A systematic review of methods for determining cross-sectional active medications using pharmacy databases

Short-acting β2-agonists (SABA) overuse in asthma and patients' perceptions for this behavior

BACKGROUND

Short-acting β2-agonists (SABA) overuse is associated with poor asthma control. The Global Initiative for Asthma (GINA) 2019-updated strategy report has therefore taken a paradigm shift in reliever therapy recommendations.

OBJECTIVES

(I) To investigate the status of SABA overuse and medication dispensing patters in asthma in the Netherlands (II) validate dispensing data for SABA overuse identification and (III) understand patients' perspectives towards this SABA-taking behavior to inform future improvement strategies.

METHODS

An annually repeated cross-sectional study was conducted from 2017 to 2021 using pharmacy dispensing data in a real-world setting, including asthma patients aged 18-45 with ≥1 inhaler. A following qualitative study was performed in identified SABA overusing patients with a questionnaire and semi-structured interviews, supported by theoretical frameworks.

RESULTS

Dispensing data was available from 87 % of all community pharmacies (n = 1994) in 2017 and 95 % (n = 2005) in 2021. SABA overuse prevalence was constant for the five study-years with 20.6 % (±0.5 %). Increased ICS-formoterol and decreased SABA dispenses were observed in starters of inhalation therapy in 2021. 53 asthma patients completed the questionnaire of whom 43 patients confirmed SABA overuse, generating a positive predictive value of 81 %. Key behavioral drivers covered 7 themes regarding capability (knowledge; skills; memory, attention and decision process) motivation (emotion; beliefs about-capabilities; consequences) and opportunity (environmental context).

CONCLUSION

SABA overuse remains in one-fifth of asthma patients across the Netherlands, requiring careful attention from healthcare professionals. Dispensing data is a valid measure for SABA overuse in a clinical setting, facilitating patient selection. To meet patients' varied supporting needs, integration of tailored behavioral interventions is essential.

Initiation of oral anticoagulation in US older adults newly diagnosed with atrial fibrillation during hospitalization

BACKGROUND

Atrial fibrillation is a common cause of stroke among older adults and is often first detected during hospitalization, given frequent use of cardiac telemetry.

METHODS

In a 20% national sample of Medicare fee-for-service beneficiaries, we identified patients aged 65-or-older newly diagnosed with atrial fibrillation while hospitalized in 2016. Our primary outcome was an oral anticoagulant claim within 7-days of discharge. Multivariable logistic regression analyses assessed relationships between anticoagulation initiation and thromboembolic and bleeding risk scores while controlling for demographics, frailty, comorbidities, and hospitalization characteristics.

RESULTS

Among 38,379 older adults newly diagnosed with atrial fibrillation while hospitalized (mean age 78.2 [SD 8.4]; 51.8% female; 83.3% white), 36,633 (95.4%) had an indication for anticoagulation and 24.6% (9011) of those initiated an oral anticoagulant following discharge. Higher CHA2 DS2 -VASc score was associated with a small increase in oral anticoagulant initiation (predicted probability 20.5% [95% CI, 18.7%-22.3%] for scores <2 and 24.9% [CI, 24.4%-25.4%] for ≥4). Elevated HAS-BLED score was associated with a small decrease in probability of anticoagulant initiation (25.4% [CI, 24.4%-26.4%] for score <2 and 23.1% [CI, 22.5%-23.8%] for ≥3). Frailty was associated with decreased likelihood of oral anticoagulant initiation (24.7% [CI, 23.2%-26.2%] for non-frail and 18.1% [CI, 16.6%-19.6%] for moderately-severely frail). Anticoagulant initiation varied by primary reason for hospitalization, with predicted probability highest among patients with a primary diagnosis of atrial fibrillation (46.1% [CI, 45.0%-47.3%]) and lowest among those with non-cardiovascular conditions (13.8% [CI, 13.3%-14.3%]) and bleeds (3.6% [CI, 2.4%-4.8%]).

CONCLUSIONS

Oral anticoagulant initiation is uncommon among older adults newly diagnosed with atrial fibrillation during hospitalization, even among patients hospitalized primarily for atrial fibrillation and patients with high thromboembolic risk. Clinicians should discuss risks and benefits of oral anticoagulants with all inpatients found to have atrial fibrillation.

New psychotropic medication use among Medicare beneficiaries with dementia after hospital discharge

BACKGROUND

Hospitalizations among people with dementia (PWD) may precipitate behavioral changes, leading to the psychotropic medication use despite adverse outcomes and limited efficacy. We sought to determine the incidence of new psychotropic medication use among community-dwelling PWD after hospital discharge and, among new users, the proportion with prolonged use.

METHODS

This was a retrospective cohort study using a 20% random sample of Medicare claims in 2017, including hospitalized PWD with traditional and Part D Medicare who were 68 years or older. The primary outcome was incident prescribing at discharge of psychotropics including antipsychotics, sedative-hypnotics, antiepileptics, and antidepressants. This was defined as new prescription fills (i.e., from classes not used in 180 days preadmission) within 7 days of hospital or skilled nursing facility discharge. Prolonged use was defined as the proportion of new users who continued to fill newly prescribed medications beyond 90 days of discharge.

RESULTS

The cohort included 117,022 hospitalized PWD with a mean age of 81 years; 63% were female. Preadmission, 63% were using at least 1 psychotropic medication; 10% were using medications from ≥3 psychotropic classes. These included antidepressants (44% preadmission), antiepileptics (29%), sedative-hypnotics (21%), and antipsychotics (11%). The proportion of PWD discharged from the hospital with new psychotropics ranged from 1.9% (antipsychotics) to 2.9% (antiepileptics); 6.6% had at least one new class started. Among new users, prolonged use ranged from 36% (sedative-hypnotics) to 63% (antidepressants); across drug classes, prolonged use occurred in 51%. Predictors of newly initiated psychotropics included length of stay (≥median vs.

CONCLUSIONS

Hospitalized PWD have a high prevalence of preadmission psychotropic medication use; against this baseline, discharge from the hospital with new psychotropics is relatively uncommon. Nevertheless, prolonged use of newly initiated psychotropics occurs in a substantial proportion of this population.

Collapse

Key Words

• dementia
• hospitalization
• prescribing
• psychotropics

Collapse

MESH Headings

• Humans
• Female
• Aged
• United States
• Aged, 80 and over
• Male
• Patient Discharge
• Retrospective Studies
• Anticonvulsants/therapeutic use
• Dementia/drug therapy
• Medicare
• Psychotropic Drugs/therapeutic use
• Antipsychotic Agents/therapeutic use
• Antidepressive Agents/therapeutic use
• Hospitals
• Hypnotics and Sedatives/therapeutic use

Collapse

Grants

• K12 HS026383 AHRQ HHS
• L30 AG074160 NIA NIH HHS
• R24 AG064025 NIA NIH HHS
• K24 AG049057 NIA NIH HHS
• R35 AG071916 NIA NIH HHS
• R03 AG064373 NIA NIH HHS
• T32 AG000212 NIA NIH HHS
• P01 AG066605 NIA NIH HHS
• K01 AG073532 NIA NIH HHS
• P30 AG044281 NIA NIH HHS
• R03 AG078804 NIA NIH HHS

Collapse

Affiliation(s)

Matthew E Growdon Division of Geriatrics, University of California, San Francisco, California, USA Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
Siqi Gan Division of Geriatrics, University of California, San Francisco, California, USA Northern California Institute for Research and Education, San Francisco, California, USA
Kristine Yaffe Mental Health, San Francisco VA Medical Center, San Francisco, California, USA Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA Departments of Neurology and Psychiatry, University of California, San Francisco, California, USA
Alexandra K Lee Division of Geriatrics, University of California, San Francisco, California, USA Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
Timothy S Anderson Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Ulrike Muench Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
W John Boscardin Division of Geriatrics, University of California, San Francisco, California, USA Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
Michael A Steinman Division of Geriatrics, University of California, San Francisco, California, USA Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA

Collapse

Is anticholinergic and sedative drug burden associated with postdischarge institutionalization in community-dwelling older patients acutely admitted to hospital? A Norwegian registry-based study

PURPOSE

Investigate the association between anticholinergic (AC) and sedative (SED) drug burden before hospitalization and postdischarge institutionalization (PDI) in community-dwelling older patients acutely admitted to hospital.

METHODS

A cross-sectional study using data from the Norwegian Patient Registry and the Norwegian Prescription Database. We studied acutely hospitalized community-dwelling patients ≥70 years during 2013 (N = 86 509). Patients acutely admitted to geriatric wards underwent subgroup analyses (n = 1715). We calculated drug burden by the Drug Burden Index (DBI), use of AC/SED drugs, and the number of AC/SED drugs. Piecewise linearity of DBI versus PDI and a knot point (DBI = 2.45) was identified. Statistical analyses included an adjusted multivariable logistic regression model.

RESULTS

In the total population, 45.4% were exposed to at least one AC/SED drug, compared to 52.5% in the geriatric subgroup. AC/SED drugs were significantly associated with PDI. The DBI with odds ratios (ORs) of 1.11 (95% CI 1.07-1.15) for DBI < 2.45 and 1.08 (95% CI 1.04-1.13) for DBI ≥ 2.45. The number of AC/SED drugs with OR of 1.07 (95% CI 1.05-1.09). The AC component of DBI with OR 1.23 and the number of AC drugs with OR 1.13. In the subgroup, ORs were closer to 1 for AC drugs.

CONCLUSIONS

The use of AC/SED drugs was highly prevalent in older patients before acute hospital admissions, and significantly associated with PDI. The number, or just using AC/SED drugs, gave similar associations with PDI compared to applying the DBI. Using AC drugs showed higher sensitivity, indicating that to reduce the risk of PDI, a clinical approach could be to reduce the number of AC drugs.

Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System

IMPORTANCE

Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization.

OBJECTIVE

To investigate outcomes associated with intensification of outpatient diabetes medications at discharge.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021.

EXPOSURE

Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge.

RESULTS

The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled.

CONCLUSIONS AND RELEVANCE

In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.

Comparison of measures of medication adherence from pharmacy dispensing and insurer claims data

OBJECTIVE

Medication nonadherence is linked to worsened clinical outcomes and increased costs. Existing system-level adherence interventions rely on insurer claims for patient identification and outcome measurement, yet suffer from incomplete capture and lags in data acquisition. Data from pharmacies regarding prescription filling, captured in retail dispensing, may be more efficient.

DATA SOURCES

Pharmacy fill and insurer claims data.

STUDY DESIGN

We compared adherence measured using pharmacy fill data to adherence using insurer claims data, expressed as proportion of days covered (PDC) over 12 months. Agreement was evaluated using correlation/validation metrics. We also explored the relationship between adherence in both sources and disease control using prediction modeling.

DATA EXTRACTION METHODS

Large pragmatic trial of cardiometabolic disease in an integrated delivery network.

PRINCIPAL FINDINGS

Among 1113 patients, adherence was higher in pharmacy fill (mean = 50.0%) versus claims data (mean = 47.4%), although they had moderately high correlation (R = 0.57, 95% CI: 0.53-0.61) with most patients (86.9%) being similarly classified as adherent or nonadherent. Sensitivity and specificity of pharmacy fill versus claims data were high (0.89, 95% CI: 0.86-0.91 and 0.80, 95% CI: 0.75-0.85). Pharmacy fill-based PDC predicted better disease control slightly more than claims-based PDC, although the difference was nonsignificant.

CONCLUSIONS

Pharmacy fill data may be an alternative to insurer claims for adherence measurement.

Paternal Exposure to Immunosuppressive and/or Biologic Agents and Birth Outcomes in Patients With Immune-Mediated Inflammatory Diseases

BACKGROUND & AIMS

We conducted a retrospective cohort study to inform the safety of exposure to immunosuppressive and/or biologic agents around conception in expectant fathers with immune-mediated inflammatory diseases (IMIDs) on birth outcomes.

METHODS

Using a deidentified administrative claims database (OptumLabs Data Warehouse), we identified 7453 expectant fathers with IMIDs (inflammatory bowel diseases, rheumatoid arthritis, psoriasis/psoriatic arthritis, and ankylosing spondylitis) linked to newborns with periconception medication exposure between 38 and 60 weeks before the newborn birth date (34-58 weeks prior for preterm newborns) and neonatal follow-up for 3 months after the birth date. Through logistic regression adjusting for paternal age and race (and, in a subset, for maternal age, race, presence of IMIDs, and nonsingleton births), we compared the risk of major congenital malformations (primary outcome) and preterm birth and low birth weight in fathers exposed to thiopurines (n = 461), methotrexate (n = 171), tumor necrosis factor (TNF) α antagonists (n = 1082), or non-TNF-targeting biologic agents (n = 132) vs fathers not exposed to any of these medications (n = 5607).

RESULTS

As compared to unexposed fathers (3.4% prevalence of major congenital malformations), exposure to thiopurines (relative risk [RR], 1.12; 95% confidence interval [CI], 0.66-1.76), methotrexate (RR, 0.67; 95% CI, 0.21-1.55), TNF-α antagonists (RR, 1.14; 95% CI, 0.81-1.57), and non-TNF-targeting biologic agents (RR, 1.75; 95% CI, 0.80-3.24) was not associated with increased risk of major congenital malformations. No association was observed between paternal medication exposure and risk of preterm birth or low birth weight. Results were stable on subanalyses of linked father-mother-newborn triads.

CONCLUSIONS

In a large cohort study of 7453 expectant fathers with IMIDs, exposure to immunosuppressive or biologic agents around conception was not associated with increased risk of adverse birth outcomes.

Self-reported medication use among coronary heart disease patients showed high validity compared with dispensing data

OBJECTIVE

To validate self-reported use of medications for secondary prevention of coronary heart disease (CHD) in a population-based health study by comparing self-report with pharmacy dispensing data, and explore different methods for defining medication use in prescription databases.

STUDY DESIGN AND SETTING

Self-reported medication use among participants with CHD (n = 1483) from the seventh wave of the Tromsø Study was linked with the Norwegian Prescription Database (NorPD). Cohen's kappa, sensitivity, specificity, and positive and negative predictive values were calculated, using NorPD as the reference standard. Medication use in NorPD was defined in three ways; fixed-time window of 180 days, and legend-time method assuming a daily dose of one dosage unit or one defined daily dose (DDD).

RESULTS

Kappa-values for antihypertensive drugs, lipid-lowering drugs and acetylsalicylic acid all showed substantial agreement (kappa ≥0.61). Validity varied depending on the method used for defining medication use in NorPD. Applying a fixed-time window gave higher agreement, positive predictive values and specificity compared with the legend-time methods.

CONCLUSION

Self-reported use of medication for secondary prevention of CHD shows high validity when compared with pharmacy dispensing data. For CHD medications, fixed-time window appears to be the most appropriate method for defining medication use in prescription databases.

Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

Importance

Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home.

Objective

To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications.

Design, Setting, and Participants

This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013.

Main Outcomes and Measures

Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics.

Results

Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels.

Conclusions and Relevance

In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.

Validation of self-reported medication use for hypertension, diabetes, and dyslipidemia among employees of large-sized companies in Japan

OBJECTIVE

The aim of this study was to evaluate the validity of self-reported medication use for hypertension, diabetes, and dyslipidemia by comparison with health insurance claims among employees of large-sized companies in Japan.

METHODS

Participants were 61 676 participants of 13 large-sized companies in Japan. Self-reports on medication use were obtained through web- or paper-based questionnaires conducted at the annual health checkup in fiscal year 2016. Health insurance claims for medication were obtained from corporate health insurance associations from April 1, 2016, to March 31, 2017. Agreement rate, sensitivity, specificity, positive and negative predictive values (PPV and NPV), and kappa statistics of self-reporting were examined for different reference periods (1-, 2-, and 3- months, and 1-year). Subgroup analysis was conducted stratified by sex, age, body mass index, smoking, alcohol drinking, blood pressure, hemoglobin A1c, and low-density lipoprotein cholesterol.

RESULTS

Agreement, sensitivity, specificity, PPV, and NPV were 0.98, 0.90, 0.98, 0.87, and 0.99 for hypertension, 0.99, 0.89, 1.00, 0.89, and 1.00 for diabetes, and 0.98, 0.86, 0.99, 0.83, and 0.99 for dyslipidemia, respectively, between self-reports and claims data for 3 months. Kappa statistics were highest with the 3-month reference period of claims data for hypertension, diabetes, and dyslipidemia. No major concordance was observed between the subgroups.

CONCLUSION

This validation of self-reported medication use for hypertension, diabetes, and dyslipidemia showed almost perfect reliability among employees of large-sized companies in Japan.

Comparison of Pharmacy Database Methods for Determining Prevalent Chronic Medication Use

BACKGROUND

Pharmacy dispensing data are frequently used to identify prevalent medication use as a predictor or covariate in observational research studies. Although several methods have been proposed for using pharmacy dispensing data to identify prevalent medication use, little is known about their comparative performance.

OBJECTIVES

The authors sought to compare the performance of different methods for identifying prevalent outpatient medication use.

RESEARCH DESIGN

Outpatient pharmacy fill data were compared with medication reconciliation notes denoting prevalent outpatient medication use at the time of hospital admission for a random sample of 207 patients drawn from a national cohort of patients admitted to Veterans Affairs hospitals. Using reconciliation notes as the criterion standard, we determined the test characteristics of 12 pharmacy database algorithms for determining prevalent use of 11 classes of cardiovascular and diabetes medications.

RESULTS

The best-performing algorithms included a 180-day fixed look-back period approach (sensitivity, 93%; specificity, 97%; and positive predictive value, 89%) and a medication-on-hand approach with a grace period of 60 days (sensitivity, 91%; specificity, 97%; and positive predictive value, 91%). Algorithms that have been commonly used in previous studies, such as defining prevalent medications to include any medications filled in the prior year or only medications filled in the prior 30 days, performed less well. Algorithm performance was less accurate among patients recently receiving hospital or nursing facility care.

CONCLUSION

Pharmacy database algorithms that balance recentness of medication fills with grace periods performed better than more simplistic approaches and should be considered for future studies which examine prevalent chronic medication use.