-standard approaches to measure effects of intervention or treatment on outcomes. They are also the designs of choice for health technology assessment (HTA). Randomization ensures comparability, in both measured and unmeasured pretreatment characteristics, of individuals assigned to treatment and control or comparator. However, even adequately powered RCTs are not always feasible for several reasons such as cost, time, practical and ethical constraints, and limited generalizability. RCTs rely on data collected on selected, homogeneous population under highly controlled conditions; hence, they provide evidence on efficacy of interventions rather than on effectiveness. Alternatively, observational studies can provide evidence on the relative effectiveness or safety of a health technology compared to one or more alternatives when provided under the setting of routine health care practice. In observational studies, however, treatment assignment is a non-random process based on an individual’s baseline characteristics; hence, treatment groups may not be comparable in their pretreatment characteristics. As a result, direct comparison of outcomes between treatment groups might lead to biased estimate of the treatment effect. Propensity score approaches have been used to achieve balance or comparability of treatment groups in terms of their measured pretreatment covariates thereby controlling for confounding bias in estimating treatment effects. Despite the popularity of propensity scores methods and recent important methodological advances, misunderstandings on their applications and limitations are all too common. In this article, we present a review of the propensity scores methods, extended applications, recent advances, and their strengths and limitations.
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Affiliation(s)
- M Sanni Ali
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Center for Statistics in Medicine (CSM), University of Oxford, Oxford, United Kingdom.,Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Osvaldo Cruz, Salvador, Brazil
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Center for Statistics in Medicine (CSM), University of Oxford, Oxford, United Kingdom.,GREMPAL Research Group (Idiap Jordi Gol) and Musculoskeletal Research Unit (Fundació IMIM-Parc Salut Mar), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Dandara Ramos
- Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Osvaldo Cruz, Salvador, Brazil
| | - Nivea Bispo
- Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Osvaldo Cruz, Salvador, Brazil
| | - Maria Y Ichihara
- Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Osvaldo Cruz, Salvador, Brazil.,Institute of Public Health, Federal University of Bahia (UFBA), Salvador, Brazil
| | - Julia M Pescarini
- Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Osvaldo Cruz, Salvador, Brazil
| | - Elizabeth Williamson
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rosemeire L Fiaccone
- Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Osvaldo Cruz, Salvador, Brazil.,Institute of Public Health, Federal University of Bahia (UFBA), Salvador, Brazil.,Department of Statistics, Federal University of Bahia (UFBA), Salvador, Brazil
| | - Mauricio L Barreto
- Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Osvaldo Cruz, Salvador, Brazil.,Institute of Public Health, Federal University of Bahia (UFBA), Salvador, Brazil
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Centre for Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Osvaldo Cruz, Salvador, Brazil
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32
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Onwubiko U, Wall K, Sales RM, Holland DP. Using Directly Observed Therapy (DOT) for latent tuberculosis treatment - A hit or a miss? A propensity score analysis of treatment completion among 274 homeless adults in Fulton County, GA. PLoS One 2019; 14:e0218373. [PMID: 31226132 PMCID: PMC6588273 DOI: 10.1371/journal.pone.0218373] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 06/02/2019] [Indexed: 01/06/2023] Open
Abstract
Latent tuberculosis infection (LTBI) treatment in persons at increased risk of disease progression is a key strategy with the strong potential to increase rate of tuberculosis (TB) decline in the United States. However, LTBI treatment in homeless persons, a population at high-risk of active TB disease, is usually associated with poor adherence. We describe the impact of using directly observed treatment (DOT) versus self-administered treatments (SAT) as an adherence-improving intervention to administer four months of daily rifampin regimen for LTBI treatment among homeless adults in Atlanta. Retrospective analysis of clinical care data on 274 homeless persons who initiated daily rifampin treatment for LTBI treatment at a county health department between January 2014 and December 2016 was performed. To reduce bias from non-random assignment of treatment, an inverse probability of treatment weighted (IPTW) logistic regression model was used to assess the effect of treatment type on treatment completion. Subgroup analyses were performed to assess heterogeneity of treatment effect on LTBI completion. Of 274 LTBI treatment initiators, 177 (65%) completed treatment [DOT 118/181 (65%), SAT 59/93 (63%)]. In the fully adjusted and weighted analysis, the odds of completing LTBI treatment on DOT was 40% higher than the odds of completing treatment by SAT [adjusted odds ratio (95% CI), aOR: 1.40 (1.07, 1.82), p = 0.014]. The unstable nature of homeless persons' lifestyle makes LTBI treatment difficult for many reasons. Our study lends support to the use of DOT to improve LTBI treatment completion among subgroups of homeless persons on treatment with daily rifampin.
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Affiliation(s)
- Udodirim Onwubiko
- Medical and Preventive Services, Fulton County Board of Health, Atlanta, Georgia, United States of America
| | - Kristin Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Rose-Marie Sales
- Tuberculosis Program, Georgia Department of Public Health, Atlanta, Georgia, United States of America
| | - David P. Holland
- Medical and Preventive Services, Fulton County Board of Health, Atlanta, Georgia, United States of America
- Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia, United States of America
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Sundbakk LM, Wood M, Gran JM, Nordeng H. Impact of prenatal exposure to benzodiazepines and z-hypnotics on behavioral problems at 5 years of age: A study from the Norwegian Mother and Child Cohort Study. PLoS One 2019; 14:e0217830. [PMID: 31170221 PMCID: PMC6553737 DOI: 10.1371/journal.pone.0217830] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/20/2019] [Indexed: 01/20/2023] Open
Abstract
Many women experience anxiety or sleep disorders during pregnancy and require pharmacological treatment with benzodiazepines (BZDs) or z-hypnotics. Limited information is currently available on how prenatal exposure to these medications affects behavioral problems in children over the long term. Therefore, from a public health perspective, this issue is highly important. The present study aimed to determine whether prenatal exposure to BZDs and z-hypnotics affected externalizing and internalizing behavior problems in children at age 5 years. This study was based on The Norwegian Mother and Child Cohort Study and The Medical Birth Registry of Norway. The final study population included data for 36 401 children, from questionnaires completed by the mothers throughout the 5-year follow up. Children’s behaviors were measured at age 5, based on parental responses to The Child Behavior Checklist. Children T-scores of 63 or above were considered to indicate clinically relevant behavior problems. We applied inverse probability of treatment weighting (IPTW) and log-binomial regression models to estimate risk ratios (RRs) and bootstrapped 95% confidence intervals (CIs) with censoring weights to account for loss during follow-up. Several sensitivity analyses were performed to assess the robustness of the main results. The final sample included 273 (0.75%) children that were exposed to BZDs and/or z-hypnotics during pregnancy. The main, IPTW and censoring weighted analyses showed that prenatal exposure to BZD and/or z-hypnotics increased the risks of internalizing behavioral problems (RR: 1.35, 95% CI: 0.73–2.49) and externalizing behavioral problems (RR: 1.51, 95% CI: 0.86–2.64). However, based on sensitivity analyses, we concluded that the risks of displaying externalizing and internalizing problems at 5 years of age did not significantly increase after prenatal exposure to BZDs and/or z-hypnotics. Instead, the sensitivity analyses suggested that residual confounding and selection bias might explain the increased risks observed in the main analyses.
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Affiliation(s)
- Lene Maria Sundbakk
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- * E-mail:
| | - Mollie Wood
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Jon Michael Gran
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Development and Health, Norwegian Institute of Public Health, Oslo, Norway
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Liu SY, Liu C, Nehus E, Macaluso M, Lu B, Kim MO. Propensity score analysis for correlated subgroup effects. Stat Methods Med Res 2019; 29:1067-1080. [PMID: 31144601 DOI: 10.1177/0962280219850595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As individuals may respond differently to treatment, estimating subgroup effects is important to understand the characteristics of individuals who may benefit. Factors that define subgroups may be correlated, complicating evaluation of subgroup effects, especially in observational studies requiring control of confounding variables. We address this problem when propensity score methods are used for confounding control. A common practice is to evaluate candidate subgroup identifiers one at a time without adjusting for other candidate identifiers. We show that this practice can be misleading if the treatment effect modification attributed to a candidate identifier is in truth due to the effect of other correlated true effect modifiers. Whereas jointly analyzing multiple identifiers provides estimates of the desired subgroup effects adjusted for the effects of the other identifiers, it requires the propensity scores to adequately reflect the underlying treatment selection processes and balance the covariates within each subgroup of interest. Satisfying the requirement in practice is hard since the number of strata may increase quickly, while the per stratum sample size may decrease dramatically. A practically helpful approach is utilizing the whole cohort for the propensity score estimation with modeling of interaction terms to reflect the potentially different treatment selection processes across strata. We empirically examine the performance of the whole cohort approach by itself and with subjecting the interaction terms to variable selection. Our results using both simulations and real data analysis suggest that the whole cohort approach should explore inclusion of high-order interactions in the propensity score model to ensure adequate covariate balance across strata, and that variable selection is of limited utility.
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Affiliation(s)
- Shan-Yu Liu
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, USA
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Eddie Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Maurizio Macaluso
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Bo Lu
- Division of Biostatistics, The Ohio State University, Columbus, USA
| | - Mi-Ok Kim
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
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Rentsch CT, Fiellin DA, Bryant KJ, Justice AC, Tate JP. Association Between Gabapentin Receipt for Any Indication and Alcohol Use Disorders Identification Test-Consumption Scores Among Clinical Subpopulations With and Without Alcohol Use Disorder. Alcohol Clin Exp Res 2019; 43:522-530. [PMID: 30620410 DOI: 10.1111/acer.13953] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/28/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current medications for alcohol use disorder (AUD) have limited efficacy and utilization. Some clinical trials have shown efficacy for gabapentin among treatment-seeking individuals. The impact of gabapentin on alcohol consumption in a more general sample remains unknown. METHODS We identified patients prescribed gabapentin for ≥180 consecutive days for any clinical indication other than substance use treatment between 2009 and 2015 in the Veterans Aging Cohort Study. We propensity-score matched each gabapentin-exposed patient with up to 5 unexposed patients. Multivariable difference-in-difference (DiD) linear regression models estimated the differential change in Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scores during follow-up between exposed and unexposed patients, by baseline level of alcohol consumption and daily gabapentin dose. Analyses were stratified by AUD history. Clinically meaningful changes were a priori considered a DiD ≥1 point. RESULTS Among patients with AUD, AUDIT-C scores decreased 0.39 points (95% confidence interval [CI] 0.05, 0.73) more among exposed than unexposed patients (p < 0.03). Potentially clinically meaningful differences were observed among those with AUD and exposed to ≥1,500 mg/d (DiD 0.77, 95% CI 0.15, 1.38, p < 0.02). No statistically significant effects were found among patients with AUD at doses lower than 1,500 mg/d or baseline AUDIT-C ≥4. Among patients without AUD, we found no overall difference in changes in AUDIT-C scores, nor in analyses stratified by baseline level of alcohol consumption. CONCLUSIONS Patients exposed to doses of gabapentin consistent with those used in clinical trials, particularly those with AUD, experienced a greater decrease in AUDIT-C scores than matched unexposed patients.
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Affiliation(s)
- Christopher T Rentsch
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David A Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Kendall J Bryant
- Director of HIV/AIDS Research (KJB), National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Amy C Justice
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Janet P Tate
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Adimadhyam S, Lee TA, Calip GS, Smith Marsh DE, Layden BT, Schumock GT. Risk of amputations associated with SGLT2 inhibitors compared to DPP-4 inhibitors: A propensity-matched cohort study. Diabetes Obes Metab 2018; 20:2792-2799. [PMID: 29971914 DOI: 10.1111/dom.13459] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/20/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
AIM To determine the risk of amputations associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i) relative to dipeptidyl peptidase-4 inhibitors (DPP4i). MATERIALS AND METHODS We conducted an active comparator, new user cohort study using data from the Truven Health MarketScan (2009-2015) databases. Patients aged ≥18 years newly initiating SGLT2i or DPP4i between April 1, 2013 and March 31, 2015 were included. Patients were matched 1:1 on high dimensional propensity scores and followed until the earliest of any amputation, treatment discontinuation, disenrollment or end of study period (December 31, 2015). Cox proportional hazards models were used to estimate hazard ratios (HR) and robust 95% confidence intervals (CI) for amputation risk. RESULTS There were 30 216 comparable patients in each arm after matching. Over a median follow-up of 0.6 years, there were 60 amputations (SGLT2i: 36; DPP4i: 24), most at the level of partial foot (75%) and associated with diabetes-related vascular disease (66.7%). The incidence of amputations was higher among SGLT2i patients (1.62 vs. 1.15 per 1000 person-years) with a HR of 1.38 (CI: 0.83-2.31). In subgroup analyses, risk differed by type of SGLT2i: canagliflozin, HR 1.15 (CI: 0.63-2.09); dapagliflozin or empagliflozin, HR 2.25 (CI: 0.78-6.47). CONCLUSION All SGLT2i had an elevated, though not statistically significant, risk for amputations.
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Affiliation(s)
- Sruthi Adimadhyam
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daphne E Smith Marsh
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Brian T Layden
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Jesse Brown Veterans Medical Center, Chicago, Illinois
| | - Glen T Schumock
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
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Zakai NA, Walker RF, MacLehose RF, Adam TJ, Alonso A, Lutsey PL. Impact of anticoagulant choice on hospitalized bleeding risk when treating cancer-associated venous thromboembolism. J Thromb Haemost 2018; 16:2403-2412. [PMID: 30240508 PMCID: PMC6289651 DOI: 10.1111/jth.14303] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Indexed: 11/30/2022]
Abstract
Essentials Bleeding risk by anticoagulant choice for cancer-associated venous thrombosis (CA-VTE) is unknown. 26 894 people with CA-VTE were followed for bleeding in a claims database in the United States. Hospitalized bleeding risk was similar with direct acting oral anticoagulants vs. warfarin. Relative hospitalized bleeding risk varied by cancer type and anticoagulant choice. SUMMARY: Background Direct acting oral anticoagulants (DOACs) are associated with less bleeding than traditional venous thromboembolism (VTE) treatments in the general population but are little studied in cancer-associated VTE (CA-VTE). Objective To determine whether different anticoagulation strategies for CA-VTE have different hospitalized bleeding rates. Patients/Methods We conducted a retrospective study of patients with CA-VTE, diagnosed between 2011 and 2015, in a large administrative database. Using validated algorithms, we identified 26 894 CA-VTE patients treated with anticoagulants and followed them for hospitalized severe bleeding. Cox models were used to assess bleeding risk, adjusted for age, sex, high dimensional propensity score and frailty. Results Over 27 281 person-years of follow-up (median 0.6 years), 1204 bleeding events occurred, for a bleeding rate of 4.4% per patient-year. Bleeding rates varied by cancer type, with the highest rate for upper gastrointestinal cancers (8.6%) and the lowest for breast cancer (2.9%). In Cox models (hazard ratio [HR]; 95% confidence interval [CI]), compared with warfarin, DOACS and low-molecular-weight heparin (LMWH) had similar hazards of bleeding (HR, 0.88; 95% CI, 0.69-1.11 and 0.98; 0.85-1.13). Compared with LMWH, there was no difference in hazard of bleeding with DOACs (0.86; 0.66-1.12). There was heterogeneity in bleeding risk with DOACs by cancer type, with a higher risk of bleeding in upper gastrointestinal cancers and lower risk of bleeding in prostate cancer and hematologic cancers. Conclusions In this practice-based sample of CA-VTE patients, DOACs were associated with similar bleeding risks to warfarin and LMWH. These findings suggest a complex association of bleeding risk with anticoagulant choice in cancer patients.
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Affiliation(s)
- Neil A. Zakai
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
- Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Rob F. Walker
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Richard F. MacLehose
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Terrence J. Adam
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, G
| | - Pamela L. Lutsey
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
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Wang JL, Dong YH, Ko WC, Chang CH, Wu LC, Chuang LM, Chen PC. Thiazolidinediones and reduced risk of incident bacterial abscess in adults with type 2 diabetes: A population-based cohort study. Diabetes Obes Metab 2018; 20:2811-2820. [PMID: 29974616 DOI: 10.1111/dom.13461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/26/2018] [Accepted: 07/01/2018] [Indexed: 01/01/2023]
Abstract
AIM Previous research has suggested that peroxisome proliferator-activated receptor-gamma (PPAR-γ) may play an important role in immunomodulation. We aimed to examine the association between thiazolidinediones, PPAR-γ agonists and incidence of bacterial abscess among patients with type 2 diabetes. MATERIALS AND METHODS This retrospective cohort study between 2000 and 2010 included 46 986 propensity (PS)-matched patients diagnosed with type 2 diabetes. We compared the incidence of bacterial abscess, including liver and non-liver abscesses, between patients treated with metformin plus a thiazolidinedione (M + T, N = 7831) or metformin plus a sulfonylurea (M + S, N = 39 155). Data were retrieved from a population-based Taiwanese database. We applied Cox proportional hazard regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), comparing M + T and M + S after PS matching. RESULTS During a median follow-up of 4.5 years, the incidence rate of bacterial abscess was lower with M + T than with M + S treatment (1.89 vs 3.15 per 1000 person-years) in the PS-matched cohort. M + T was associated with a reduced risk of bacterial abscess (HRs after PS matching, 0.58; 95% CI, 0.42-0.80 for total bacterial abscess; 0.54; 95% CI, 0.28-1.07 for liver abscess; 0.59; 95% CI, 0.41-0.85 for non-liver abscess). Results did not change materially after accounting for unmeasured confounding factors using high-dimenional PS matching and differential censoring between regimen groups. Rosiglitazone and pioglitazone, in combination with metformin, produced similar reductions in risk of all abscess outcomes. CONCLUSION We found that M + T may provide a protective benefit in reducing the incidence of bacterial abscesses. These findings merit further investigation.
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Affiliation(s)
- Jiun-Ling Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Yaa-Hui Dong
- Faculty of Pharmacy, School of Pharmaceutical Science, National Yang-Ming University, Taipei, Taiwan
- Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Li-Chiu Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Lee-Ming Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Pau-Chung Chen
- Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Environmental and Occupational Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Wang SV, Jin Y, Fireman B, Gruber S, He M, Wyss R, Shin H, Ma Y, Keeton S, Karami S, Major JM, Schneeweiss S, Gagne JJ. Relative Performance of Propensity Score Matching Strategies for Subgroup Analyses. Am J Epidemiol 2018; 187:1799-1807. [PMID: 29554199 DOI: 10.1093/aje/kwy049] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 03/05/2018] [Indexed: 11/13/2022] Open
Abstract
Postapproval drug safety studies often use propensity scores (PSs) to adjust for a large number of baseline confounders. These studies may involve examining whether treatment safety varies across subgroups. There are many ways a PS could be used to adjust for confounding in subgroup analyses. These methods have trade-offs that are not well understood. We conducted a plasmode simulation to compare relative performance of 5 methods involving PS matching for subgroup analysis, including methods frequently used in applied literature whose performance has not been previously directly compared. These methods varied as to whether the overall PS, subgroup-specific PS, or no rematching was used in subgroup analysis as well as whether subgroups were fully nested within the main analytical cohort. The evaluated PS subgroup matching methods performed similarly in terms of balance, bias, and precision in 12 simulated scenarios varying size of the cohort, prevalence of exposure and outcome, strength of relationships between baseline covariates and exposure, the true effect within subgroups, and the degree of confounding within subgroups. Each had strengths and limitations with respect to other performance metrics that could inform choice of method.
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Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yinzhu Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bruce Fireman
- Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California, Oakland, California
| | - Susan Gruber
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mengdong He
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Richard Wyss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - HoJin Shin
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yong Ma
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Stephine Keeton
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Sara Karami
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Jacqueline M Major
- Office of Pharmacovigilance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Li H, Mitchell L, Zhang X, Heiselman D, Motsko S. Testosterone Therapy and Risk of Acute Myocardial Infarction in Hypogonadal Men: An Administrative Health Care Claims Study. J Sex Med 2018; 14:1307-1317. [PMID: 29110802 DOI: 10.1016/j.jsxm.2017.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 09/12/2017] [Accepted: 09/16/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are some ongoing debates on the potential link between testosterone therapy (TT) and risk of acute myocardial infarction (MI). AIM To investigate the association between acute MI and TT use compared with non-use in men having documented hypogonadism (diagnostic International Classification of Diseases, Ninth Revision codes 257.2, 257.8, 257.9, 758.7) in patient claims records. METHODS This retrospective cohort study used a real-world US-based administrative health care claims database (MarketScan 2004-2013; Truven Health Analytics, Ann Arbor, MI, USA) to compare MI rates between TT-treated men and a cohort of untreated hypogonadal men matched by a calendar time-specific propensity score. Subgroup analyses were performed by route of administration, age, and prior cardiovascular disease (CVD). OUTCOMES Incidence rates of MI (per 1,000 person-years) and hazard ratio. RESULTS After 1:1 calendar time-specific propensity score matching, 207,176 TT-treated men and 207,176 untreated hypogonadal men were included in the analysis (mean age = 51.8 years). Incidence rates of MI were 4.20 (95% CI = 3.87-4.52) in the TT-treated cohort and 4.67 (95% CI = 4.43-4.90) in the untreated hypogonadal cohort. Cox regression model showed no significant association between TT use and MI when comparing TT-treated with untreated hypogonadal men overall (hazard ratio = 0.99, 95% CI = 0.89-1.09), by age, or by prior CVD. A significant association was observed when comparing a subgroup of injectable (short- and long-acting combined) TT users with untreated hypogonadal men (hazard ratio = 1.55, 95% CI = 1.24-1.93). CLINICAL IMPLICATION In this study, there was no association between TT (overall) and risk of acute MI. STRENGTHS AND LIMITATIONS Strengths included the use of a comprehensive real-world database, sophisticated matching based on calendar blocks of 6 months to decrease potential bias in this observational study, carefully chosen index dates for the untreated cohort to avoid immortal time bias, and implemented sensitivity analysis to further investigate the findings (stratification by administration route, age, and prior CVD). Key limitations included no information about adherence, hypogonadism condition based solely on diagnosis (no information on clinical symptoms or testosterone levels), lack of information on disease severity, inability to capture diagnoses, medical procedures, and medicine dispensing if corresponding billing codes were not generated and findings could contain biases or fail to generalize well to other populations. CONCLUSION This large, retrospective, real-world observational study showed no significant association between TT use and acute MI when comparing TT-treated with untreated hypogonadal men overall, by age, or by prior CVD; the suggested association between injectable TT and acute MI deserves further investigation. Li H, Mitchell L, Zhang X, et al. Testosterone Therapy and Risk of Acute Myocardial Infarction in Hypogonadal Men: An Administrative Health Care Claims Study. J Sex Med 2017;14:1307-1317.
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Affiliation(s)
- Hu Li
- Eli Lilly and Company, Indianapolis, IN, USA.
| | - Lucy Mitchell
- Eli Lilly and Company Limited, Erlwood, Windlesham, Surrey, UK
| | - Xiang Zhang
- Eli Lilly and Company, Indianapolis, IN, USA
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Miano TA, Lautenbach E, Wilson FP, Guo W, Borovskiy Y, Hennessy S. Attributable Risk and Time Course of Colistin-Associated Acute Kidney Injury. Clin J Am Soc Nephrol 2018; 13:542-550. [PMID: 29545383 PMCID: PMC5969457 DOI: 10.2215/cjn.06980717] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/19/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite colistin's longstanding reported association with nephrotoxicity, the attributable risk and timing of toxicity onset are still unknown. Whether substantial toxicity occurs during the initial 72 hours of exposure has important implications for early treatment decisions. The objective of this study was to compare colistin-exposed patients with a matched control group given other broad spectrum antibiotics. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study in patients treated for multidrug-resistant Pseudomonas, Klebsiella, or Acinetobacter spp. Colistin-exposed patients were matched to unexposed controls using propensity scores. AKI was defined according to the Kidney Disease Improving Global Outcomes creatinine criteria. Incidence rate ratios and risk differences of AKI in the matched cohort were estimated with the generalized estimating equation Poisson regression model. Risk factors for AKI were tested for effect modification in the matched cohort. RESULTS The study included 150 propensity-matched pairs with similar types of infection, similar delays to effective treatment, and similar baseline characteristics. Incidence of AKI was 77 of 150 (51%) in the colistin group versus 33 of 150 (22%) in matched controls (risk difference, 29%; 95% confidence interval, 19 to 39), corresponding to a number needed to harm of 3.5. Early toxicity was apparent, because AKI risk was higher in colistin-exposed patients at 72 hours of exposure (incidence rate ratio, 1.9; 95% confidence interval, 1.1 to 3.5). In both groups, hospital mortality in patients who experienced AKI was lower if kidney function returned to baseline during hospitalization. The effect of colistin exposure on AKI risk varied inversely according to baseline hemoglobin concentration. CONCLUSIONS Colistin is associated with substantial excess AKI that is apparent within the first 72 hours of treatment. Colistin's toxicity varied according to baseline hemoglobin concentration. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_03_15_CJASNPodcast_18_4_M.mp3.
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Affiliation(s)
- Todd A Miano
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Dong YH, Jin Y, Tsacogianis TN, He M, Hsieh PH, Gagne JJ. Use of olmesartan and enteropathy outcomes: a multi-database study. Aliment Pharmacol Ther 2018; 47:792-800. [PMID: 29359522 DOI: 10.1111/apt.14518] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/06/2017] [Accepted: 12/22/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Multiple case reports suggest that olmesartan may be linked to sprue-like enteropathy; however, few epidemiological studies have examined this association and results have been mixed. AIM To assess whether olmesartan is associated with a higher rate of enteropathy vs other angiotensin II receptor blockers (ARBs). METHODS We conducted a cohort study among ARB initiators in 5 US claims databases representing different health insurance programmes. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for enteropathy-related outcomes, including coeliac disease, malabsorption, concomitant diagnoses of diarrhoea and weight loss, and non-infectious enteropathy, comparing olmesartan initiators to initiators of other ARBs after propensity score (PS) matching. RESULTS We identified 1 928 469 eligible patients. The unadjusted incidence rates were 0.82, 1.41, 1.66 and 29.20 per 1000 person-years for coeliac disease, malabsorption, concomitant diagnoses of diarrhoea and weight loss, and non-infectious enteropathy respectively. HRs after PS matching comparing olmesartan to other ARBs were 1.21 (95% CI, 1.05-1.40), 1.00 (95% CI, 0.88-1.13), 1.22 (95% CI, 1.10-1.36) and 1.04 (95% CI, 1.01-1.07) for each outcome. HRs were larger for patients aged 65 years and older (eg for coeliac disease, 1.57 [95% CI, 1.20-2.05]), for patients receiving treatment for more than 1 year (1.62 [95% CI, 1.24-2.12]), and for patients receiving higher cumulative olmesartan doses (1.78 [95% CI, 1.33-2.37]). CONCLUSIONS This large-scale, multi-database study found a higher rate of enteropathy in olmesartan initiators as compared to initiators of other ARBs, although the absolute incidence rate was low in both groups.
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Affiliation(s)
- Y-H Dong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Faculty of Pharmacy, School of Pharmaceutical Science, National Yang-Ming University, Taipei, Taiwan
| | - Y Jin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - T N Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - M He
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - P-H Hsieh
- Department of Hepato-Gastroenterology, Chi Mei Medical Center, Tainan, Taiwan
| | - J J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Dahan M, Scemama C, Porcher R, Biau DJ. Reporting of heterogeneity of treatment effect in cohort studies: a review of the literature. BMC Med Res Methodol 2018; 18:10. [PMID: 29329525 PMCID: PMC5767059 DOI: 10.1186/s12874-017-0466-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 12/22/2017] [Indexed: 11/30/2022] Open
Abstract
Background This article corresponds to a literature review and analyze how heterogeneity of treatment (HTE) is reported and addressed in cohort studies and to evaluate the use of the different measures to HTE analysis. Methods prospective cohort studies, in English language, measuring the effect of a treatment (pharmacological, interventional, or other) published among 119 core clinical journals (defined by the National Library of Medicine) in the last 16 years were selected in the following data source: Medline. One reviewer randomly sampled journal articles with 1: 1 stratification by journal type: high impact journals (the New England Journal of Medicine, JAMA, LANCET, Annals of Internal Medicine, BMJ and Plos Medicine) and low impact journal (the remaining journals) to identify 150 eligible studies. Two reviewers independently and in duplicate used standardized piloted forms to screen study reports for eligibility and to extract data. They also used explicit criteria to determine whether a cohort study reported HTE analysis. Logistic regression was used to examine the association of prespecified study characteristics with reporting versus not reporting of heterogeneity of treatment effect. Results One hundred fifty cohort studies were included of which 88 (58%) reported HTE analysis. High impact journals (Odds Ratio: 3.5, 95% CI: 1.78–7.5; P < 0.001), pharmacological studies (Odds Ratio: 0.26, 95% CI: 0.13–0.51; P < 0.001) and studies published after 2014 (Odds Ratio: 0.5, 95% CI: 0.25–0.97; P = 0.004) were associated with more frequent reporting of HTE. 27 (31%) studies which reported HTE used an interaction test. Conclusion More than half cohort studies report some measure of heterogeneity of treatment effect. Prospective cohort studies published in high impact journals, with large sample size, or studying a pharmacological treatment are associated with more frequent HTE reporting. The source of funding was not associated with HTE reporting. There is a need for guidelines on how to perform HTE analyses in cohort studies. Electronic supplementary material The online version of this article (10.1186/s12874-017-0466-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Meryl Dahan
- INSERM U1153, ECAMO, METHODS, 27 rue du faubourg Saint-Jacques, Université Paris-Descartes, 75014, Paris 5, France.
| | - Caroline Scemama
- INSERM U1153, ECAMO, METHODS, 27 rue du faubourg Saint-Jacques, Université Paris-Descartes, 75014, Paris 5, France
| | - Raphael Porcher
- INSERM U1153, ECAMO, METHODS, 27 rue du faubourg Saint-Jacques, Université Paris-Descartes, 75014, Paris 5, France
| | - David J Biau
- INSERM U1153, ECAMO, METHODS, 27 rue du faubourg Saint-Jacques, Université Paris-Descartes, 75014, Paris 5, France
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Lee CC, Lee MTG, Hsu TC, Porta L, Chang SS, Yo CH, Tsai KC, Lee M. A Population-Based Cohort Study on the Drug-Specific Effect of Statins on Sepsis Outcome. Chest 2017; 153:805-815. [PMID: 28962887 DOI: 10.1016/j.chest.2017.09.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/16/2017] [Accepted: 09/06/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Whether statin treatment, proved by recent experimental studies to have an antimicrobial activity, exerts a drug- or a class-specific effect in sepsis remains unknown. METHODS Short-term mortality in patients with sepsis was analyzed using data from the National Health Insurance Research Database. Use of statins was defined as the cumulative use of a specific statin (atorvastatin, simvastatin, or rosuvastatin) for > 30 days prior to the index sepsis admission. We determined the association between statin and sepsis outcome by multivariate-adjusted Cox models and propensity score (PS)-matched analysis, using a 1:1:1 PS matching technique. RESULTS A total of 52,737 patients with sepsis fulfilled the inclusion criteria, of which 1,855 were prescribed atorvastatin, 916 were prescribed simvastatin, and 732 were prescribed rosuvastatin. Compared with nonusers, simvastatin (hazard ratio [HR], 0.72; 95% CI, 0.58-0.90) and atorvastatin (HR, 0.78; 95% CI, 0.68-0.90) were associated with an improved 30-day survival, whereas rosuvastatin was not (HR, 0.87; 95% CI, 0.73-1.04). Using rosuvastatin as the reference, atorvastatin (HR, 0.79; 95% CI, 0.64-0.99) and simvastatin (HR, 0.77; 95% CI, 0.59-0.99) had superior effectiveness in preventing mortality. CONCLUSIONS Compatible with in vitro experimental findings, our results suggest that the drug-specific effect of statins on sepsis is not correlated to their lipid-lowering potency.
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Affiliation(s)
- Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Meng-Tse Gabriel Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzu-Chun Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Lorenzo Porta
- Dipartimento di scienze Biomediche e Cliniche, Ospedale "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Shy-Shin Chang
- Department of Family Medicine, Taipei Medical University Hospital and School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chia-Hung Yo
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kuang-Chau Tsai
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
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Clinical Outcomes of Concomitant Use of Warfarin and Selective Serotonin Reuptake Inhibitors: A Multidatabase Observational Cohort Study. J Clin Psychopharmacol 2017; 37:200-209. [PMID: 28129313 DOI: 10.1097/jcp.0000000000000658] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patients treated with warfarin are often coprescribed selective serotonin reuptake inhibitors (SSRIs) for coexisting depression. Some SSRIs are potent CYP2C9 inhibitors that may increase warfarin plasma concentrations and the risk of bleeding. We aimed to examine the effect of the putative CYP2C9-mediated warfarin-SSRI interaction on clinical outcomes. METHODS We conducted an observational cohort study among warfarin initiators who had a subsequent SSRI prescription in 5 US claims databases. Patients were followed for up to 180 days as long as they were exposed to both warfarin and their index SSRI groups. Cox regression models were used to estimate hazard ratios and 95% confidence intervals for bleeding events, ischemic or thromboembolic events, and mortality comparing patients treated with SSRIs that are potent CYP2C9 inhibitors (fluoxetine, fluvoxamine) with those treated with other SSRIs after propensity score matching. FINDINGS The eligible cohort comprised 52,129 patients. Hazard ratios were 1.14 (95% confidence interval [CI], 0.94-1.38) for bleeding events, 1.03 (95% CI, 0.87-1.21) for ischemic or thromboembolic events, and 0.90 (95% CI, 0.72-1.14) for mortality. Results were consistent across individual component outcomes, different warfarin stabilization periods, and subgroup analyses. CONCLUSIONS Patients concomitantly treated with warfarin and SSRIs that are potent CYP2C9 inhibitors had comparable rates of bleeding events, ischemic or thromboembolic events, and mortality as did patients cotreated with warfarin and other SSRIs, although small but potentially meaningful effects on bleeding cannot be completely excluded. SSRI inhibition of CYP2C9 does not appear to affect major safety or effectiveness outcomes of warfarin treatment in clinical practice, where patients may be closely monitored.
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Bohn J, Eddings W, Schneeweiss S. Conducting Privacy-Preserving Multivariable Propensity Score Analysis When Patient Covariate Information Is Stored in Separate Locations. Am J Epidemiol 2017; 185:501-510. [PMID: 28399565 DOI: 10.1093/aje/kww155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/24/2016] [Indexed: 11/13/2022] Open
Abstract
Distributed networks of health-care data sources are increasingly being utilized to conduct pharmacoepidemiologic database studies. Such networks may contain data that are not physically pooled but instead are distributed horizontally (separate patients within each data source) or vertically (separate measures within each data source) in order to preserve patient privacy. While multivariable methods for the analysis of horizontally distributed data are frequently employed, few practical approaches have been put forth to deal with vertically distributed health-care databases. In this paper, we propose 2 propensity score-based approaches to vertically distributed data analysis and test their performance using 5 example studies. We found that these approaches produced point estimates close to what could be achieved without partitioning. We further found a performance benefit (i.e., lower mean squared error) for sequentially passing a propensity score through each data domain (called the "sequential approach") as compared with fitting separate domain-specific propensity scores (called the "parallel approach"). These results were validated in a small simulation study. This proof-of-concept study suggests a new multivariable analysis approach to vertically distributed health-care databases that is practical, preserves patient privacy, and warrants further investigation for use in clinical research applications that rely on health-care databases.
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Affiliation(s)
- Justin Bohn
- Department of Education and Psychology, Free University Berlin, Germany
| | - Wesley Eddings
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
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Schneeweiss S, Carver PL, Datta K, Galar A, Johnson MD, Johnson MG, Marty FM, Nagel J, Najdzinowicz M, Saul M, Shoham S, Silveira FP, Varughese CA, Wilck M, Weatherby L, Auton T, Walker AM. Short-term risk of liver and renal injury in hospitalized patients using micafungin: a multicentre cohort study. J Antimicrob Chemother 2016; 71:2938-44. [PMID: 27407049 DOI: 10.1093/jac/dkw225] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/12/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although echinocandins are generally well tolerated, there is little information on the frequency with which renal and hepatic adverse effects occur during use of micafungin or other parenteral antifungal (PAF) agents in clinical practice. METHODS MYCOS is a multicentre cohort study of adult and paediatric patients who received micafungin or other PAFs between 2005 and 2012 at seven tertiary care hospitals from six centres in the USA. PAF cohort controls were selected through propensity score (PS) matching to micafungin recipients using clinical characteristics, other treatments, procedures and hospital service where PAF treatment was initiated. Analysis was restricted to patients without chronic liver and kidney conditions at the time of cohort entry. Treatment-emergent hepatic and renal injury was documented by changes in liver enzymes or estimated glomerular filtration rate through 30 days following completion of PAF treatment. Comparisons were quantified using the HR from a proportional hazards analysis. RESULTS There were 2970 micafungin recipients PS matched to 6726 recipients of comparator PAFs. Balance was achieved in all baseline covariates between treatment groups. There were similar rates of hepatic injury (micafungin, 13 events per 100 patients and other PAF, 12 per 100; HR = 0.99; 95% CI 0.86-1.14) and lower rates of renal injury (micafungin, 63 events per 100 patients and other PAF, 65 per 100; HR = 0.93; 95% CI 0.87-0.99) for micafungin recipients versus PAF comparators. CONCLUSION For a wide spectrum of underlying conditions, we observed no increase in liver injury by micafungin and possibly a reduced risk of renal dysfunction in comparison with other PAF medications.
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Affiliation(s)
- Sebastian Schneeweiss
- WHISCON, Newton, MA, USA Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Peggy L Carver
- University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Kausik Datta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alicia Galar
- Division of Infectious Diseases, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Melissa D Johnson
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Matthew G Johnson
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | | | - Jerod Nagel
- University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Maryann Najdzinowicz
- Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa Saul
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fernanda P Silveira
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christy A Varughese
- Division of Infectious Diseases, Department of Pharmacy, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Marissa Wilck
- Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Tim Auton
- Astellas Pharma Europe, Leiden, The Netherlands
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Li H, Benoit K, Wang W, Motsko S. Association between Use of Exogenous Testosterone Therapy and Risk of Venous Thrombotic Events among Exogenous Testosterone Treated and Untreated Men with Hypogonadism. J Urol 2016; 195:1065-72. [DOI: 10.1016/j.juro.2015.10.134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Hu Li
- Lilly Research Laboratories, Eli Lilly and Co., Indianapolis, Indiana
| | - Karin Benoit
- Lilly Research Laboratories, Eli Lilly and Co., Indianapolis, Indiana
| | - Wei Wang
- Lilly Research Laboratories, Eli Lilly and Co., Indianapolis, Indiana
| | - Stephen Motsko
- Lilly Research Laboratories, Eli Lilly and Co., Indianapolis, Indiana
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Intra-Aortic Balloon Pump Counterpulsation during Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction and Cardiogenic Shock: Insights from the British Columbia Cardiac Registry. PLoS One 2016; 11:e0148931. [PMID: 26870950 PMCID: PMC4752444 DOI: 10.1371/journal.pone.0148931] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 01/18/2016] [Indexed: 12/05/2022] Open
Abstract
Background Cardiogenic shock complicating ST-elevation myocardial infarction (STEMI) is associated with significant morbidity and mortality. In the primary percutaneous coronary intervention (PPCI) era, randomized trials have not shown a survival benefit with intra-aortic balloon pump (IABP) therapy. This differs to observational data which show a detrimental effect, potentially reflecting bias and confounding. Without robust and valid risk adjustment, findings from non-randomized studies may remain biased. Methods We compared long-term mortality following IABP therapy in patients with cardiogenic shock undergoing PPCI during 2008–2013 from the British Columbia Cardiac Registry. We addressed measured and unmeasured confounding using propensity score and instrumental variable methods. Results A total of 12,105 patients with STEMI were treated with PPCI during the study period. Of these, 700 patients (5.8%) had cardiogenic shock. Of the patients with cardiogenic shock, 255 patients (36%) received IABP therapy. Multivariable analyses identified IABP therapy to be associated with increased mortality up to 3 years (HR = 1.67, 95% CI:1.20–2.67, p<0.001). This association was lost in propensity-matched analyses (HR = 1.23, 95% CI: 0.84–1.80, p = 0.288). When addressing measured and unmeasured confounders, instrumental variable analyses demonstrated that IABP therapy was not associated with mortality at 3 years (Δ = 16.7%, 95% CI: -12.7%, 46.1%, p = 0.281). Subgroup analyses demonstrated IABP was associated with increased mortality in non-diabetics; patients not undergoing multivessel intervention; patients without renal disease and patients not having received prior thrombolysis. Conclusions In this observational analysis of patients with STEMI and cardiogenic shock, when adjusting for confounding, IABP therapy had a neutral effect with no association with long-term mortality. These findings differ to previously reported observational studies, but are in keeping with randomized trial data.
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Seeger JD, Bykov K, Bartels DB, Huybrechts K, Zint K, Schneeweiss S. Safety and effectiveness of dabigatran and warfarin in routine care of patients with atrial fibrillation. Thromb Haemost 2015; 114:1277-89. [PMID: 26446507 DOI: 10.1160/th15-06-0497] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/28/2015] [Indexed: 12/14/2022]
Abstract
The RE-LY study demonstrated the safety and efficacy of dabigatran relative to warfarin for stroke prevention in non-valvular atrial fibrillation. It is important to further evaluate safety and effectiveness of drugs in routine care. This study used a sequential cohort design with propensity score matching to compare dabigatran with warfarin among patients in two commercial health insurance databases. New users of these anticoagulants were followed from initiation until discontinuation, the end of the study, or the occurrence of a study outcome (primary study outcomes were stroke and major bleeding). Proportional hazards regression was conducted separately within each data source and results were pooled. Among 19,189 matched dabigatran and warfarin initiators (mean age: 68 years, 36 % female), as-treated follow-up (average of 5 months for dabigatran, 4 months for warfarin) identified 62 and 69 strokes, respectively (pooled HR = 0.77; 95 % CI = 0.54 to 1.09), and 354 and 395 major haemorrhages, respectively (HR = 0.75; 0.65 to 0.87). No meaningful heterogeneity was identified across subgroups, but numeric trends suggest more pronounced stroke prevention by dabigatran relative to warfarin among patients age 75+ (HR = 0.57; 0.33 to 0.97) or with < 6 months of use (HR = 0.51; 0.19 to 1.42). Major bleeds were reduced more by dabigatran among patients aged < 55 (HR = 0.51; 0.30 to 0.87) and with CHADS2 < 2 (HR = 0.58; 0.44 to 0.77). In conclusion, in routine care of patients with non-valvular atrial fibrillation, dabigatran treatment resulted in improved health outcomes compared with warfarin.
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Affiliation(s)
- John D Seeger
- John Seeger, PharmD, DrPH, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA, Tel.: +1 617 278 0335, Fax: +1 617 232 8602, E-mail:
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