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Parra-Rodriguez L, Sahrmann JM, Butler AM, Olsen MA, Powderly WG, O'Halloran JA. Antiretroviral Therapy and Cardiovascular Risk in People With HIV in the United States-An Updated Analysis. Open Forum Infect Dis 2024; 11:ofae485. [PMID: 39296337 PMCID: PMC11409880 DOI: 10.1093/ofid/ofae485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/26/2024] [Indexed: 09/21/2024] Open
Abstract
Background Several antiretroviral therapy (ART) medications have been associated with increased cardiovascular risk, but less is known about the safety of modern ART. We sought to compare the risk of major adverse cardiac events (MACEs) among different ART regimens. Methods Using insurance claims databases from 2008 to 2020, we identified adults aged <65 years who newly initiated ART. We compared non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens to protease inhibitors (PI)- and integrase inhibitors (INSTI)-based regimens. We used propensity score-weighted Kaplan-Meier functions to estimate the 6, 12, 18, 24, 36, and 48 months' risk and risk differences (RD) of MACE. Results Among 37 935 ART initiators (median age, 40 years; 23% female; 26% Medicaid-insured), 45% started INSTI-, 16% PI-, and 39% NNRTI-based regimens. MACE occurred in 418 individuals (1.1%) within 48 months after ART initiation. Compared to NNRTI initiators, the risk of MACE was higher at 12 months (RD, 0.50; 95% CI, 0.14-0.99), 18 months (RD, 0.53; 95% CI, 0.11-1.06), and 24 months (RD, 0.62; 95% CI, 0.04-1.29) for PI initiators, and at 12 (RD, 0.20; 95% CI, 0.03-0.37) and 18 months (RD, 0.31; 95% CI, 0.06-0.54) for INSTI initiators; the precision of estimates was limited for longer duration of follow-up. Conclusions Among ART initiators, PI-based and INSTI-based regimens were associated with higher short-term risk of MACE compared to NNRTI-based regimens. The pattern of association between INSTIs and PIs with excess risk of MACE was similar.
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Affiliation(s)
- Luis Parra-Rodriguez
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John M Sahrmann
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anne M Butler
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Margaret A Olsen
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - William G Powderly
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jane A O'Halloran
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Hwang YJ, Chang HY, Metkus T, Andersen KM, Singh S, Alexander GC, Mehta HB. Risk of Major Bleeding Associated with Concomitant Direct-Acting Oral Anticoagulant and Clopidogrel Use: A Retrospective Cohort Study. Drug Saf 2024; 47:251-260. [PMID: 38141156 PMCID: PMC10942724 DOI: 10.1007/s40264-023-01388-z] [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] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND AND AIM Combined anticoagulant-antiplatelet therapy is often indicated in adults with cardiovascular disease and atrial fibrillation or venous thromboembolism. The study aim was to assess the comparative risk of bleeding between rivaroxaban and apixaban when combined with clopidogrel. METHODS We conducted a retrospective cohort study of commercially insured US adults newly treated with a combination of rivaroxaban+clopidogrel or apixaban+clopidogrel (2015-2018) using Merative™ Marketscan Research Databases. We used propensity score-based inverse probability of treatment weighting (IPTW) to balance the treatment groups. Weighted Cox proportional hazards regression was used to estimate the risk of major bleeding. RESULTS The study cohort included 2895 rivaroxaban+clopidogrel users and 3628 apixaban+clopidogrel users. The median (range) duration of follow up was 61 (73) days. Rivaroxaban+clopidogrel users had a similar risk of major bleeding compared with apixaban+clopidogrel users (IPTW incidence rate per 100 person-years 7.96 vs 7.38; IPTW hazard ratio [HR] 1.13 [95% CI 0.78-1.63]). In the subcohort of adults who were treated with DOAC or clopidogrel monotherapy prior to the combined therapy, the risk of major bleeding did not differ by the drug of monotherapy (IPTW HR for rivaroxaban+clopidogrel group: 0.66 [95% CI 0.33-1.32]; IPTW HR for apixaban+clopidogrel group: 1.10 [95% CI 0.55-2.23]) CONCLUSIONS: In our study of commercially insured US adults, the concomitant use of rivaroxaban+clopidogrel and apixaban+clopidogrel conferred a similar risk of major bleeding. DOAC versus clopidogrel monotherapy prior to the concomitant therapy did not influence the risk of major bleeding.
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Affiliation(s)
- Y Joseph Hwang
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA.
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 2024 E. Monument Street, 2-300A, Baltimore, MD, 21287, USA.
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Janssen Scientific Affairs LLC, Titusville, NJ, USA
| | - Thomas Metkus
- Divisions of Cardiology and Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen M Andersen
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sonal Singh
- UMass Chan Medical School, Worcester, MA, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 2024 E. Monument Street, 2-300A, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Tedeschi SK, Yoshida K, Huang W, Solomon DH. Confirming Prior and Identifying Novel Correlates of Acute Calcium Pyrophosphate Crystal Arthritis. Arthritis Care Res (Hoboken) 2023; 75:283-288. [PMID: 34397174 PMCID: PMC8847549 DOI: 10.1002/acr.24770] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/30/2021] [Accepted: 08/12/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To investigate previously identified and novel correlates of acute calcium pyrophosphate (CPP) crystal arthritis among well-characterized cases. METHODS In this case-control study, we identified cases of acute CPP crystal arthritis using a validated algorithm (positive predictive value 81%) applied in the Partners HealthCare electronic health record (EHR). Cases were matched to general patient controls on the year of first EHR encounter and index date. Prespecified potential correlates included sex, race, and comorbidities and medications previously associated with CPP deposition/acute CPP crystal arthritis in the literature. We estimated odds ratios (ORs) and 95% confidence intervals using conditional logistic regression models adjusted for demographic characteristics, comorbidities, medications prescribed in the past 90 days, health care utilization, and multimorbidity score. RESULTS We identified 1,697 cases matched to 6,503 controls. Mean ± SD age was 73.7 ± 11.8 years, 56.7% were female, 80.8% were White, and 10.3% were Black. All prespecified covariates were more common in cases than controls. Osteoarthritis (OR 3.08), male sex (OR 1.35), rheumatoid arthritis (OR 2.09), gout (OR 2.83), proton pump inhibitors (OR 1.94), loop diuretics (OR 1.60), and thiazides (OR 1.46) were significantly associated with acute CPP crystal arthritis after full adjustment. Black race was associated with lower odds for acute CPP crystal arthritis compared to White race (OR 0.47). CONCLUSION Using a validated algorithm to identify nearly 1,700 patients with acute CPP crystal arthritis, we confirmed important correlates of this acute manifestation of CPP deposition. This is the first study to report higher odds for acute CPP crystal arthritis among males.
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Affiliation(s)
- Sara K. Tedeschi
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Kazuki Yoshida
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Weixing Huang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Daniel H. Solomon
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Noninterventional studies in the COVID-19 era: methodological considerations for study design and analysis. J Clin Epidemiol 2023; 153:91-101. [PMID: 36400263 PMCID: PMC9671552 DOI: 10.1016/j.jclinepi.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/27/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022]
Abstract
The global COVID-19 pandemic has generated enormous morbidity and mortality, as well as large health system disruptions including changes in use of prescription medications, outpatient encounters, emergency department admissions, and hospitalizations. These pandemic-related disruptions are reflected in real-world data derived from electronic medical records, administrative claims, disease or medication registries, and mobile devices. We discuss how pandemic-related disruptions in healthcare utilization may impact the conduct of noninterventional studies designed to characterize the utilization and estimate the effects of medical interventions on health-related outcomes. Using hypothetical studies, we highlight consequences that the pandemic may have on study design elements including participant selection and ascertainment of exposures, outcomes, and covariates. We discuss the implications of these pandemic-related disruptions on possible threats to external validity (participant selection) and internal validity (for example, confounding, selection bias, missing data bias). These concerns may be amplified in populations disproportionately impacted by COVID-19, such as racial/ethnic minorities, rural residents, or people experiencing poverty. We propose a general framework for researchers to carefully consider during the design and analysis of noninterventional studies that use real-world data from the COVID-19 era.
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Takeuchi M, Inokuchi S, Kimura T, Eguchi N, Kawakami K, Takahashi T. Descriptive epidemiology of COVID-19 in Japan 2020: insights from a multihospital database. ANNALS OF CLINICAL EPIDEMIOLOGY 2022; 5:5-12. [PMID: 38505379 PMCID: PMC10760473 DOI: 10.37737/ace.23002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/17/2022] [Indexed: 03/21/2024]
Abstract
BACKGROUND Epidemiological data are essential for developing strategies against the current coronavirus disease 2019 (COVID-19) pandemic. Data on COVID-19 epidemiology in Japan are limited owing to a focus on specific regions and patient groups, particularly in the early phase of the pandemic. METHODS We investigated COVID-19 epidemiology in Japan in 2020 using a large nationwide multihospital database containing insurance claim records and medical records. Inclusion criteria were inpatient and outpatient referrals for COVID-19 in 2020. We analyzed demographic data, comorbidities, drug use, severe COVID-19 risk, and clinical course of hospitalized patients (including death). RESULTS We identified 11,868 COVID-19 cases from 56 institutions: 6,440 outpatients and 5,428 inpatients. Of the patients, 53.2% had comorbid conditions, the most common of which was tumor (22.1%), and 56.4% were classed as having a high risk of COVID-19. Pharmacological management patterns were generally consistent between the first and second half of 2020, except for glucocorticoid use. The use of unauthorized medications (hydroxychloroquine, ivermectin, and favipiravir) was infrequent. For hospitalized patients, the median length of stay was 10 days, and 2.4% of patients were admitted to intensive care units. Post-COVID-19 all-cause mortality, all-cause 30-day mortality, and in-hospital deaths were recorded for 7.9%, 5.4%, and 4.6% of patients, respectively. Patients with high-risk conditions had a lower survival probability. CONCLUSIONS This descriptive study of COVID-19 in 2020 identified differences in care across outpatient and inpatient settings and changes in care delivery as the pandemic progressed. These findings could inform strategies for future infectious disease pandemics.
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Affiliation(s)
- Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | | | | | | | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Tai Takahashi
- Department of Social Services and Healthcare Management, School of Health and Welfare, International University of Health and Welfare
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Tedeschi SK, Huang W, Yoshida K, Solomon DH. Risk of cardiovascular events in patients having had acute calcium pyrophosphate crystal arthritis. Ann Rheum Dis 2022; 81:1323-1329. [PMID: 35613842 PMCID: PMC10043830 DOI: 10.1136/annrheumdis-2022-222387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/16/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Calcium pyrophosphate deposition (CPPD) disease, broadly defined, has been associated with increased risk of cardiovascular (CV) events. We investigated risk of CV events in patients with acute CPP crystal arthritis, the acute manifestation of CPPD. METHODS Cohort study using Mass General Brigham electronic health record (EHR) data, 1991-2017. Patients with acute CPP crystal arthritis were identified using a published machine learning algorithm with positive predictive value 81%. Comparators were matched on year of EHR entry and index date of patients with acute CPP crystal arthritis (first positive synovial fluid CPP result or mention of 'pseudogout', or matched encounter). Major adverse cardiovascular event (MACE) was a composite of non-fatal CV event (myocardial infarction, acute coronary syndrome, coronary revascularisation, stroke) and death. We estimated incidence rates (IRs) and adjusted hazard ratios for MACE, non-fatal CV event and death, allowing for differential estimates during years 0-2 and 2-10. Sensitivity analyses included: (1) patients with acute CPP crystal arthritis diagnosed during outpatient visits, (2) patients with linked Medicare data, 2007-2016 and (3)patients matched on number of CV risk factors. RESULTS We matched 1200 acute CPP crystal arthritis patients to 3810 comparators. IR for MACE in years 0-2 was 91/1000 person-years (p-y) in acute CPP crystal arthritis and 59/1000 p-y in comparators. In years 2-10, IR for MACE was 58/1000 p-y in acute CPP crystal arthritis and 53/1000 p-y in comparators. Acute CPP crystal arthritis was significantly associated with increased risk for MACE in years 0-2 (HR 1.32, 95% CI 1.01 to 1.73) and non-fatal CV event in years 0-2 (HR 1.92, 95% CI 1.12 to 3.28) and years 2-10 (HR 2.18, 95% CI 1.27 to 3.75), but not death. Results of sensitivity analyses were similar to the primary analysis; in the outpatient-only analysis, risk of non-fatal CVE was significantly elevated in years 2-10 but not in years 0-2. CONCLUSIONS Acute CPP crystal arthritis was significantly associated with elevated short and long-term risk for non-fatal CV event.
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Affiliation(s)
- Sara K Tedeschi
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Weixing Huang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kazuki Yoshida
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel H Solomon
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Harton J, Segal B, Mamtani R, Mitra N, Hubbard RA. Combining Real-World and Randomized Control Trial Data Using Data-Adaptive Weighting via the On-Trial Score. Stat Biopharm Res 2022. [DOI: 10.1080/19466315.2022.2071982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Joanna Harton
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
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8
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Ødegaard KM, Lirhus SS, Melberg HO, Hallén J, Halvorsen S. A nationwide registry study on heart failure in Norway from 2008 to 2018: variations in lookback period affect incidence estimates. BMC Cardiovasc Disord 2022; 22:88. [PMID: 35247979 PMCID: PMC8898410 DOI: 10.1186/s12872-022-02522-y] [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: 04/14/2021] [Accepted: 02/21/2022] [Indexed: 12/20/2022] Open
Abstract
Background The incidence of heart failure (HF) has declined in Europe during the past two decades. However, incidence estimates from registry-based studies may vary, partly because they depend on retrospective searches to exclude previous events. The aim of this study was to assess to what extent different lookback periods (LPs) affect temporal trends in incidence, and to identify the minimal acceptable LP. Further, we wanted to estimate temporal trends in incidence and prevalence of HF in a nationwide population, using the minimal acceptable LP.
Methods We identified all in- and out-patient contacts for HF in Norway during 2008 to 2018 from the Norwegian Patient Registry. To calculate the influence of varying LP on incident cases, we defined 2018 with 10 years of LP as a reference and calculated the relative difference by using one through 9 years of lookback. Temporal trends in incidence rates were estimated with sensitivity analyses applying varying LPs and different case definitions. Standardised incidence rates and prevalence were calculated by applying direct age- and sex-standardization to the 2013 European Standard Population. Results The overestimation of incident cases declined with increasing number of years included in the LP. Compared to a 10-year LP, application of 4, 6, and 8 years resulted in an overestimation of incident cases by 13.5%, 6.2% and 2.3%, respectively. Temporal trends in incidence were affected by the number of years in the LP and whether the LP was fixed or varied. Including all available data mislead to conclusions of declining incidence rates over time due to increasing LPs. Conclusions When taking the number of years with available data and HF mortality and morbidity into consideration, we propose that 6 years of fixed lookback is sufficient for identification of incident HF cases. HF incidence rates and prevalence increased from 2014 to 2018. Trial registration Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02522-y.
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Nanditha NGA, Dong X, McLinden T, Sereda P, Kopec J, Hogg RS, Montaner JSG, Lima VD. The impact of lookback windows on the prevalence and incidence of chronic diseases among people living with HIV: an exploration in administrative health data in Canada. BMC Med Res Methodol 2022; 22:1. [PMID: 34991473 PMCID: PMC8734246 DOI: 10.1186/s12874-021-01448-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/21/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND We described the impact of different lengths of lookback window (LW), a retrospective time period to observe diagnoses in administrative data, on the prevalence and incidence of eight chronic diseases. METHODS Our study populations included people living with HIV (N = 5151) and 1:5 age-sex-matched HIV-negative individuals (N = 25,755) in British Columbia, Canada, with complete follow-up between 1996 and 2012. We measured period prevalence and incidence of diseases in 2012 using LWs ranging from 1 to 16 years. Cases were deemed prevalent if identified in 2012 or within a defined LW, and incident if newly identified in 2012 with no previous cases detected within a defined LW. Chronic disease cases were ascertained using published case-finding algorithms applied to population-based provincial administrative health datasets. RESULTS Overall, using cases identified by the full 16-year LW as the reference, LWs ≥8 years and ≥ 4 years reduced the proportion of misclassified prevalent and incidence cases of most diseases to < 20%, respectively. The impact of LWs varied across diseases and populations. CONCLUSIONS This study underscored the importance of carefully choosing LWs and demonstrated data-driven approaches that may inform these choices. To improve comparability of prevalence and incidence estimates across different settings, we recommend transparent reporting of the rationale and limitations of chosen LWs.
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Affiliation(s)
- Ni Gusti Ayu Nanditha
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Xinzhe Dong
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Taylor McLinden
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Paul Sereda
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Jacek Kopec
- Arthritis Research Canada, Richmond, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Viviane D Lima
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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Ye Y, Yin Y, Huh SY, Almansa C, Bennett D, Camilleri M. Epidemiology, Etiology, and Treatment of Gastroparesis: Real-World Evidence From a Large US National Claims Database. Gastroenterology 2022; 162:109-121.e5. [PMID: 34624355 DOI: 10.1053/j.gastro.2021.09.064] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/23/2021] [Accepted: 09/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Although gastroparesis carries a considerable health care and patient burden, associated epidemiological data are limited. To provide new real-world evidence for gastroparesis, we estimated disease prevalence, and investigated patient demographics and disease etiology in a large US claims database. METHODS This retrospective, cross-sectional analysis used de-identified, longitudinal patient-level enrollment and billing data for adults from the Optum Clinformatics Data Mart database, a large US national administrative health insurance claims database. Prevalence was age-, sex-, and geographical region-standardized using the 2018 US census. Descriptive analyses of demographic and clinical variables and underlying disease etiologies were performed. RESULTS The overall standardized prevalence of gastroparesis was 267.7 (95% confidence interval [CI] 264.8-270.7) per 100,000 US adults, whereas prevalence of "definite" gastroparesis (individuals diagnosed within 3 months of gastric emptying scintigraphy testing with persistent symptoms for more than 3 months) was 21.5 (95% CI 20.6-22.4) per 100,000 persons. Patients with gastroparesis had an overall Charlson Comorbidity Index score of 4.2, indicating substantial comorbidity burden. The most frequently documented comorbidities were chronic pulmonary disease (46.4%), diabetes with chronic complication (37.3%), and peripheral vascular disease (30.4%). Patients most commonly had a diabetic etiology (57.4%; type 1, 5.7% and type 2, 51.7%), followed by postsurgical (15.0%), drug-induced (11.8%), and idiopathic (11.3%) etiologies. CONCLUSIONS New evidence is provided regarding the prevalence, patient demographics, and etiology of gastroparesis in the US general population. Wider availability of reliable objective gastric emptying measures and further education of medical professionals in recognizing and diagnosing gastroparesis would benefit future studies and improve understanding of disease epidemiology.
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Affiliation(s)
- Yizhou Ye
- Global Evidence and Outcomes, Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Yu Yin
- Safety and Health Value Statistics, Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Susanna Y Huh
- Clinical Science, Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Cristina Almansa
- Clinical Science, Takeda Development Center Americas, Inc., Cambridge, Massachusetts
| | - Dimitri Bennett
- Global Evidence and Outcomes, Takeda Development Center Americas, Inc., Cambridge, Massachusetts; Perelman School of Medicine, Adjunct, University of Pennsylvania, Philadelphia, Pennsylvania.
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Constructing Epidemiologic Cohorts from Electronic Health Record Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413193. [PMID: 34948800 PMCID: PMC8701170 DOI: 10.3390/ijerph182413193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
In the United States, electronic health records (EHR) are increasingly being incorporated into healthcare organizations to document patient health and services rendered. EHRs serve as a vast repository of demographic, diagnostic, procedural, therapeutic, and laboratory test data generated during the routine provision of health care. The appeal of using EHR data for epidemiologic research is clear: EHRs generate large datasets on real-world patient populations in an easily retrievable form permitting the cost-efficient execution of epidemiologic studies on a wide array of topics. Constructing epidemiologic cohorts from EHR data involves as a defining feature the development of data machinery, which transforms raw EHR data into an epidemiologic dataset from which appropriate inference can be drawn. Though data machinery includes many features, the current report focuses on three aspects of machinery development of high salience to EHR-based epidemiology: (1) selecting study participants; (2) defining “baseline” and assembly of baseline characteristics; and (3) follow-up for future outcomes. For each, the defining features and unique challenges with respect to EHR-based epidemiology are discussed. An ongoing example illustrates key points. EHR-based epidemiology will become more prominent as EHR data sources continue to proliferate. Epidemiologists must continue to improve the methods of EHR-based epidemiology given the relevance of EHRs in today’s healthcare ecosystem.
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Levintow SN, Orroth KK, Breskin A, Park AS, Flores-Arredondo JH, Dluzniewski P, Navar AM, Sørensen HT, Brookhart MA. Use of negative control outcomes to assess the comparability of patients initiating lipid-lowering therapies. Pharmacoepidemiol Drug Saf 2021; 31:383-392. [PMID: 34894377 DOI: 10.1002/pds.5396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Clinical trials have demonstrated efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in reducing risk of cardiovascular disease events, but effectiveness in routine clinical care has not been well-studied. We used negative control outcomes to assess potential confounding in an observational study of PCSK9i versus ezetimibe or high-intensity statin. METHODS Using commercial claims, we identified U.S. adults initiating PCSK9i, ezetimibe, or high-intensity statin in 2015-2018, with other lipid-lowering therapy (LLT) use in the year prior (LLT cohort) or atherosclerotic cardiovascular disease (ASCVD) in the past 90 days (ASCVD cohort). We compared initiators of PCSK9i to ezetimibe and high-intensity statin by estimating one-year risks of negative control outcomes influenced by frailty or health-seeking behaviors. Inverse probability of treatment and censoring weighted estimators of risk differences (RDs) were used to evaluate residual confounding after controlling for covariates. RESULTS PCSK9i initiators had lower one-year risks of negative control outcomes associated with frailty, such as decubitus ulcer in the ASCVD cohort (PCSK9i vs. high-intensity statin RD = -3.5%, 95% confidence interval (CI): -4.6%, -2.5%; PCSK9i vs. ezetimibe RD = -1.3%, 95% CI: -2.1%, -0.6%), with similar but attenuated associations in the LLT cohort. Lower risks of accidents and fractures were also observed for PCSK9i, varying by cohort. Risks were similar for outcomes associated with health-seeking behaviors, although trended higher for PCSK9i in the ASCVD cohort. CONCLUSIONS Observed associations suggest lower frailty and potentially greater health-seeking behaviors among PCSK9i initiators, particularly those with a recent ASCVD diagnosis, with the potential to bias real-world analyses of treatment effectiveness.
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Affiliation(s)
- Sara N Levintow
- NoviSci, Inc., Durham, North Carolina, USA.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Alexander Breskin
- NoviSci, Inc., Durham, North Carolina, USA.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | | | - Ann Marie Navar
- Departments of Internal Medicine and Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - M Alan Brookhart
- NoviSci, Inc., Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
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DuMontier C, Fillmore NR, Yildirim C, Cheng D, La J, Orkaby AR, Charest B, Cirstea D, Yellapragada S, Gaziano JM, Do N, Brophy MT, Kim DH, Munshi NC, Driver JA. Contemporary Analysis of Electronic Frailty Measurement in Older Adults with Multiple Myeloma Treated in the National US Veterans Affairs Healthcare System. Cancers (Basel) 2021; 13:cancers13123053. [PMID: 34207459 PMCID: PMC8233717 DOI: 10.3390/cancers13123053] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 12/31/2022] Open
Abstract
Simple Summary Geriatric and frailty assessment are recommended for all older adults with cancer undergoing systemic therapy, but assessments remain difficult to scale. The aim of this study was to use an electronic frailty index based on data from administrative claims and electronic health records—the Veterans Affairs Frailty Index (VA-FI-10)—to estimate frailty and its impact on older United States (US) military veterans treated for multiple myeloma (MM) throughout the national VA Healthcare System. We found frailty to be prevalent and strongly associated with mortality and hospitalizations—independently of age, race, and MM stage. We also showed that changing the way in which the VA-FI-10 is measured affects its classification of frailty for individual veterans but not its association with mortality. These findings support the VA-FI-10’s use in research investigating outcomes in frail veterans treated with contemporary MM therapies. We provide further insights into the VA-FI-10’s potential use in clinical practice. Abstract Electronic frailty indices based on data from administrative claims and electronic health records can be used to estimate frailty in large populations of older adults with cancer where direct frailty measures are lacking. The objective of this study was to use the electronic Veterans Affairs Frailty Index (VA-FI-10)—developed and validated to measure frailty in the national United States (US) VA Healthcare System—to estimate the prevalence and impact of frailty in older US veterans newly treated for multiple myeloma (MM) with contemporary therapies. We designed a retrospective cohort study of 4924 transplant-ineligible veterans aged ≥ 65 years initiating MM therapy within VA from 2004 to 2017. Initial MM therapy was measured using inpatient and outpatient treatment codes from pharmacy data in the VA Corporate Data Warehouse. In total, 3477 veterans (70.6%) were classified as frail (VA-FI-10 > 0.2), with 1510 (30.7%) mildly frail (VA-FI-10 > 0.2–0.3), 1105 (22.4%) moderately frail (VA-FI-10 > 0.3–0.4), and 862 (17.5%) severely frail (VA-FI-10 > 0.4). Survival and time to hospitalization decreased with increasing VA-FI-10 severity (log-rank p-value < 0.001); the VA-FI-10 predicted mortality and hospitalizations independently of age, sociodemographic variables, and measures of disease risk. Varying data sources and assessment periods reclassified frailty severity for a substantial portion of veterans but did not substantially affect VA-FI-10’s association with mortality. Our study supports use of the VA-FI-10 in future research involving older veterans with MM and provides insights into its potential use in identifying frailty in clinical practice.
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Affiliation(s)
- Clark DuMontier
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA 02130, USA; (C.D.); (A.R.O.)
- Division of Aging, Brigham and Women’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
| | - Nathanael R. Fillmore
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
- VA Boston CSP Center, Boston, MA 02130, USA; (N.D.); (M.T.B.)
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Cenk Yildirim
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
| | - David Cheng
- Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Jennifer La
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
| | - Ariela R. Orkaby
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA 02130, USA; (C.D.); (A.R.O.)
- Division of Aging, Brigham and Women’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
| | - Brian Charest
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
| | - Diana Cirstea
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Sarvari Yellapragada
- Michael E. Debakey VA Medical Center and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA;
| | - John Michael Gaziano
- Division of Aging, Brigham and Women’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
| | - Nhan Do
- VA Boston CSP Center, Boston, MA 02130, USA; (N.D.); (M.T.B.)
- Boston University School of Medicine, Boston, MA 02118, USA
| | - Mary T. Brophy
- VA Boston CSP Center, Boston, MA 02130, USA; (N.D.); (M.T.B.)
- Boston University School of Medicine, Boston, MA 02118, USA
| | - Dae H. Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA 02131, USA;
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Nikhil C. Munshi
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
- VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Jane A. Driver
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA 02130, USA; (C.D.); (A.R.O.)
- Division of Aging, Brigham and Women’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
- Correspondence: ; Tel.: +1-857-364-2560
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14
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Cheng D, DuMontier C, Yildirim C, Charest B, Hawley CE, Zhuo M, Paik JM, Yaksic E, Gaziano JM, Do N, Brophy M, Cho K, Kim DH, Driver JA, Fillmore NR, Orkaby AR. Updating and Validating the U.S. Veterans Affairs Frailty Index: Transitioning From ICD-9 to ICD-10. J Gerontol A Biol Sci Med Sci 2021; 76:1318-1325. [PMID: 33693638 PMCID: PMC8202143 DOI: 10.1093/gerona/glab071] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The Veterans Affairs Frailty Index (VA-FI) is an electronic frailty index developed to measure frailty using administrative claims and electronic health records data in Veterans. An update to ICD-10 coding is needed to enable contemporary measurement of frailty. METHOD International Classification of Diseases, ninth revision (ICD-9) codes from the original VA-FI were mapped to ICD-10 first using the Centers for Medicaid and Medicare Services (CMS) General Equivalence Mappings. The resulting ICD-10 codes were reviewed by 2 geriatricians. Using a national cohort of Veterans aged 65 years and older, the prevalence of deficits contributing to the VA-FI and associations between the VA-FI and mortality over years 2012-2018 were examined. RESULTS The updated VA-FI-10 includes 6422 codes representing 31 health deficits. Annual cohorts defined on October 1 of each year included 2 266 191 to 2 428 115 Veterans, for which the mean age was 76 years, 97%-98% were male, 78%-79% were White, and the mean VA-FI was 0.20-0.22. The VA-FI-10 deficits showed stability before and after the transition to ICD-10 in 2015, and maintained strong associations with mortality. Patients classified as frail (VA-FI > 0.2) consistently had a hazard of death more than 2 times higher than nonfrail patients (VA-FI ≤ 0.1). Distributions of frailty and associations with mortality varied with and without linkage to CMS data and with different assessment periods for capturing deficits. CONCLUSIONS The updated VA-FI-10 maintains content validity, stability, and predictive validity for mortality in a contemporary cohort of Veterans aged 65 years and older, and may be applied to ICD-9 and ICD-10 claims data to measure frailty.
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Affiliation(s)
- David Cheng
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Clark DuMontier
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Cenk Yildirim
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Brian Charest
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Chelsea E Hawley
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
| | - Min Zhuo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Julie M Paik
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
| | - Enzo Yaksic
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - J Michael Gaziano
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Nhan Do
- Boston VA Cooperative Studies Program, Massachusetts, USA
- Boston University School of Medicine, Massachusetts, USA
| | - Mary Brophy
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Jane A Driver
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathanael R Fillmore
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ariela R Orkaby
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Al-Moujahed A, Tran EM, Azad A, Vail D, Ludwig CA, Pasricha MV, Rosenblatt TR, Callaway NF, Moshfeghi DM. Risk of Retinal Artery Occlusion in Patients with Migraine. Am J Ophthalmol 2021; 225:157-165. [PMID: 33359716 DOI: 10.1016/j.ajo.2020.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 01/03/2023]
Abstract
PURPOSE We sought to determine if migraine is associated with increased risk of retinal artery occlusion (RAO). DESIGN Retrospective cohort study. METHODS We reviewed a large insurance claims database for patients with migraine and matched control subjects without migraine between 2007 and 2016. Cox proportional hazard regression models were used to investigate the association between migraine and risk of all RAO, central RAO (CRAO), branch RAO (BRAO), and "other" RAO, which includes transient and partial RAO. Primary outcome measures included the incidence of all RAO, including CRAO, BRAO, and other RAO, after first migraine diagnosis. RESULT There were 418,965 patients with migraine who met the study criteria and were included in the analysis with the appropriate matched control subjects. Among the 418,965 patients with migraine, 1060 (0.25%) were subsequently diagnosed with RAO, whereas only 335 (0.08%) of the patients without migraine were diagnosed with RAO. The hazard ratio (HR) for incident all RAO in patients with migraine compared with those without migraine was 3.48 (95% confidence interval [CI] 3.07-3.94; P < .0001). This association was consistent across all types of RAO, including CRAO (HR 1.62 [95% CI 1.15-2.28]; P = .004), BRAO (HR 2.09 [95% CI 1.60-2.72]; P < .001), and other types of RAO (HR 4.61 [95% CI 3.94-5.38]; P < .001). Patients with migraine with aura had a higher risk for incident RAO compared with those with migraine without aura (HR 1.58 [95% CI 1.40-1.79]; P < .001). This association was consistent for BRAO (HR 1.43 [95% CI 1.04-1.97]; P < .03) and other types of RAO (HR 1.67 [95% CI 1.45-1.91]; P < .001) but was not statistically significant for CRAO (HR 1.18 [95% CI 0.75-1.87]; P = .475). Significant risk factors for this association included increased age, male sex, acute coronary syndrome, valvular disease, carotid disease, hyperlipidemia, hypertension, retinal vasculitis or inflammation, and systemic lupus erythematosus. CONCLUSIONS Migraine is associated with increased risk of all types of RAO and migraine with aura is associated with increased risk of RAO compared with migraine without aura.
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16
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Mantravadi S, George M, Brensinger C, Du M, Baker JF, Ogdie A. Impact of tumor necrosis factor inhibitors and methotrexate on diabetes mellitus among patients with inflammatory arthritis. BMC Rheumatol 2020; 4:39. [PMID: 32905192 PMCID: PMC7466800 DOI: 10.1186/s41927-020-00138-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/06/2020] [Indexed: 01/03/2023] Open
Abstract
Background To determine whether initiation of a tumor necrosis factor inhibitor (TNFi) or methotrexate improves hemoglobin A1c in patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA), or ankylosing spondylitis (AS) who also have diabetes mellitus (DM). Methods A retrospective cohort study was conducted in Optum's de-identified Clinformatics® Data Mart Database, an administrative claims database, using data from 2000 to 2014. Patients with PsA, RA, or AS, with DM (defined by ICD-9-CM codes) and/or HbA1c ≥7%, who newly initiated either a TNFi, MTX, or metformin (positive control) were identified. The change in HbA1c after drug initiation was calculated. Statistical differences in the change in HbA1c between drugs were assessed using the Wilcoxon rank sum test and linear regression models adjusting for potential confounders. Results Among 10,389 drug initiations in 9541 patients with PsA, RA, or AS, and available HbA1c values, HbA1c was ≥7 at baseline in 254 (35%) TNFi initiations, 361(37%) MTX initiations, and 2144 (50%) metformin initiations. Median HbA1c change was - 0.35 (IQR -1.10, 0.30) after TNFi initiation, - 0.40 (IQR -1.20, 0.30) after MTX initiation, and - 0.80 (IQR -1.60, - 0.10) after metformin initiation. In adjusted analyses, TNFi initiators had less of a decrease in HbA1c compared to MTX initiators (β 0.22, 95% CI: 0.004, 0.43), p = 0.046. Metformin initiators had a significantly greater decrease in HbA1c than MTX, β - 0.38 (95% CI: - 0.52, - 0.23), p < 0.001. Glucocorticoid use was not accounted for in the models. Conclusion HbA1c decreased with TNFi initiation or MTX initiation. Reductions in HbA1c after initiation of a TNFi or MTX are about half (~ 0.4 units) the decrease observed after initiation of metformin.
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Affiliation(s)
- Santhi Mantravadi
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 132 South 10th Street, 1170 Main Building, Philadelphia, PA 19107-5244 USA.,Department of Medicine, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, White Building Rm 5023, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Michael George
- Department of Medicine, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, White Building Rm 5023, 3400 Spruce St, Philadelphia, PA 19104 USA.,Department of Biostatistics, Epidemiology, and Informatics, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 USA
| | - Colleen Brensinger
- Department of Biostatistics, Epidemiology, and Informatics, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 USA
| | - Min Du
- Department of Biostatistics, Epidemiology, and Informatics, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 USA
| | - Joshua F Baker
- Department of Medicine, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, White Building Rm 5023, 3400 Spruce St, Philadelphia, PA 19104 USA.,Department of Biostatistics, Epidemiology, and Informatics, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 USA
| | - Alexis Ogdie
- Department of Medicine, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, White Building Rm 5023, 3400 Spruce St, Philadelphia, PA 19104 USA.,Department of Biostatistics, Epidemiology, and Informatics, Division of Rheumatology, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 USA
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17
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Sammon CJ, Leahy TP, Ramagopalan S. Nonindependence of patient data in the clinical practice research datalink: a case study in atrial fibrillation patients. J Comp Eff Res 2020; 9:395-403. [DOI: 10.2217/cer-2019-0191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The impact of different strategies to handle patients with data recorded under multiple Clinical Practice Research Datalink (CPRD) identifiers (IDs) is unknown. Patients and methods: Six approaches to handling patients appearing under multiple CPRD IDs were defined. The impact of the approaches was illustrated using a case study describing the clinical characteristics of a population of nonvalvular atrial fibrillation patients. Results: 5.6% of patients had more than one CPRD ID. Across all six approaches implemented, no material difference in the characteristics of nonvalvular atrial fibrillation patients were observed. Conclusion: While strategies which longitudinally append patient registration periods under different CPRD IDs maintain independence while using all available data, their implementation had little impact on the results of our case study.
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Affiliation(s)
| | | | - Sreeram Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UK
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18
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Roberto G, Spini A, Bartolini C, Moscatelli V, Barchielli A, Paoletti D, Giorgi S, Fabbri A, Bocchia M, Donnini S, Gini R, Ziche M. Real word evidence on rituximab utilization: Combining administrative and hospital-pharmacy data. PLoS One 2020; 15:e0229973. [PMID: 32163477 PMCID: PMC7067445 DOI: 10.1371/journal.pone.0229973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/17/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To describe patterns of utilization, survival and infectious events in patients treated with rituximab at the University Hospital of Siena (UHS) to explore the feasibility of combining routinely collected administrative and hospital-pharmacy data for examining the real-world use of intravenous antineoplastic drugs. METHODS A retrospective, longitudinal cohort study was conducted using data from the Hospital Pharmacy of Siena (HPS) and the Regional Administrative Database of Tuscany (RAD). Patients aged ≥18 years with ≥1 rituximab administration recorded between January 2012 and June 2016 were identified in the HPS database. Anonymized patient-level data were linked to RAD. Rituximab utilization during the first year of treatment was described using HPS. Hospital diagnoses of adverse infectious events that occurred during the first year of follow-up and four-year survival were observed using RAD. RESULTS A total of 311 new users of rituximab were identified: 264 patients received rituximab for non-Hodgkin's lymphoma (NHL) and 47 were treated for chronic lymphocytic leukemia (CLL). Among new users with one complete year of follow-up (n = 203) over 95% received rituximab as the first-line treatment, and approximately 70% of them received 5-8 doses. No patient in the CLL group received >8 administrations. Four-year survival was approximately 70% in both CLL and NHL patients. Sepsis was the most frequent infectious event observed (5.1%). CONCLUSION HPS and RAD provided complementary information on rituximab utilization, demonstrating their potential for future pharmacoepidemiological studies on antineoplastic medications administered in the Italian hospital setting. Overall, this general description of the real-world utilization of rituximab in patients treated for NHL and CLL at UHS was in line with treatment guidelines and current knowledge on the rituximab safety profile.
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MESH Headings
- Administration, Intravenous
- Administrative Claims, Healthcare/statistics & numerical data
- Adolescent
- Adult
- Aged
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Databases, Factual/statistics & numerical data
- Drug Utilization/statistics & numerical data
- Female
- Follow-Up Studies
- Humans
- Infections/chemically induced
- Infections/epidemiology
- Infections/immunology
- Italy/epidemiology
- Kaplan-Meier Estimate
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Longitudinal Studies
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/immunology
- Lymphoma, Non-Hodgkin/mortality
- Male
- Middle Aged
- Pharmacy Service, Hospital/statistics & numerical data
- Retrospective Studies
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Time Factors
- Treatment Outcome
- Young Adult
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Affiliation(s)
| | - Andrea Spini
- Department of Medical Science, Surgery and Neuroscience, University of Siena, and Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | | | | | | | - Davide Paoletti
- Farmacia Oncologica, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Silvano Giorgi
- Farmacia Oncologica, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Alberto Fabbri
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | - Monica Bocchia
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | - Sandra Donnini
- Department of Life sciences, University of Siena, Siena, Italy
| | - Rosa Gini
- Agenzia Regionale di Sanità della Toscana, Firenze, Italy
| | - Marina Ziche
- Department of Medical Science, Surgery and Neuroscience, University of Siena, and Azienda Ospedaliera Universitaria Senese, Siena, Italy
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19
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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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Schultze A, Graham S, Nordstrom BL, Mehmud F, Ramagopalan SV. Commonly used definitions in real-world studies may underestimate the prevalence of renal disease among nonvalvular atrial fibrillation patients. J Comp Eff Res 2019; 8:961-968. [PMID: 31317772 DOI: 10.2217/cer-2019-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To describe comorbidities among treated nonvalvular atrial fibrillation (NVAF) patients and assess the impact of using different time ('look back' windows) on the prevalence estimates. Patients & methods: We included all adult nonvalvular atrial fibrillation patients newly initiating treatment in the Clinical Practice Research Datalink. Comorbidities included in the Charlson Comorbidity Index were defined using an all available, 3- and 1-year look back window before the start of treatment. Results: The prevalence of comorbidities was high and increased when using longer look back windows; the largest difference was observed for renal disease (+15.6%). Conclusion: Our findings emphasize the importance of using all available data when characterizing chronic conditions and highlights the high comorbidity burden in this population.
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Affiliation(s)
| | | | | | - Faisal Mehmud
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
| | - Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, Uxbridge, UB8 1DH, UK
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21
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Lyu H, Yoshida K, Tedeschi SK, Zhao S, Xu C, Nigwekar SU, Leder BZ, Solomon DH. Intervals between bone mineral density testing with dual-energy X-ray absorptiometry scans in clinical practice. Osteoporos Int 2019; 30:923-927. [PMID: 30680429 PMCID: PMC6499657 DOI: 10.1007/s00198-019-04847-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/06/2019] [Indexed: 11/28/2022]
Abstract
Intervals between dual-energy X-ray absorptiometry (DXA) scans were evaluated in a large cohort of typical clinical practice. Intensive DXA scanning (intervals < 23 months) decreased substantially, from 16.7% in 2006 to 6.7% in 2015. INTRODUCTION Serial dual-energy X-ray absorptiometry (DXA) measurements are suggested for patients at high risk of fractures. However, little is known about how often DXA testing occurs in clinical practice. METHODS We examined time intervals between DXA testing for monitoring purpose at two academic medical centers in the US between 2004 and 2017. The primary outcome was the presence of testing intervals < 23 months (termed "intensive DXA testing"). A generalized linear mixed model was used to evaluate the association between selected patient-level clinical factors and intensive DXA testing. RESULTS Forty-nine thousand four hundred ninety-four DXA tests from 20,200 patients were analyzed. The mean time interval between scans was 36 ± 21 months. Only 11.1% of the repeated DXA testing met the criterion for intensive testing. The percentage of intensive DXA testing dropped from 16.7% in 2006 to 6.7% in 2015 (p for trend < 0.001). After adjusting for age, gender, number of outpatient visits, and calendar year, correlates of intensive DXA testing included a baseline T-score < -2.5 at any anatomic site (OR, 4.8; 95%CI, 4.0-5.7), active use of drugs for osteoporosis (OR, 1.6; 95%CI, 1.3-1.9), and active use of glucocorticoids (OR, 1.3; 95%CI, 1.2-1.4). CONCLUSIONS The predictors of intensive DXA testing suggest that this practice is used preferentially in patients with multiple risk factors and to monitor the response to pharmacotherapy. However, intensive DXA testing has become less common in real-world clinical practice over the last decade. Further studies are required to better define the optimal use of bone mineral density testing in this vulnerable population.
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Affiliation(s)
- H Lyu
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - K Yoshida
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - S K Tedeschi
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - S Zhao
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - C Xu
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
| | - S U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - B Z Leder
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - D H Solomon
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA.
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Dregan A, Matcham F, Harber-Aschan L, Rayner L, Brailean A, Davis K, Hatch S, Pariante C, Armstrong D, Stewart R, Hotopf M. Common mental disorders within chronic inflammatory disorders: a primary care database prospective investigation. Ann Rheum Dis 2019; 78:688-695. [DOI: 10.1136/annrheumdis-2018-214676] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/24/2019] [Accepted: 02/17/2019] [Indexed: 01/30/2023]
Abstract
ObjectiveThere is inconsistent evidence about the association between inflammatory disorders and depression and anxiety onset in a primary care context. The study aimed to evaluate the risk of depression and anxiety within multisystem and organ-specific inflammatory disorders.MethodsThis is a prospective cohort study with primary care patients from the UK Clinical Practice Research Datalink diagnosed with an inflammatory disorder between 1 January 2001 and 31 December 2016. These patients were matched on age, gender, practice and index date with patients without an inflammatory disorder. The study exposures were seven chronic inflammatory disorders. Clinical diagnosis of depression and anxiety represented the outcome measures of interest.ResultsAmong 538 707 participants, the incidence of depression ranged from 14 per 1000 person-years (severe psoriasis) to 9 per 1000 person-years (systemic vasculitis), substantively higher compared with their comparison group (5–7 per 1000 person-years). HRs of multiple depression and anxiety events were 16% higher within inflammatory disorders (HR, 1.16, 95% CI 1.12 to 1.21, p<0.001) compared with the matched comparison group. The incidence of depression and anxiety was strongly associated with the age at inflammatory disorder onset. The overall HR estimate for depression was 1.90 (95% CI 1.66 to 2.17, p<0.001) within early-onset disorder (<40 years of age) and 0.93 (95% CI 0.90 to 1.09, p=0.80) within late-onset disorder (≥60 years of age).ConclusionsPrimary care patients with inflammatory disorders have elevated rates of depression and anxiety incidence, particularly those patients with early-onset inflammatory disorders. This finding may reflect the impact of the underlying disease on patients’ quality of life, although the precise mechanisms require further investigation.
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Connolly JG, Schneeweiss S, Glynn RJ, Gagne JJ. Quantifying bias reduction with fixed-duration versus all-available covariate assessment periods. Pharmacoepidemiol Drug Saf 2019; 28:665-670. [PMID: 30786103 DOI: 10.1002/pds.4729] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 11/08/2022]
Abstract
PURPOSE Implementing a cohort study in longitudinal healthcare databases requires looking back over some covariate assessment period (CAP) preceding cohort entry to measure confounders. We used simulations to compare fixed-duration versus all-available CAPs for confounder adjustment in the presence of differences in available baseline time between exposure groups. METHODS We simulated cohorts of 10 000 patients with binary variables for a single confounder, exposure, and outcome. Baseline time was simulated based on the observed distribution in a claims-based comparison of statin users versus nonusers. We compared bias after measuring confounders using fixed-duration and all-available CAPs, both when exposure groups had similar and discrepant amounts of available baseline time. RESULTS When the comparison groups had similar amounts of baseline time, an all-available CAP was less biased than a fixed-duration CAP. When baseline time differed between comparison groups, the preferable CAP approach depended on the direction of confounding and which exposure group had higher covariate sensitivity. These findings were consistent in direction across sensitivity analyses. CONCLUSION In certain settings of differential available baseline time between exposure groups, the all-available CAP was more biased than the fixed-duration CAP. The relative directions and strengths of confounding and misclassification biases are an important consideration when choosing between a fixed-duration or all-available CAP, but they are often unknown. Therefore, we recommend comparing the amount of available baseline time between exposure groups. When there is a large discrepancy, despite appropriate design choices, we recommend a fixed-duration approach to avoid potential increases in bias because of differential data availability.
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Affiliation(s)
- John G Connolly
- 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
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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24
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Rassen JA, Bartels DB, Schneeweiss S, Patrick AR, Murk W. Measuring prevalence and incidence of chronic conditions in claims and electronic health record databases. Clin Epidemiol 2018; 11:1-15. [PMID: 30588119 PMCID: PMC6301730 DOI: 10.2147/clep.s181242] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Health care databases are natural sources for estimating prevalence and incidence of chronic conditions, but substantial variation in estimates limits their interpretability and utility. We evaluated the effects of design choices when estimating prevalence and incidence in claims and electronic health record databases. Methods Prevalence and incidence for five chronic diseases at increasing levels of expected frequencies, from cystic fibrosis to COPD, were estimated in the Clinical Practice Research Datalink (CPRD) and MarketScan databases from 2011 to 2014. Estimates were compared using different definitions of lookback time and contributed person-time. Results Variation in lookback time substantially affected estimates. In 2014, for CPRD, use of an all-time vs a 1-year lookback window resulted in 4.3–8.3 times higher prevalence (depending on disease), reducing incidence by 1.9–3.3 times. All-time lookback resulted in strong temporal trends. COPD prevalence between 2011 and 2014 in MarketScan increased by 25% with an all-time lookback but stayed relatively constant with a 1-year lookback. Varying observability did not substantially affect estimates. Conclusion This framework draws attention to the underrecognized potential for widely varying incidence and prevalence estimates, with implications for care planning and drug development. Though prevalence and incidence are seemingly straightforward concepts, careful consideration of methodology is required to obtain meaningful estimates from health care databases.
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Affiliation(s)
| | | | - Sebastian Schneeweiss
- Aetion, Inc, New York, NY, USA, .,Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - William Murk
- Aetion, Inc, New York, NY, USA, .,Jacobs School of Medicine, University at Buffalo, Buffalo, NY, USA
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25
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Hurtado-Navarro I, García-Sempere A, Rodríguez-Bernal C, Santa-Ana-Tellez Y, Peiró S, Sanfélix-Gimeno G. Estimating Adherence Based on Prescription or Dispensation Information: Impact on Thresholds and Outcomes. A Real-World Study With Atrial Fibrillation Patients Treated With Oral Anticoagulants in Spain. Front Pharmacol 2018; 9:1353. [PMID: 30559661 PMCID: PMC6287024 DOI: 10.3389/fphar.2018.01353] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 11/05/2018] [Indexed: 01/13/2023] Open
Abstract
Objective: To estimate drug exposure, Proportion of Days Covered (PDC) and percentage of patients with PDC ≥ 80% from a cohort of atrial fibrillation patients initiating oral anticoagulant (OAC) treatment. We employed three different approaches to estimate PDC, using either data from prescription and dispensing (PD cohort) or two common designs based on dispensing information only, requiring at least one (D1) or at least two (D2) refills for inclusion in the cohorts. Finally, we assessed the impact of adherence on health outcomes according to each method. Methods: Population-based retrospective cohort of all patients with Non Valvular Atrial Fibrillation (NVAF), who were newly prescribed acenocoumarol, apixaban, dabigatran or rivaroxaban from November 2011 to December 2015 in the region of Valencia (Spain). Patients were followed for 12 months to assess adherence using three different approaches (PD, D1 and D2 cohorts). To analyze the relationship between adherence (PDC ≥ 80) defined according to each method of calculation and health outcomes (death for any cause, stroke or bleeding) Cox regression models were used. For the identification of clinical events patients were followed from the end of the adherence assessment period to the end of the available follow-up period. Results: PD cohort included all patients with an OAC prescription (n = 38,802), D1 cohort excluded fully non-adherent patients (n = 265) and D2 cohort also excluded patients without two refills separated by 180 days (n = 2,614). PDC ≥ 80% ranged from 94% in the PD cohort to 75% in the D1 cohort. Drug exposure among adherent (PDC ≥ 80%) and non-adherent (PDC < 80%) patients was different between cohorts. In adjusted analysis, high adherence was associated with a reduced risk of death [Hazard Ratio (HR): from 0.82 to 0.86] and (except in the PD cohort) the risk for ischemic stroke (HR: from 0.61 to 0.64) without increasing the risk of bleeding. Conclusion: Common approaches to assess adherence using measures based on days' supply exclude groups of non-adherent patients and, also, misattribute periods of doctors' discontinuation to patient non-adherence, misestimating adherence overall. Physician-initiated discontinuation is a major contributor to reduced OAC exposure. When using the PDC80 threshold, very different groups of patients may be classified as adherent or non-adherent depending on the method used for the calculation of days' supply measures. High adherence and high exposure to OAC treatment in NVAF patients is associated with better health outcomes.
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Affiliation(s)
- Isabel Hurtado-Navarro
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Aníbal García-Sempere
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Clara Rodríguez-Bernal
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Yared Santa-Ana-Tellez
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Salvador Peiró
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
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26
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Young JC, Conover MM, Jonsson Funk M. Measurement Error and Misclassification in Electronic Medical Records: Methods to Mitigate Bias. CURR EPIDEMIOL REP 2018; 5:343-356. [PMID: 35633879 PMCID: PMC9141310 DOI: 10.1007/s40471-018-0164-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW We sought to: 1) examine common sources of measurement error in research using data from electronic medical records (EMR), 2) discuss methods to assess the extent and type of measurement error, and 3) describe recent developments in methods to address this source of bias. RECENT FINDINGS We identified eight sources of measurement error frequently encountered in EMR studies, the most prominent being that EMR data usually reflect only the health services and medications delivered within the specific health facility/system contributing to the EMR data. Methods for assessing measurement error in EMR data usually require gold standard or validation data, which may be possible using data linkage. Recent methodological developments to address the impact of measurement error in EMR analyses were particularly rich in the multiple imputation literature. SUMMARY Presently, sources of measurement error impacting EMR studies are still being elucidated, as are methods for assessing and addressing them. Given the magnitude of measurement error that has been reported, investigators are urged to carefully evaluate and rigorously address this potential source of bias in studies based in EMR data.
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27
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Conover MM, Stürmer T, Poole C, Glynn RJ, Simpson RJ, Pate V, Jonsson Funk M. Classifying medical histories in US Medicare beneficiaries using fixed vs all-available look-back approaches. Pharmacoepidemiol Drug Saf 2018; 27:771-780. [PMID: 29655187 DOI: 10.1002/pds.4435] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 03/02/2018] [Accepted: 03/12/2018] [Indexed: 11/10/2022]
Abstract
PURPOSE Evaluate use of fixed and all-available look-backs to identify eligibility criteria and confounders among Medicare beneficiaries. METHODS We identified outpatient visits (2007-2012) with recently documented (≤180 days) cardiovascular risk and classified patients according to whether the exposure (statin) was initiated within 14 days. We selected each beneficiary's first eligible visit (in each treatment group) that met criteria during the respective look-backs: continuous enrollment (1 or 3 years for fixed look-back; 180 days for all-available), no cancer history, and no statin claims. We estimated crude and standardized mortality ratio weighted hazard ratios (HRs) for the effect of statin initiation on incident 6-month cancer (a known null effect) and 2-year mortality, separately, adjusting for covariates assessed by using each look-back. RESULTS Analyzing short-term cancer, the estimated HR from the all-available approach (HR = 0.90, 95% CI: 0.83, 0.98) was less biased than the 1-year look-back (HR = 0.79, 95% CI: 0.73, 0.84), which included beneficiaries with prevalent cancer. The 3-year look-back (HR = 1.05, 95% CI: 0.90, 1.21) was somewhat less biased than the all-available estimate but less precise due the exclusion of a large proportion of observations without sufficient continuous enrollment (62.0% and 59.9% of initiators and non-initiators, respectively). All approaches produced similar estimates of the effect on all-cause mortality. Alternative look-backs did not differ in their ability to control confounding. CONCLUSIONS The all-available look-back performed nearly as well as the 3-year fixed, which produced the least biased point estimate. If 3-year look-backs are infeasible (eg, due to power/sample), all-available look-backs may be preferable to short (1-year) fixed look-backs.
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Affiliation(s)
- Mitchell M Conover
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Til Stürmer
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charles Poole
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ross J Simpson
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Virginia Pate
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michele Jonsson Funk
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Curtis JR, Xie F, Chen L, Greenberg JD, Zhang J. Evaluation of a Methodologic Approach to Define an Inception Cohort of Rheumatoid Arthritis Patients Using Administrative Data. Arthritis Care Res (Hoboken) 2018; 70:1541-1545. [PMID: 29409118 DOI: 10.1002/acr.23533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/30/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Identifying incident rheumatoid arthritis (RA) is desirable in order to create inception cohorts. We evaluated an approach to identify incident RA in health plan claims data. METHODS Both Medicare and commercial claims data were linked to Corrona, a US RA registry. We evaluated the accuracy of year of RA onset in the registry (gold standard) versus different claims algorithms, varying International Classification of Diseases, Ninth Revision codes for RA/arthritis, duration of health plan enrollment preceding diagnosis (minimum of 1 versus 2 years), and use of RA medications. Results were reported as positive predictive values (PPVs) of the claims-based algorithm for incident RA. RESULTS Depending on the algorithm tested and whether patients were enrolled in Medicare or the commercial health plan, the PPVs for incident RA ranged from 68-81%. A 2-year clean period free of all RA-related diagnoses and medications was somewhat more optimal although, by comparison, a 1-year clean period yielded similar PPVs and retained approximately 90% more RA patients for analysis. CONCLUSION Claims-based algorithms can accurately identify incident RA.
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Affiliation(s)
| | | | | | - Jeffrey D Greenberg
- Corrona, Southborough, Massachusetts, and New York University School of Medicine, New York, New York
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Jackson JW, Schmid I, Stuart EA. Propensity Scores in Pharmacoepidemiology: Beyond the Horizon. CURR EPIDEMIOL REP 2017; 4:271-280. [PMID: 29456922 DOI: 10.1007/s40471-017-0131-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose of review Propensity score methods have become commonplace in pharmacoepidemiology over the past decade. Their adoption has confronted formidable obstacles that arise from pharmacoepidemiology's reliance on large healthcare databases of considerable heterogeneity and complexity. These include identifying clinically meaningful samples, defining treatment comparisons, and measuring covariates in ways that respect sound epidemiologic study design. Additional complexities involve correctly modeling treatment decisions in the face of variation in healthcare practice, and dealing with missing information and unmeasured confounding. In this review, we examine the application of propensity score methods in pharmacoepidemiology with particular attention to these and other issues, with an eye towards standards of practice, recent methodological advances, and opportunities for future progress. Recent findings Propensity score methods have matured in ways that can advance comparative effectiveness and safety research in pharmacoepidemiology. These include natural extensions for categorical treatments, matching algorithms that can optimize sample size given design constraints, weighting estimators that asymptotically target matched and overlap samples, and the incorporation of machine learning to aid in covariate selection and model building. Summary These recent and encouraging advances should be further evaluated through simulation and empirical studies, but nonetheless represent a bright path ahead for the observational study of treatment benefits and harms.
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Affiliation(s)
- John W Jackson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Ian Schmid
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
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Lin TC, Solomon DH, Tedeschi SK, Yoshida K, Kao Yang YH. Comparative Risk of Cardiovascular Outcomes Between Topical and Oral Nonselective NSAIDs in Taiwanese Patients With Rheumatoid Arthritis. J Am Heart Assoc 2017; 6:e006874. [PMID: 29079568 PMCID: PMC5721772 DOI: 10.1161/jaha.117.006874] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/26/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Topical NSAIDs have less systemic absorption than oral NSAIDs. We examined the risk of cardiovascular events associated with nonselective topical NSAIDs versus oral NSAIDs among patients with rheumatoid arthritis in Taiwan. METHODS AND RESULTS We conducted a retrospective cohort study that included patients with incident rheumatoid arthritis who were newly starting therapy with nonselective topical NSAIDs or oral NSAIDs. We used the Taiwan National Health Insurance Research Database (NHIRD). The first date patients received either type of NSAID was defined as the index date. NSAID exposures continued until there was a treatment gap of >30 days. The main outcome was composite cardiovascular events, including myocardial infarction, unstable angina, heart failure, stroke, or revascularization. Follow-up was censored at treatment discontinuation, switch or addition of other NSAID category, cardiovascular outcome, death, or the end of the study. Propensity score weighted Cox regression models were used to compare the risk of cardiovascular events between topical NSAIDs and oral NSAIDs. There were 10 758 and 78 056 treatment episodes for topical and oral NSAIDs identified. After weighting by propensity score, the cohorts were well balanced over all covariates. The crude cardiovascular event rate was 1.87 per 100 person-years for topical NSAIDs and 2.14 per 100 person-years for oral NSAIDs. Results of propensity score weighted Cox regression found the topical NSAID group had 36% lower risk for cardiovascular events compared with the oral NSAID group (hazard ratio, 0.64; 95% confidence interval, 0.43-0.95). CONCLUSIONS We found topical NSAID users experienced a reduced risk of cardiovascular events compared with oral NSAID users. If future studies with a larger sample size and longer follow-up confirm these results, NSAID prescribing might change accordingly.
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Affiliation(s)
- Tzu-Chieh Lin
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Daniel H Solomon
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Pharmacoepideimiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA
| | - Sara K Tedeschi
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kazuki Yoshida
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Yea-Huei Kao Yang
- Health Outcome Research Center, National Cheng Kung University, Tainan, Taiwan
- School of Pharmacy, College of Medicine, Tainan, Taiwan
- Institute of Clinical Pharmacy and Pharmaceutical Science, National Cheng Kung University, Tainan, Taiwan
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Horton DB, Haynes K, Denburg MR, Thacker MM, Rose CD, Putt ME, Leonard MB, Strom BL. Oral glucocorticoid use and osteonecrosis in children and adults with chronic inflammatory diseases: a population-based cohort study. BMJ Open 2017; 7:e016788. [PMID: 28733303 PMCID: PMC5642748 DOI: 10.1136/bmjopen-2017-016788] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We studied oral glucocorticoids and osteonecrosis, a rare but serious bone disease, in individuals with various chronic inflammatory diseases. We hypothesised that we would find stronger associations in adults versus children and in people with autoimmune diseases. DESIGN Retrospective cohort study. SETTING Population-representative data (1994-2013) from general practices in the UK. PARTICIPANTS Children and adults diagnosed with asthma; inflammatory bowel disease; juvenile, psoriatic or rheumatoid arthritis; psoriasis; or systemic lupus. EXPOSURES Oral glucocorticoid patterns. PRIMARY AND SECONDARY OUTCOME MEASURES Diagnosed osteonecrosis (primary) and osteonecrosis plus clinical features (eg, symptoms, pain medication, surgical repair) (secondary). Discrete time failure models estimated the adjusted hazard ratio (aHR) of incident osteonecrosis following oral glucocorticoid exposure. Hypothesis testing was one sided (with corresponding 90% CI) since glucocorticoids were unlikely protective. RESULTS After adjusting for demographic, disease-related and health utilisation factors, glucocorticoid exposure was associated with osteonecrosis in adults (ages 18-49, aHR 2.1 (90% CI 1.5 to 2.9); ages ≥50, aHR 1.3 (90% CI 1.01 to 1.7)). However, low-dose glucocorticoids, corresponding to average doses <7.5 mg prednisolone daily and maximum doses <30 mg daily, were not associated with osteonecrosis in adults. Furthermore, even at high glucocorticoid doses, there was no evidence of increased osteonecrosis among glucocorticoid-exposed children (p=0.04 for interaction by age) (any glucocorticoid exposure, ages 2-9: aHR 1.1 (90% CI 0.7 to 1.7); ages 10-17: aHR 0.6 (90% CI 0.3 to 1.6)). Arthritis, inflammatory bowel disease and lupus were independently associated with osteonecrosis, but there was a similar dose relationship between glucocorticoids and osteonecrosis among adults with low-risk and high-risk diseases. CONCLUSIONS Glucocorticoid use was clearly associated with osteonecrosis in a dose-related fashion in adults, especially young adults, but this risk was not detectable in children. The absolute risk of glucocorticoid-associated osteonecrosis in the general paediatric population and in adults taking low glucocorticoid doses is at most extremely small.
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Affiliation(s)
- Daniel B Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers School of Public Health, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey, USA
| | | | - Michelle R Denburg
- Division of Nephrology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mihir M Thacker
- Department of Orthopedics, Nemours A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware, USA
| | - Carlos D Rose
- Division of Rheumatology, Department of Pediatrics, Nemours A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware, USA
| | - Mary E Putt
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary B Leonard
- Division of Nephrology, Departments of Pediatrics and Medicine, Stanford School of Medicine, Stanford University, Stanford, California, USA
| | - Brian L Strom
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
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