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Pauly BB, Kurz M, Dale LM, Macevicius C, Kalicum J, Pérez DG, McCall J, Urbanoski K, Barker B, Slaunwhite A, Lindsay M, Nosyk B. Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209341. [PMID: 38490334 DOI: 10.1016/j.josat.2024.209341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/15/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC. METHODS We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation. RESULTS Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure. CONCLUSIONS BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.
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Affiliation(s)
- Bernadette Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Nursing, Box 1700 Stn CSC, Victoria, BC 250, Canada.
| | - Megan Kurz
- Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, Vancouver, BC V6Z IY6b, Canada.
| | - Laura M Dale
- Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, Vancouver, BC V6Z IY6b, Canada.
| | - Celeste Macevicius
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Jeremy Kalicum
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Daniel Gudiño Pérez
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Jane McCall
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Brittany Barker
- School of Public Health and Social Policy, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada; First Nations Health Authority, 501 - 100 Park Royal South, 170-6371 Crescent Road, Coast Salish Territory (West Vancouver), BC V7T 1A2, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada.
| | - Amanda Slaunwhite
- BC Centre for Disease Control, 655 W 12th Ave, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3, Canada; Centre for Advancing Health Outcomes, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z1Y6, Canada.
| | - Morgan Lindsay
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada.
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada; Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z1Y6, Canada.
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2
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Vanderbleek JJ, Owensby JK, McAnnally A, England BR, Chen L, Curtis JR, Yun H. Classifying Multimorbidity Using Drug Concepts via the Rx-Risk Comorbidity Index: Methods and Comparative Cross-Sectional Study. Arthritis Care Res (Hoboken) 2024; 76:559-569. [PMID: 37986017 DOI: 10.1002/acr.25273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/26/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE The study objective was to update a method to identify comorbid conditions using only medication information in circumstances in which diagnosis codes may be undercaptured, such as in single-specialty electronic health records (EHRs), and to compare the distribution of comorbidities across Rx-Risk versus other traditional comorbidity indices. METHODS Using First Databank, RxNorm, and its web-based clients, RxNav and RxClass, we mapped Drug Concept Unique Identifiers (RxCUIs), National Drug Codes (NDCs), and Anatomical Therapeutic Chemical (ATC) codes to Rx-Risk, a medication-focused comorbidity index. In established rheumatoid arthritis (RA) and osteoarthritis (OA) cohorts within the Rheumatology Informatics System for Effectiveness registry, we then compared Rx-Risk with other comorbidity indices, including the Charlson Comorbidity Index, Rheumatic Disease Comorbidity Index (RDCI), and Elixhauser. RESULTS We identified 965 unique ingredient RxCUIs representing the 46 Rx-Risk comorbidity categories. After excluding dosage form and ingredient related RxCUIs, 80,911 unique associated RxCUIs were mapped to the index. Additionally, 187,024 unique NDCs and 354 ATC codes were obtained and mapped to the index categories. When compared to traditional comorbidity indices in the RA cohort, the median score for Rx-Risk (median 6.00 [25th percentile 2, 75th percentile 9]) was much greater than for Charlson (median 0 [25th percentile 0, 75th percentile 0]), RDCI (median 0 [25th percentile 0, 75th percentile 0]), and Elixhauser (median 1 [25th percentile 1, 75th percentile 1]). Analyses of the OA cohort yielded similar results. For patients with a Charlson score of 0 (85% of total), both the RDCI and Elixhauser were close to 1, but the Rx-Risk score ranged from 0 to 16 or more. CONCLUSION The misclassification and under-ascertainment of comorbidities in single-specialty EHRs can largely be overcome by using a medication-focused comorbidity index.
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Affiliation(s)
- Jared J Vanderbleek
- University of Alabama at Birmingham and University of Alabama at Birmingham Hospital
| | | | | | - Bryant R England
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha
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Salter E, Louks A, Pham C, Arenz B, Delate T. Prior authorization for diabetes medications: Clinical outcomes and health disparities. Diabetes Metab Syndr 2024; 18:102954. [PMID: 38310735 DOI: 10.1016/j.dsx.2024.102954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Prior authorization (PA) is a utilization management strategy used by health plans to ensure affordable, cost-effective care; however, PA may lead to therapy delay/abandonment and exacerbate health disparities. The purpose of this observational study was to assess the clinical outcomes and any health disparities associated with PA for diabetes mellitus (DM) medications. MATERIALS AND METHODS This was a cohort study of US adult patients from health plans with integrated and non-integrated system providers who were prescribed a DM medication that required a PA. Patients were categorized into three groups: received the requested DM medication (PA Med) or a new, alternative DM medication (DM Med), or did not receive the requested or new DM medication (No Med). The primary outcome was change in hemoglobin A1c (HbA1c). Adjusted and unadjusted analyses were performed. Patient characteristics associated with the No Med group were identified, also, with multivariable logistic regression modeling. RESULTS 6305 patients were included: 2434, 1323, and 2548 in the PA Med, DM Med, and No Med groups, respectively. Patients in the PA Med (-0.9 %) and DM Med (-1.0 %) groups had statistically significantly greater reductions in HbA1c compared to the No Med group (-0.4 %) in both unadjusted and adjusted analyses (all p < 0.05). Patients who were Hispanic/Latino, had a non-integrated system prescriber, and had a higher burden of chronic disease were statistically significantly associated with the No Med group. CONCLUSIONS Receiving a new DM medication following PA was associated with better clinical outcomes but health disparities were present in the PA process.
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Affiliation(s)
- Ella Salter
- Ambulatory Care Department, Franciscan Health, Indianapolis, IN, USA
| | - Aimee Louks
- Pharmacy Department, Kaiser Permanente Washington, Renton, WA, USA
| | - Catherine Pham
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy, Downey, CA, USA
| | - Barbara Arenz
- Pharmacy Department, Kaiser Permanente Washington, Renton, WA, USA
| | - Thomas Delate
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy, Aurora, CO, USA.
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Pellekooren S, Ben ÂJ, van Dongen JM, Pool-Goudzwaard AL, van Tulder MW, van den Berg JM, Ostelo RW. Predicting direct healthcare costs of general practitioner-guided care in patients with musculoskeletal complaints. Pain 2024; 165:404-411. [PMID: 37590126 PMCID: PMC10785053 DOI: 10.1097/j.pain.0000000000003028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/23/2023] [Accepted: 07/02/2023] [Indexed: 08/19/2023]
Abstract
ABSTRACT Information on healthcare utilization and costs of general practitioner (GP)-guided care in patients with musculoskeletal complaints is important for keeping healthcare affordable and accessible. A registry-based study was performed to describe healthcare utilization and costs of GP-guided care in patients with musculoskeletal complaints and to predict having higher direct healthcare costs. Healthcare costs of GP-guided care included all healthcare resources used by patients due to a musculoskeletal condition in 2018. Data were extracted from the database with a 1-year follow-up and descriptively analyzed. A general linear model was developed to predict having higher direct healthcare costs. In total, 403,719 patients were included, of whom 92% only received a single consultation. The number of referrals varied across the different types of complaints. Total annual direct healthcare costs amounted to €39,180,531, of which a key cost driver was referrals. Primary care consultations accounted for the largest part of referral-related costs. For all musculoskeletal conditions combined, the mean annual direct healthcare cost per patient was €97 (SEM = €0.18). Older age, being a woman, low socioeconomic status, spine complaints, high number of musculoskeletal diagnoses, and a high comorbidity score were predictive of having higher direct healthcare costs and explained 0.7% of the variance. This study showed that mean annual direct healthcare costs of GP-guided care in patients with musculoskeletal conditions were relatively low and did not differ considerably across conditions. The predictive model explained a negligible part of the variance in costs. Thus, it is unclear which factors do predict high direct healthcare costs in this population.
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Affiliation(s)
- Sylvia Pellekooren
- Department Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Research Institute Amsterdam, the Netherlands
| | - Ângela J. Ben
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Johanna M. van Dongen
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Research Institute Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Annelies L. Pool-Goudzwaard
- Department Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
- Somt University of Physiotherapy, Amersfoort, the Netherlands
| | - Maurits W. van Tulder
- Department Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
| | - Jesse M. van den Berg
- PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
- Department of General Practice, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health, Health Behaviors and Chronic Diseases, Amsterdam, the Netherlands
| | - Raymond W.J.G. Ostelo
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Research Institute Amsterdam, the Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
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Duff K, Dixon A, Embree L. A Closer Look at Practice Effects in Mild Cognitive Impairment and Alzheimer's Disease. Arch Clin Neuropsychol 2024; 39:1-10. [PMID: 37323010 PMCID: PMC10802223 DOI: 10.1093/arclin/acad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/17/2023] Open
Abstract
Practice effects have become a potentially important variable regarding the diagnosis, prognosis, and treatment recommendations in mild cognitive impairment (MCI) and Alzheimer's disease (AD). However, the understanding of these short-term changes in test scores remains unclear. The current observational study sought to examine variables that influence the magnitude of short-term practice effects in MCI and AD, including demographic information, cognitive performance, daily functioning, and medical comorbidities. One hundred sixty-six older adults classified as cognitively intact, amnestic MCI, or mild AD were tested twice across 1 week with a brief battery of neuropsychological tests. Correlational and regression analyses examined the relationship of practice effects with demographic and clinical variables. Results indicated that practice effects were minimally related to demographic variables and medical comorbidities, but they were significantly related to cognitive variables, depressive symptoms, and daily functioning. These findings expand our understanding of practice effects in MCI and AD, and they may allow a better appreciation of how they could affect clinical care and research.
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Affiliation(s)
- Kevin Duff
- Layton Aging and Alzheimer’s Disease Center, Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Center for Alzheimer’s Care, Imaging and Research, Department of Neurology, University of Utah, Salt Lake City UT, USA
| | - Ava Dixon
- Center for Alzheimer’s Care, Imaging and Research, Department of Neurology, University of Utah, Salt Lake City UT, USA
| | - Lindsay Embree
- Center for Alzheimer’s Care, Imaging and Research, Department of Neurology, University of Utah, Salt Lake City UT, USA
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Kurz M, Guerra-Alejos BC, Min JE, Barker B, Pauly B, Urbanoski K, Nosyk B. Influence of physician networks on the implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia. Implement Sci 2024; 19:3. [PMID: 38184548 PMCID: PMC10771688 DOI: 10.1186/s13012-023-01331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/22/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Characterizing the diffusion of adopted changes in policy and clinical practice can inform enhanced implementation strategies to ensure prompt uptake in public health emergencies and other rapidly evolving disease areas. A novel guidance document was introduced at the onset of the COVID-19 pandemic in British Columbia (BC), Canada, which supported clinicians to prescribe opioids, stimulants, and benzodiazepines. We aimed to determine the extent to which uptake and discontinuation of an initial attempt at a prescribed safer supply (PSS) program were influenced through networks of prescribers. METHODS We executed a retrospective population-based study using linked health administrative data that captured all clinicians who prescribed to at least one client with a substance use disorder from March 27, 2020, to August 31, 2021. Our main exposure was the prescribing patterns of an individuals' peers, defined as the proportion of a prescribers' professional network (based on shared clients), which had previously prescribed PSS, updated monthly. The primary outcome measured whether a clinician had prescribed their initial PSS prescription during a given calendar month. The secondary outcome was the discontinuation of PSS prescribing, defined as an absence for PSS prescriptions for at least 3 months. We estimated logistic regression models using generalized estimated equations on monthly repeated measurements to determine and characterize the extent to which peer networks influenced the initiation and discontinuation of PSS prescribing, controlling for network, clinician, and caseload characteristics. Innovators were defined as individuals initiating PSS prior to May 2020, and early adopters were individuals initiating PSS after. RESULTS Among 14,137 prescribers treating clients with substance use disorder, there were 228 innovators of prescribed safer supply and 1062 early adopters through the end of study follow-up, but 653 (50.6%) were no longer prescribing by August 2021. Prescribers with over 20% of peers whom had adopted PSS had a nearly fourfold higher adjusted odds of PSS prescribing themselves (aOR: 3.79, 95% CI: (3.15, 4.56)), compared to those with no connected safer supply prescribers. CONCLUSIONS The uptake of PSS in BC was highly dependent on the behavior of prescribers' peer networks. Future implementation strategies to support PSS or other policies would benefit from leveraging networks of prescribers.
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Affiliation(s)
- Megan Kurz
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada
| | | | - Jeong Eun Min
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada
| | - Brittany Barker
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada
- First Nations Health Authority, Vancouver, BC, Canada
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Bernadette Pauly
- Department of Nursing, University of Victoria, Victoria, BC, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Karen Urbanoski
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, BC, Canada
| | - Bohdan Nosyk
- Centre for Advancing Health Outcomes, Vancouver, BC, Canada.
- Faculty of Health Sciences, Simon Fraser University, Burnaby, V5A 1S6, Canada.
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Kim OM, Givens TK, Tang EG, Schimmer JJ, Ramsey T, Boyd K, Delate T. Real-World Outcomes of Proprotein Convertase Subtilisin Kexin-9 Inhibitor Use. J Cardiovasc Pharmacol 2023; 81:339-347. [PMID: 36795508 DOI: 10.1097/fjc.0000000000001404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/19/2023] [Indexed: 02/17/2023]
Abstract
ABSTRACT Although the proprotein convertase subtilisin kexin-9 inhibitors (PCSK9i) were shown to significantly lower low-density lipoprotein and reduce atherosclerotic cardiovascular disease events in clinical trials, there is a dearth of use data on these agents in real-world settings. This study compares PCSK9i use in a population of real-world patients with atherosclerotic cardiovascular disease or familial hypercholesterolemia. This was a matched cohort study of adult patients who were dispensed a PCSK9i along with adult patients who did not receive a PCSK9i. PCSK9i patients were matched on a propensity to have received a PCSK9i score up to 1:10 to non-PCSK9i patients. The primary outcomes were changes in cholesterol levels. Secondary outcomes included a composite outcome of all-cause mortality, major cardiovascular events, and ischemic strokes along with health care utilization during follow-up. Adjusted conditional, multivariate Cox proportional hazards, and negative binomial modeling were performed. Ninety-one PCSK9i patients were matched to 840 non-PCSK9i patients. Seventy-one percent of PCSK9i patients either discontinued or switched PCSK9i therapy. PCSK9i patients had greater median reductions in low-density lipoprotein (-73.0 mg/dL vs. -30.0 mg/dL) and total (-77.0 vs. -31.0) cholesterol (both P < 0.001). No adjusted between-group differences in the composite outcome or individual components of the composite outcome were identified (all P > 0.05). PCSK9i patients had a lower rate of medical office visits during follow-up (adjusted incidence rate ratio = 0.61, P = 0.019). These findings support the effectiveness of PCSK9i therapy in real-world settings but suggest that use may be limited by PCSK9i adverse reactions and patient cost barriers.
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Affiliation(s)
- Olivia M Kim
- Pharmacy Department, Kaiser Permanente Northwest, Portland, OR
| | - Tatyana K Givens
- Pharmacy Department, Kaiser Permanente Georgia, Atlanta, GA
- Pharmacy Department, VillageMD, Atlanta, GA; and
| | - Emily G Tang
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO
- Pharmacy Department, Yale New Haven Hospital, New Haven, CT
| | | | - Tanya Ramsey
- Pharmacy Department, Kaiser Permanente Northwest, Portland, OR
| | - Kayla Boyd
- Pharmacy Department, Kaiser Permanente Georgia, Atlanta, GA
| | - Thomas Delate
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy Services, Aurora, CO
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Cline L, Generoso EMG, D'Apice N, Dellinger SK, Tovey A, Clark NP, Nui F, Hui R, Hale SA, Ramsey T, Pontoppidan K, Ekmekdjian H, Fink K, Witt DM, Crowther MA, Delate T. Effectiveness and safety of direct oral anticoagulants in patients with venous thromboembolism and creatinine clearance < 30 mL/min. J Thromb Thrombolysis 2023; 55:355-364. [PMID: 36564588 DOI: 10.1007/s11239-022-02758-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
The few studies that compared direct oral anticoagulants (DOAC) vs. warfarin in the setting of advanced renal insufficiency have focused on patients with atrial fibrillation. The purpose of this observational, matched, cohort study of patients was to assess the effectiveness and safety of DOAC vs. warfarin for the treatment of venous thromboembolism (VTE) among patients with a creatinine clearance (CrCl) < 30 mL/min. This observational, cohort study included patients with VTE and CrCl < 30 mL/min who were newly initiated on a DOAC or warfarin between January 1, 2016 and December 31, 2020. DOAC patients were matched up to 1:2 to warfarin patients. Primary outcome was a composite of recurrent VTE, clinically-relevant bleeding, ischemic stroke, and all-cause mortality. Adjusted conditional, multivariate Cox proportional hazards modeling was used to assess outcomes. 626 DOAC patients were matched to 1071 warfarin patients. DOAC patients had a higher mean age, higher mean baseline CrCl, and were less likely to have been receiving dialysis. There was no statistically significant difference in the composite outcome between groups (adjusted hazard ratio [aHR] 1.13, 95% confidence interval [CI] 0.87-1.47) or in the individual components of the composite (all HR 95% CI crossed 1.00). Identification of statistically non-significant rates of bleeding and thromboembolic outcomes suggest that the use of DOAC or warfarin is reasonable in patients with VTE and CrCl < 30 mL/min.
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Affiliation(s)
- Lauren Cline
- Pharmacy Department, University of Maryland St. Joseph Medical Center, Towson, MD, USA
| | | | | | - Sara K Dellinger
- Pharmacy Department, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Amber Tovey
- Pharmacy Department, Kaiser Permanente Northwest, Portland, OR, USA
| | - Nathan P Clark
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Fang Nui
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy, Downey, CA, USA
| | - Rita Hui
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy, Oakland, CA, USA
| | - Stephanie A Hale
- Pharmacy Department, Kaiser Permanente Georgia, Atlanta, GA, USA
| | - Tanya Ramsey
- Pharmacy Department, Kaiser Permanente Northwest, Portland, OR, USA
| | - Kimi Pontoppidan
- Pharmacy Department, Kaiser Permanente Southern California, Woodland Hills, CA, USA
| | - Hasmig Ekmekdjian
- Pharmacy Department, Kaiser Permanente Southern California, Woodland Hills, CA, USA
| | - Kristen Fink
- Pharmacy Department, Kaiser Permanente Mid-Atlantic States, Hyattsville, MD, USA
| | - Daniel M Witt
- College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Mark A Crowther
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Thomas Delate
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy, 16601 E. Centretech Pkwy, Aurora, CO, 80011, USA.
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Guo Ie H, Tang CH, Sheu ML, Liu HY, Lu N, Tsai TY, Chen BL, Huang KC. Evaluation of risk adjustment performance of diagnosis-based and medication-based comorbidity indices in patients with chronic obstructive pulmonary disease. PLoS One 2022; 17:e0270468. [PMID: 35802678 PMCID: PMC9269939 DOI: 10.1371/journal.pone.0270468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/12/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives
This study assessed risk adjustment performance of six comorbidity indices in two categories of comorbidity measures: diagnosis-based comorbidity indices and medication-based ones in patients with chronic obstructive pulmonary disease (COPD).
Methods
This was a population–based retrospective cohort study. Data used in this study were sourced from the Taiwan National Health Insurance Research Database. The study population comprised all patients who were hospitalized due to COPD for the first time in the target year of 2012. Each qualified patient was individually followed for one year starting from the index date to assess two outcomes of interest, medical expenditures within one year after discharge and in-hospital mortality of patients. To assess how well the added comorbidity measures would improve the fitted model, we calculated the log-likelihood ratio statistic G2. Subsequently, we compared risk adjustment performance of the comorbidity indices by using the Harrell c-statistic measure derived from multiple logistic regression models.
Results
Analytical results demonstrated that that comorbidity measures were significant predictors of medical expenditures and mortality of COPD patients. Specifically, in the category of diagnosis-based comorbidity indices the Elixhauser index was superior to other indices, while the RxRisk-V index was a stronger predictor in the framework of medication-based codes, for gauging both medical expenditures and in-hospital mortality by utilizing information from the index hospitalization only as well as the index and prior hospitalizations.
Conclusions
In conclusion, this work has ascertained that comorbidity indices are significant predictors of medical expenditures and mortality of COPD patients. Based on the study findings, we propose that when designing the payment schemes for patients with chronic diseases, the health authority should make adjustments in accordance with the burden of health care caused by comorbid conditions.
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Affiliation(s)
- Huei Guo Ie
- Teaching Resource Center, Office of Academic Affairs, Taipei Medical University, Taipei City, Taiwan
| | - Chao-Hsiun Tang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei City, Taiwan
| | - Mei-Ling Sheu
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei City, Taiwan
| | - Hung-Yi Liu
- Health and Clinical Research Data Center, Taipei Medical University, Taipei City, Taiwan
| | - Ning Lu
- Department of Health Administration, College of Health and Human Services, Governors State University, University Park, Illinois, United States of America
| | - Tuan-Ya Tsai
- Department of Pharmacy, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Bi-Li Chen
- Department of Pharmacy, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Kuo-Cherh Huang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei City, Taiwan
- * E-mail:
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Holvik K, Hjellvik V, Karlstad Ø, Gunnes N, Hoff M, Tell GS, Meyer HE. Contribution of an extensive medication-based comorbidity index (Rx-Risk) in explaining the excess mortality after hip fracture in older Norwegians: a NOREPOS cohort study. BMJ Open 2022; 12:e057823. [PMID: 35501100 PMCID: PMC9062812 DOI: 10.1136/bmjopen-2021-057823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/07/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Patients with hip fracture are typically characterised by extensive comorbidities and excess mortality. Methods that account for a wide range of comorbidities are needed when attempting to identify causal associations in registry-based studies. We aimed to study the association between the prescription-based Rx-Risk Comorbidity Index (abbreviated Rx-Risk) and mortality by history of hip fracture, and to quantify the contribution of Rx-Risk in explaining the excess mortality after hip fracture. SETTING In this prospective study, we used nationwide registry data from outpatient care. Rx-Risk was based on filled prescriptions recorded in the Norwegian Prescription Database. Medications were mapped to 46 comorbidity categories by Anatomical Therapeutic Chemical code. Information on hip fractures during 1994-2013 was available from the Norwegian Epidemiologic Osteoporosis Studies hip fracture database, and year of death was obtained from Statistics Norway. We estimated 1-year mortality risk (January through December 2014) according to Rx-Risk score based on dispensed prescriptions in 2013, history of hip fracture, age and sex using Poisson regression. PARTICIPANTS All individuals aged 65 years and older who were alive by the end of 2013 and had filled at least one prescription in an outpatient pharmacy in Norway in 2013 (n=735 968). RESULTS Mortality increased exponentially with increasing Rx-Risk scores, and it was highest in persons with a history of hip fracture across the major range of Rx-Risk scores. Age- and sex-adjusted mortality risk difference according to history of hip fracture (yes vs no) was 4.4 percentage points (7.8% vs 3.4%). Adjustment for Rx-Risk score further attenuated this risk difference to 3.3 percentage points. CONCLUSIONS History of hip fracture and comorbidity assessed by Rx-Risk are independent risk factors for mortality in the community-dwelling older population in Norway. Comorbidity explained a quarter of the excess mortality in persons with a history of hip fracture.
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Affiliation(s)
- Kristin Holvik
- Department of Physical Health and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Vidar Hjellvik
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Øystein Karlstad
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Nina Gunnes
- Department of Physical Health and Ageing, Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Research Centre for Women's Health, Oslo University Hospital, Oslo, Norway
| | - Mari Hoff
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Rheumatology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Grethe S Tell
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Haakon E Meyer
- Department of Physical Health and Ageing, Norwegian Institute of Public Health, Oslo, Norway
- Department of Community Medicine and Global Health, University of Oslo Faculty of Medicine, Oslo, Norway
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Du Vall M, Weffald L, Delate T, Shetterly S, Bayliss EA. Clinical Factors Associated With Nonadherence to Chronic Medications in People With Cognitive Impairment. Sr Care Pharm 2022; 37:191-199. [PMID: 35450561 DOI: 10.4140/tcp.n.2022.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To study assessed adherence to 11 chronic medications and one medication class with high medical necessity in people with cognitive impairment (CIM) and identified clinical characteristics associated with nonadherence. Design This was a retrospective cohort study. 180-day adherence was calculated as the percent of days covered (PDC). Multi-variable logistic regression modeling was used to identify clinical factors associated with a PDC less than 80% (ie, nonadherence) to one or more studied chronic medication(s). Setting Primary care in an integrated health care delivery system. Patients People with CIM 65 years of age or older who were dispensed five or more chronic medications in one month between March 1, 2019, and October 31, 2019. Results Overall, the 1,109 patients included were older (mean age = 79.8 years of age), female (54.1%), White (78.6%), had a high burden of chronic disease, and 396 (35.7%) were nonadherent to one or more study medication(s). Two medications (tiotropium and venlafaxine) and one medication class (direct oral anticoagulants) had a mean PDC less than 80%. Alzheimer's disease and related dementias (ADRD), chronic pain, chronic obstructive pulmonary disease (COPD), male, nonwhite race, and one or more mental health visits were associated independently with nonadherence. Conclusions Chronic pain, COPD, ADRD, male sex, nonwhite race, and mental health care use were associated with nonadherence. These findings can help guide clinicians as they navigate medication therapy in people with CIM.
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12
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Hill RR, Willett EC, Manuel JD, Delate T. Impact of Palliative Care Clinical Pharmacists in an Inpatient Care Setting on Total Health Care Expenditures. J Palliat Med 2022; 25:1518-1523. [PMID: 35442799 DOI: 10.1089/jpm.2021.0642] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Inpatient palliative care clinical pharmacy specialists (IPCPS) on multidisciplinary palliative care (PC) teams have expanding roles in the treatment of pain, nausea, and other symptoms for patients with serious illnesses. Objectives: The aim of this study was to assess the clinical and financial outcomes associated with an IPCPS on an inpatient PC team. Setting and Design: This was a retrospective cohort study conducted in Colorado. Adult patients with an inpatient stay and a PC consult between October 1, 2016 and February 28, 2019 were included. Patients were assigned to the observation group if they received PC from a clinical pharmacist and control group if they received usual PC. The primary outcome was the 180-day change in daily total cost-of-care expenditures. Secondary outcomes included length of index hospitalization and 180-day change in daily morphine milligram equivalents (MME), health care utilization, and opioid adverse effects (AE). Results: A total of 1543 patients were included with 228 and 1315 in the IPCPS and usual care groups, respectively. After adjustment, the IPCPS group had a greater median decrease in daily expenditures (-$22 vs. $6, p = 0.003), higher median increase in daily MME (16.5 vs. 9.7 mg, p = 0.007), and fewer patients with a subsequent hospitalization (34.2% vs. 39.2%, p = 0.010) or urgent care visit (10.5% vs. 14.6%, p = 0.024) but longer mean index hospitalization (9.3 vs. 7.7 days, p = 0.003) and no differences in AE during follow-up (all p > 0.05). Conclusion: IPCPS participation on the PC team can be a component of health care cost reduction while contributing to patient-centered quality care.
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Affiliation(s)
- Robin R Hill
- Department of Pharmacy, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | | | - Jeffrey D Manuel
- Department of Supportive Care, Colorado Permanente Medical Group, Denver, Colorado, USA
| | - Thomas Delate
- Drug Evaluation, Strategy, and Outcomes Department, Kaiser Permanente National Pharmacy, Aurora, Colorado, USA.,Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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13
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Kurz M, Min JE, Dale LM, Nosyk B. Assessing the determinants of completing OAT induction and long-term retention: A population-based study in British Columbia, Canada. J Subst Abuse Treat 2022; 133:108647. [PMID: 34740484 PMCID: PMC9833672 DOI: 10.1016/j.jsat.2021.108647] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/16/2021] [Accepted: 10/13/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pharmacological treatments for opioid use disorder are essential, life-saving medications, yet successful induction of them and long-term retention on them is limited in many settings. Induction into opioid agonist treatment (OAT) features the highest risk of mortality throughout the treatment course, and greatest risk of discontinuation. We aimed to identify determinants of completing OAT induction and, among those completing induction, time to OAT discontinuation in British Columbia (BC), Canada. METHODS We conducted a retrospective study using linked population-level health administrative databases to capture all individuals in BC receiving at least one OAT dispensation from January 1, 2008, to September 30, 2018. We constructed covariates capturing client demographics, clinical history, and characteristics of the treatment episode and the primary prescribing physician. We estimated a two-part model to identify determinants of the probability of completing induction using a generalized linear mixed model with logit link and the time to OAT discontinuation among those completing induction using a Cox proportional hazards frailty model. RESULTS We observed 220,474 OAT episodes (73.9% initiated with methadone, 24.7% with buprenorphine, and 1.4% with slow-release oral morphine) among 45,608 individuals over the study period. Less than 60% of all OAT episodes completed induction (59.0% for methadone episodes, 56.7% for buprenorphine/naloxone, 41.0% for slow-release oral morphine) and half of all episodes that completed induction reached the minimum effective dosage (51.0% for methadone episodes [60 mg/day], 48.2% for buprenorphine/naloxone [12 mg/day], 59.4% for slow-release oral morphine [240 mg/day]). In multiple regression analysis, the adjusted odds of completing induction with buprenorphine improved over time, exceeding that of methadone in 2018: 1.46 (1.40, 1.51). For those who completed induction, buprenorphine use was associated with shorter times to discontinuation throughout the study period, but the estimated rate of discontinuation decreased over time (adjusted hazard ratio, vs. methadone in 2008: 2.50 (2.35, 2.66); in 2018: 1.79 (1.74, 1.85)). CONCLUSION We found low rates of completing OAT induction and, for those who did complete it, low rates of reaching the minimum effective dose.
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Affiliation(s)
- Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Laura M. Dale
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada,Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada,Corresponding author at: Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, Canada. (B. Nosyk)
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14
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Charlson ME, Carrozzino D, Guidi J, Patierno C. Charlson Comorbidity Index: A Critical Review of Clinimetric Properties. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 91:8-35. [PMID: 34991091 DOI: 10.1159/000521288] [Citation(s) in RCA: 356] [Impact Index Per Article: 178.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022]
Abstract
The present critical review was conducted to evaluate the clinimetric properties of the Charlson Comorbidity Index (CCI), an assessment tool designed specifically to predict long-term mortality, with regard to its reliability, concurrent validity, sensitivity, incremental and predictive validity. The original version of the CCI has been adapted for use with different sources of data, ICD-9 and ICD-10 codes. The inter-rater reliability of the CCI was found to be excellent, with extremely high agreement between self-report and medical charts. The CCI has also been shown either to have concurrent validity with a number of other prognostic scales or to result in concordant predictions. Importantly, the clinimetric sensitivity of the CCI has been demonstrated in a variety of medical conditions, with stepwise increases in the CCI associated with stepwise increases in mortality. The CCI is also characterized by the clinimetric property of incremental validity, whereby adding the CCI to other measures increases the overall predictive accuracy. It has been shown to predict long-term mortality in different clinical populations, including medical, surgical, intensive care unit (ICU), trauma, and cancer patients. It may also predict in-hospital mortality, although in some instances, such as ICU or trauma patients, the CCI did not perform as well as other instruments designed specifically for that purpose. The CCI thus appears to be clinically useful not only to provide a valid assessment of the patient's unique clinical situation, but also to demarcate major diagnostic and prognostic differences among subgroups of patients sharing the same medical diagnosis.
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Affiliation(s)
- Mary E Charlson
- Division of Clinical Epidemiology and Evaluative Sciences Research, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Danilo Carrozzino
- Department of Psychology "Renzo Canestrari," University of Bologna, Bologna, Italy
| | - Jenny Guidi
- Department of Psychology "Renzo Canestrari," University of Bologna, Bologna, Italy
| | - Chiara Patierno
- Department of Psychology "Renzo Canestrari," University of Bologna, Bologna, Italy
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15
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Enns B, Krebs E, Thomson T, Dale LM, Min JE, Nosyk B. Opioid analgesic prescribing for opioid-naïve individuals prior to identification of opioid use disorder in British Columbia, Canada. Addiction 2021; 116:3422-3432. [PMID: 33861882 DOI: 10.1111/add.15515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/08/2020] [Accepted: 03/31/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Prescription opioid analgesics have contributed to the development of opioid use disorder (OUD) in many individuals. We aimed to characterize non-cancer opioid prescribing for opioid-naive individuals prior to OUD identification. DESIGN Population-based retrospective cohort study using six linked health administrative databases. SETTING British Columbia (BC), Canada. PARTICIPANTS People with OUD between 1 January 2001 and 30 September 2018 who initiated opioid analgesic therapy for non-cancer pain prior to OUD identification. MEASUREMENTS Dose (morphine milligram equivalent per day), days prescribed and clinical guideline non-concordance for initial opioid prescriptions (dose ≥ 90 morphine milligram equivalent per day; ≥ 7 days prescribed; concomitant sedative prescription). We estimated the probability of non-concordant initial prescriptions by source (inpatient post-discharge, non-inpatient acute, non-acute) using logistic regression, adjusting for individual characteristics and comorbidities. FINDINGS Among 66 372 individuals identified with OUD from 2001 to 2018, 21 331 (32.1%) received opioid analgesics prior to OUD identification. This proportion increased from 3.0% in 2001 to 41.0% in 2011, before decreasing to 34.2% in 2017. Roughly half of opioid prescriptions were attributed to non-acute care visits, peaking at 56.8% in 2007, while the proportion from inpatient visits increased from 19.7% in 2001 to 28.5% in 2017. The predicted probability of receiving non-guideline concordant prescriptions declined over time-periods across all three measures for inpatient and non-inpatient acute care, while remaining stable for non-acute care. In particular, the predicted probability of receiving ≥ 7-day prescriptions following inpatient visits decreased from 53.3% [95% confidence interval (CI) = 50.9, 55.8%] in 2001-06 to 37.2% (95% CI = 33.9, 40.5%) in 2013-18. CONCLUSIONS Among the 66 372 individuals in British Columbia, Canada diagnosed with opioid use disorder between 2001 and 2018, more than 32% were earlier prescribed non-cancer opioid analgesics. The proportion who had received an opioid analgesic prescription prior to OUD identification peaked at more than 40% in 2011, before stabilizing between 2011 and 2016 and declining thereafter. Guideline concordance improved over time for high-dose and concomitant sedative prescribing.
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Affiliation(s)
- Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Emanuel Krebs
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Trevor Thomson
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Laura M Dale
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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16
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Clinical outcomes of dabigatran use in patients with non-valvular atrial fibrillation and weight >120 kg. Thromb Res 2021; 208:176-180. [PMID: 34808409 DOI: 10.1016/j.thromres.2021.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/03/2021] [Accepted: 11/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with obesity were underrepresented in studies evaluating the safety and effectiveness of direct oral anticoagulants (DOAC) in patients with non-valvular atrial fibrillation (NVAF). This study compared clinical outcomes in patients with NVAF and weighing >120 kg and ≤120 kg who were receiving dabigatran. MATERIALS AND METHODS This retrospective, matched, longitudinal cohort study included patients from three integrated healthcare delivery systems. Patients ≥18 years of age with NVAF were included if between September 1, 2016 and June 30, 2019 they received dabigatran. Patients >120 kg and ≤120 kg were matched up to 1:6 on age, sex, and CHA2DS2-VASc score. Data were extracted from administrative databases. The primary outcome was a composite of ischemic stroke, clinically-relevant bleeding, systemic embolism, and all-cause mortality. Multivariable regression analyses were performed. RESULTS 777 and 3522 patients >120 kg and ≤120 kg, respectively, were matched. The >120 kg group tended to be younger with a higher burden of chronic disease. There was no difference between groups in the composite outcome (adjusted hazard ratio [AHR] 1.10, 95% confidence interval 0.89-1.37) or individual components of the composite. A subanalysis of clinically-relevant bleeding identified that patients >120 kg were at a greater risk of gastrointestinal bleeding (AHR 1.44, 95% CI 1.01-2.05). CONCLUSIONS In patients with NVAF and >120 kg, dabigatran use was associated with a small increased risk of gastrointestinal bleeding but no differences in stroke, mortality or clinically-relevant bleeding. These findings suggest that dabigatran use is reasonable in patients with NVAF and weight >120 kg.
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17
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Olson KL, Stine JM, Stadler SL, Angleson J, Campbell SM, Friesleben C, Schimmer JJ. Using pharmacy technicians and electronic health record capabilities to improve outcomes for patients with cardiovascular disease. J Am Pharm Assoc (2003) 2021; 62:604-611. [PMID: 34753672 DOI: 10.1016/j.japh.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/01/2021] [Accepted: 10/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to compare lipid and blood pressure (BP) control before and after implementing a certified pharmacy technician (CPhT) protocol that optimized electronic health record (EHR) capabilities and shifted work from clinical pharmacy specialists (CPSs) to CPhT. SETTING Kaiser Permanente Colorado's pharmacist-managed cardiac risk reduction service (which manages dyslipidemia, hypertension, and diabetes for all patients with atherosclerotic cardiovascular disease). PRACTICE DESCRIPTION In 2019, a protocol that optimized EHR capabilities and allowed work to be offloaded from CPS to CPhT was implemented. Filtered views within the EHR were created that bucketed patients with specific lipid results criteria. The CPhT protocol provided guidance to CPhT on determining whether patients were at low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein (non-HDL) goals, on appropriate statin intensity, adherent to medications, and whether the most recent BP was controlled. The CPhT notified CPS of uncontrolled patients who would assess and manage these patients, as necessary. The CPhT notified controlled patients of their results. PRACTICE INNOVATION Data on the outcomes of incorporating pharmacy technicians to support CPS clinical activities in ambulatory clinical pharmacy are limited. EVALUATION METHODS This retrospective study compared a "Pharmacist-Driven" (index date: January 1, 2016) with a "Tech-Enhanced" (index date: January 1, 2019) group. The primary outcome was the proportion of patients at all goals defined as LDL-C < 70 mg/dL, non-HDL < 100 mg/dL, and BP < 140/90 mm Hg at 1 year after the index dates. RESULTS There were 6813 patients included (mean age: 70.2 ± 11.1 years, 71.4% male): 3130 and 3683 in the "Pharmacist-Driven" and "Tech-Enhanced" groups, respectively. The proportion of patients who attained LDL-C, non-HDL, and BP goals was higher in the "Tech-Enhanced" group (51.1% vs. 39.7%, P < 0.001) than the "Pharmacist-Driven" group. CONCLUSION A protocol integrating EHR decision support and CPhTs enabled work to shift to from CPS to CPhT and improved clinical outcomes.
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18
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Kerr MM, Graves SE, Duszynski KM, Inacio MC, de Steiger RN, Harris IA, Ackerman IN, Jorm LR, Lorimer MF, Gulyani A, Pratt NL. Does a Prescription-based Comorbidity Index Correlate with the American Society of Anesthesiologists Physical Status Score and Mortality After Joint Arthroplasty? A Registry Study. Clin Orthop Relat Res 2021; 479:2181-2190. [PMID: 34232146 PMCID: PMC8445560 DOI: 10.1097/corr.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/17/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND When analyzing the outcomes of joint arthroplasty, an important factor to consider is patient comorbidities. The presence of multiple comorbidities has been associated with longer hospital stays, more postoperative complications, and increased mortality. The American Society of Anesthesiologists (ASA) physical status classification system score is a measure of a patient's overall health and has been shown to be associated with complications and mortality after joint arthroplasty. The Rx-Risk score is another measure for determining the number of different health conditions for which an individual is treated, with a possible score ranging from 0 to 47. QUESTIONS/PURPOSES For patients undergoing THA or TKA, we asked: (1) Which metric, the Rx-Risk score or the ASA score, correlates more closely with 30- and 90-day mortality after TKA or THA? (2) Is the Rx-Risk score correlated with the ASA score? METHODS This was a retrospective analysis of the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) database linked to two other national databases, the National Death Index (NDI) database and the Pharmaceutical Benefits Scheme (PBS), a dispensing database. Linkage to the NDI provided outcome information on patient death, including the fact of and date of death. Linkage to the PBS was performed to obtain records of all medicines dispensed to patients undergoing a joint replacement procedure. Patients were included if they had undergone either a THA (119,076 patients, 131,336 procedures) or TKA (182,445 patients, 215,712 procedures) with a primary diagnosis of osteoarthritis, performed between 2013 and 2017. We excluded patients with missing ASA information (THA: 3% [3055 of 119,076]; TKA: 2% [4095 of 182,445]). This left 127,761 primary THA procedures performed in 116,021 patients (53% [68,037 of 127,761] were women, mean age 68 ± 11 years) and 210,501 TKA procedures performed in 178,350 patients (56% [117,337 of 210,501] were women, mean age 68 ± 9 years) included in this study. Logistic regression models were used to determine the concordance of the ASA and Rx-Risk scores and 30-day and 90-day postoperative mortality. The Spearman correlation coefficient (r) was used to estimate the correlation between the ASA score and Rx-Risk score. All analyses were performed separately for THAs and TKAs. RESULTS We found both the ASA and Rx-Risk scores had high concordance with 30-day mortality after THA (ASA: c-statistic 0.83 [95% CI 0.79 to 0.86]; Rx-Risk: c-statistic 0.82 [95% CI 0.79 to 0.86]) and TKA (ASA: c-statistic 0.73 [95% CI 0.69 to 0.78]; Rx-Risk: c-statistic 0.74 [95% CI 0.70 to 0.79]). Although both scores were strongly associated with death, their correlation was moderate for patients undergoing THA (r = 0.45) and weak for TKA (r = 0.38). However, the median Rx-Risk score did increase with increasing ASA score. For example, for THAs, the median Rx-Risk score was 1, 3, 5, and 7 for ASA scores 1, 2, 3, and 4, respectively. For TKAs, the median Rx-Risk score was 2, 4, 5, and 7 for ASA scores 1, 2, 3, and 4, respectively. CONCLUSION The ASA physical status and RxRisk were associated with 30-day and 90-day mortality; however, the scores were only weakly to moderately correlated with each other. This suggests that although both scores capture a similar level of patient illness, each score may be capturing different aspects of health. The Rx-Risk may be used as a complementary measure to the ASA score. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Mhairi M. Kerr
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Stephen E. Graves
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
- Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Katherine M. Duszynski
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Maria C. Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Richard N. de Steiger
- Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Department of Surgery, Epworth HealthCare, University of Melbourne, Richmond, Australia
| | - Ian A. Harris
- Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- South Western Sydney Clinical School, University of New South Wales, Liverpool Hospital, Liverpool, Australia
| | - Ilana N. Ackerman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Louisa R. Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Michelle F. Lorimer
- Australian Orthopaedic Association National Joint Replacement Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Aarti Gulyani
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
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Meena A. CORR Insights®: Does a Prescription-based Comorbidity Index Correlate with the American Society of Anesthesiologists Physical Status Score and Mortality After Joint Arthroplasty? A Registry Study. Clin Orthop Relat Res 2021; 479:2191-2193. [PMID: 34435981 PMCID: PMC8445583 DOI: 10.1097/corr.0000000000001959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/11/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Amit Meena
- Senior Resident, Vardhman Mahavir Medical College and Safdarjung Hospital, Central Institute of Orthopaedics, New Delhi, India
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20
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Piske M, Homayra F, Min JE, Zhou H, Marchand C, Mead A, Ng J, Woolner M, Nosyk B. Opioid Use Disorder and Perinatal Outcomes. Pediatrics 2021; 148:peds.2021-050279. [PMID: 34479983 DOI: 10.1542/peds.2021-050279] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Evidence on the perinatal health of mother-infant dyads affected by opioids is limited. Elevated risks of opioid-related harms for people with opioid use disorder (OUD) increase the urgency to identify protective factors for mothers and infants. Our objectives were to determine perinatal outcomes after an OUD diagnosis and associations between opioid agonist treatment and birth outcomes. METHODS We conducted a population-based retrospective study among all women with diagnosed OUD before delivery and within the puerperium period in British Columbia, Canada, between 2000 and 2019 from provincial health administrative data. Controlling for demographic and clinical characteristics, we determined associations of opioid agonist treatment on birth weight, gestational age, infant disorders related to gestational age and birth weight, and neonatal abstinence syndrome via logistic regression. RESULTS The population included 4574 women and 6720 live births. Incidence of perinatal OUD increased from 166 in 2000 to 513 in 2019. Compared with discontinuing opioid agonist treatment during pregnancy, continuous opioid agonist treatment reduced odds of preterm birth (adjusted odds ratio: 0.6; 95% confidence interval: 0.4-0.8) and low birth weight (adjusted odds ratio: 0.4; 95% confidence interval: 0.2-0.7). Treatment with buprenorphine-naloxone (compared with methadone) reduced odds of each outcome including neonatal abstinence syndrome (adjusted odds ratio: 0.6; 95% confidence interval: 0.4-0.9). CONCLUSIONS Perinatal OUD in British Columbia tripled in incidence over a 20-year period. Sustained opioid agonist treatment during pregnancy reduced the risk of adverse birth outcomes, highlighting the need for expanded services, including opioid agonist treatment to support mothers and infants.
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Affiliation(s)
- Micah Piske
- Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fahmida Homayra
- Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Jeong E Min
- Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Haoxuan Zhou
- Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Carolyn Marchand
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Annabel Mead
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Ng
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Megan Woolner
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada.,Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada .,Simon Fraser University, Faculty of Health Sciences, Burnaby, British Columbia, Canada
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21
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Gersch WD, Delate T, Bergquist KM, Smith K. Clinical Effectiveness of an Outpatient Multidisciplinary Chronic Pain Management Telementoring Service. Clin J Pain 2021; 37:740-746. [PMID: 34265787 DOI: 10.1097/ajp.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 07/02/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to assess the effectiveness of a Pain E-Consult Program (PEP), a multidisciplinary telementoring service based on the Extension for Community Healthcare Outcomes (ECHO) model to reduce opioid use in the outpatient setting. MATERIALS AND METHODS This was a retrospective matched cohort study conducted in an integrated health care delivery system. Adult patients without cancer and with a 90-day morphine milligram equivalent (MME) ≥30 mg/d between April 1, 2016, and June 30, 2017, were included. Patients whose primary care clinician received the PEP (observation) were compared with usual care (control) patients. Observation patients were matched up to 1:5 to control patients. Outcomes included change in MME and initiation of nonopioid alternative medications. Multivariable regression analyses were performed. RESULTS A total of 665 patients were matched: 125 and 540 in the observation and control groups, respectively. Patients were primarily female, white, and Medicare beneficiaries. The observation group had a statistically significantly greater decrease in median MME/day during the 6-month (-7.4 vs. 1.5 mg, P=0.002) and 12-month (-15.1 vs. -2.8 mg, P<0.001) follow-up and rates of ≥20% decrease (6 mo: 41.6% vs. 24.6%, P=0.003; 12 mo: 48.0% vs. 32.6%, P=0.017). There were no differences in the rates of initiation of nonopioid alternative medications. CONCLUSIONS A PEP was associated with greater reductions in MME/day compared with usual care despite similar rates of nonopioid alternative medication initiation. A prospective randomized study of this program should be undertaken to confirm these findings.
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Affiliation(s)
- William D Gersch
- Veterans Affairs Northern California Health Care System, Mather, CA
| | - Thomas Delate
- Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Karen Smith
- Rueckert-Hartman College for Health Professions, Regis University, Denver, CO
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22
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Davis H, Heilmann R, Milchak J, Delate T. Factors associated with A1C reduction with GLP-1 agonist or SGLT-2 inhibitor use. Fam Pract 2021; 38:623-629. [PMID: 33755123 DOI: 10.1093/fampra/cmab021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND While use of glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose cotransporter-2 (SGLT-2) inhibitors reduces the risk of atherosclerotic cardiovascular disease outcomes and lowers glycosylated haemoglobin (A1C), evidence on patient characteristics associated with clinically relevant A1C reduction is lacking. OBJECTIVE The objective of this retrospective cohort study was to identify patient characteristics associated with A1C reduction with initial GLP-1 or SGLT-2 use. METHODS Patients with type 2 diabetes and a baseline A1C ≥7% who were dispensed a GLP-1 or SGLT-2 between 01/01/10 and 12/31/17 were included. Patients were categorized as having a ≥1% or <1% A1C reduction during the 90-365 days after GLP-1/SGLT-2 initiation. Patient characteristics were collected during the 180 days prior to initiation. Multivariable logistic and linear regression modelling was performed to identify characteristics associated with a ≥1% A1C reduction and absolute change in A1C, respectively. RESULTS Five hundred and seventy-two patients were included with 261 (46%) and 311 (54%) having and not having an ≥1% A1C reduction. Patients were primarily middle-aged, female, white, non-Hispanic and had a high burden of chronic disease. Characteristics associated with a ≥1% A1C reduction included: GLP-1/SGLT-2 persistence, congestive heart failure comorbidity, phentermine dispensing, care management team (CMT) enrollee and higher baseline A1C. Characteristics associated with absolute A1C reduction included: age, baseline A1C, CMT enrollee, GLP-1/SGLT-2 persistence and a phentermine dispensing. CONCLUSIONS The results of this study provide practitioners with guidance on the patients who are most likely to have a clinically relevant A1C reduction with GLP-1 or SGLT-2 use.
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Affiliation(s)
- Hanifah Davis
- Ambulatory Care Department, Oklahoma City Veterans Affairs Health Care System, Oklahoma City, OK, USA
| | - Rachel Heilmann
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jessica Milchak
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Thomas Delate
- Drug Evaluation, Strategy, and Outcomes Department, Pharmacy Outcomes Research Group, Kaiser Permanente National Pharmacy, Aurora, CO, USA.,Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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23
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Suls J, Bayliss EA, Berry J, Bierman AS, Chrischilles EA, Farhat T, Fortin M, Koroukian SM, Quinones A, Silber JH, Ward BW, Wei M, Young-Hyman D, Klabunde CN. Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source. Med Care 2021; 59:743-756. [PMID: 33974576 PMCID: PMC8263466 DOI: 10.1097/mlr.0000000000001566] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures. OBJECTIVE The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures. DESIGN Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018. RESULTS Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity. CONCLUSIONS The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.
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Affiliation(s)
- Jerry Suls
- Behavioral Research Program, National Cancer Institute, Bethesda, MD
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jay Berry
- Complex Care Services, Division of General Pediatrics, Boston Children's Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Arlene S Bierman
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD
| | | | - Tilda Farhat
- Office of Science Policy, Strategic Planning, Reporting, and Data, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, University of Sherbrooke, Chicoutimi, Quebec, QC, Canada
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Ana Quinones
- Department of Family Medicine, Oregon Health and Science University, Portland, OR
| | - Jeffrey H Silber
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Brian W Ward
- Division of Health Care Statistics, National Center for Health Statistics, Hyattsville, MD
| | - Melissa Wei
- Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Deborah Young-Hyman
- Office of Behavioral and Social Sciences Research, National Institutes of Health
| | - Carrie N Klabunde
- Office of Disease Prevention, National Institutes of Health, Bethesda, MD
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24
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A narrative review of using prescription drug databases for comorbidity adjustment: A less effective remedy or a prescription for improved model fit? Res Social Adm Pharm 2021; 18:2283-2300. [PMID: 34246572 DOI: 10.1016/j.sapharm.2021.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The use of claims data for identifying comorbid conditions in patients for research purposes has been widely explored. Traditional measures of comorbid adjustment included diagnostic data (e.g., ICD-9-CM or ICD-10-CM codes), with the Charlson and Elixhauser methodology being the two most common approaches. Prescription data has also been explored for use in comorbidity adjustment, however early methodologies were disappointing when compared to diagnostic measures. OBJECTIVE The objective of this methodological review is to compare results from newer studies using prescription-based data with more traditional diagnostic measures. METHODS A review of studies found on PubMed, Medline, Embase or CINAHL published between January 1990 and December 2020 using prescription data for comorbidity adjustment. A total of 50 studies using prescription drug measures for comorbidity adjustment were found. CONCLUSIONS Newer prescription-based measures show promise fitting models, as measured by predictive ability, for research, especially when the primary outcomes are utilization or drug expenditure rather than diagnostic measures. More traditional diagnostic-based measures still appear most appropriate if the primary outcome is mortality or inpatient readmissions.
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25
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Giovannini-Green ZEM, Gamble JM, Barrett B, Gao Z, Stuckless S, Parfrey PS. Variation and appropriateness of antipsychotic use in long-term care facilities across Newfoundland and Labrador. Can Pharm J (Ott) 2021; 154:205-212. [PMID: 34104274 PMCID: PMC8165880 DOI: 10.1177/17151635211005161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective: The use of antipsychotics to treat seniors in long-term care facilities (LTCFs) has raised concern because of health consequences (i.e., increased risk of falls, stroke, death) in this vulnerable population. This study measured geographic patterns of antipsychotic utilization among seniors living in LTCFs in Newfoundland and Labrador (NL) and assessed potential inappropriateness. Method: We analyzed prescription records among adults 66 years and older with provincial prescription drug coverage admitted to LTCFs in NL between April 1, 2011, and March 31, 2014. Patterns of use were analyzed across the 4 regional health authorities (RHAs) in NL and LTCFs. Logistic, Poisson and linear regression models were used to test variations in prevalence, rate and volume of antipsychotic utilization. To assess potential inappropriateness of antipsychotic use, we analyzed data from Resident Assessment Instrument–Minimum Data Set (RAI-MDS) 2.0 forms from NL LTCFs between January 1, 2016, and December 31, 2018. Pearson chi-squared analysis was performed at the RHA and LTCF levels to determine changes in percentage of total prescriptions or antipsychotic prescriptions without psychosis. Results: Between 2011 and 2014, 2843 seniors were admitted to LTCFs across NL; of these, 1323 residents were prescribed 1 or more antipsychotics. Within the 3-year period, the percentage of antipsychotic use across facilities ranged from 35% to 78%. Using data from 27,260 RAI-MDS 2.0 assessments between 2016 and 2018, 71% (6995/9851) of antipsychotic prescriptions were potentially inappropriate. Discussion: There is substantial variation across NL regions concerning the utilization of antipsychotics for senior in LTCFs. Facility size and management styles may be reasons for this. Conclusion: With nearly three-quarters of antipsychotic prescriptions shown to be potentially inappropriate, systematic interventions to assess indications for antipsychotic use are warranted. Can Pharm J (Ott) 2021;154:xx-xx.
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Affiliation(s)
| | | | - Brendan Barrett
- Translational and Personalized Medicine Initiative, Memorial University of Newfoundland, St. John's, NL
| | - Zhiwei Gao
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL
| | - Susan Stuckless
- Translational and Personalized Medicine Initiative, Memorial University of Newfoundland, St. John's, NL
| | - Patrick S Parfrey
- Translational and Personalized Medicine Initiative, Memorial University of Newfoundland, St. John's, NL
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26
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Mehta HB, Wang L, Malagaris I, Duan Y, Rosman L, Alexander GC. More than two-dozen prescription drug-based risk scores are available for risk adjustment: A systematic review. J Clin Epidemiol 2021; 137:113-125. [PMID: 33838274 DOI: 10.1016/j.jclinepi.2021.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 02/10/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE While several prescription drug-based risk indices have been developed, their design, performance, and application has not previously been synthesized. STUDY DESIGN AND SETTING We searched Ovid MEDLINE, CINAHL and Embase from inception through March 3, 2020 and included studies that developed or updated a prescription drug-based risk index. Two reviewers independently performed screening and extracted information on data source, study population, cohort sizes, outcomes, study methodology and performance. Predictive performance was evaluated using C statistics for binary outcomes and R2 for continuous outcomes. The PROSPERO ID for this review is CRD42020165498. RESULTS Of 19,112 articles that were retrieved, 124 were full-text screened and 25 were included, each of which represented a de novo or updated drug-based index. The indices were customized to varied age groups and clinical populations and most commonly evaluated outcomes including mortality (36%), hospitalization (24%) and healthcare costs (24%). C statistics ranged from 0.62 to 0.92 for mortality and 0.59 to 0.72 for hospitalization, while adjusted R2 for healthcare costs ranged from 0.06 to 0.62. Seven of the 25 risk indices included used global drug classification algorithms. CONCLUSIONS More than two-dozen prescription drug-based risk indices have been developed and they differ significantly in design, performance and application.
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Affiliation(s)
- Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Lin Wang
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ioannis Malagaris
- Department of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Yanjun Duan
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lori Rosman
- Welch Medical Library, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Romirowsky A, Zweig R, Glick Baker L, Sirey JA. The Relationship Between Maladaptive Personality and Social Role Impairment in Depressed Older Adults in Primary Care. Clin Gerontol 2021; 44:192-205. [PMID: 30362909 PMCID: PMC6486454 DOI: 10.1080/07317115.2018.1536687] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Personality pathology is associated with impaired social functioning in adults, though further evidence is needed to examine the individual contributions of personality traits and processes to social functioning in depressed older adults. This study is a secondary analysis examining the relationship between maladaptive personality traits and processes and social role impairment in depressed older adults in primary care. Methods: Participants (N = 56) were 77% female and ranged in age between 55-89 (M = 66.82, SD = 8.75). Personality pathology was measured by maladaptive traits (NEO-FFI) and processes (Inventory of Interpersonal Problems; IIP-PD-15). Individual variable as well as combined predictive models of social role impairment were examined. Results: Higher neuroticism (β = 0.30, p < .05), lower agreeableness (β = -0.35 p < .001) and higher IIP-PD-15 (β = 0.28, p < .01) scores predicted greater impairment in social role functioning. A combined predictive model of neuroticism and IIP-PD-15 scores predicted unique variance in social role impairment (R2 = .71). Conclusion: These results link select personality traits and interpersonal processes to social role impairment, suggesting that these are indicators of personality pathology in older adults. Clinical Implications: These findings lend preliminary support for clinical screening of personality pathology in depressed older adults utilizing both personality trait and process measures.
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Affiliation(s)
| | - Richard Zweig
- Ferkauf Graduate School of Psychology, Yeshiva University
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28
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González-González AI, Dinh TS, Meid AD, Blom JW, van den Akker M, Elders PJM, Thiem U, Kuellenberg de Gaudry D, Snell KIE, Perera R, Swart KMA, Rudolf H, Bosch-Lenders D, Trampisch HJ, Meerpohl JJ, Flaig B, Kom G, Gerlach FM, Hafaeli WE, Glasziou PP, Muth C. Predicting negative health outcomes in older general practice patients with chronic illness: Rationale and development of the PROPERmed harmonized individual participant data database. Mech Ageing Dev 2021; 194:111436. [PMID: 33460622 DOI: 10.1016/j.mad.2021.111436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 12/11/2022]
Abstract
The prevalence of multimorbidity and polypharmacy increases significantly with age and are associated with negative health consequences. However, most current interventions to optimize medication have failed to show significant effects on patient-relevant outcomes. This may be due to ineffectiveness of interventions themselves but may also reflect other factors: insufficient sample sizes, heterogeneity of population. To address this issue, the international PROPERmed collaboration was set up to obtain/synthesize individual participant data (IPD) from five cluster-randomized trials. The trials took place in Germany and The Netherlands and aimed to optimize medication in older general practice patients with chronic illness. PROPERmed is the first database of IPD to be drawn from multiple trials in this patient population and setting. It offers the opportunity to derive prognostic models with increased statistical power for prediction of patient-relevant outcomes resulting from the interplay of multimorbidity and polypharmacy. This may help patients from this heterogeneous group to be stratified according to risk and enable clinicians to identify patients that are likely to benefit most from resource/time-intensive interventions. The aim of this manuscript is to describe the rationale behind PROPERmed collaboration, characteristics of the included studies/participants, development of the harmonized IPD database and challenges faced during this process.
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Affiliation(s)
- Ana I González-González
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.
| | - Truc S Dinh
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120, Heidelberg, Germany
| | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, 2300RC, Leiden, the Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; School of CAPHRI, Department of Family Medicine, Maastricht University, 6211 LK, Maastricht, the Netherlands; Academic Centre for General Practice, Department of Public Health and Primary Care, KU, Leuven, Belgium
| | - Petra J M Elders
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, 1007 MB, Amsterdam, the Netherlands
| | - Ulrich Thiem
- Chair of Geriatrics and Gerontology, University Clinic Eppendorf, 20246, Hamburg, Germany
| | - Daniela Kuellenberg de Gaudry
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, 79110, Freiburg, Germany
| | - Kym I E Snell
- Centre for Prognosis Research, School of Primary Care Research, Community and Social Care, Keele University, Staffordshire, ST5 5BG, United Kingdom
| | - Rafael Perera
- Nuffield Department of Primary Care, University of Oxford, Oxford, OX2 6GG, United Kingdom
| | - Karin M A Swart
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, 1007 MB, Amsterdam, the Netherlands
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, 44780, Bochum, Germany
| | - Donna Bosch-Lenders
- School of CAPHRI, Department of Family Medicine, Maastricht University, 6211 LK, Maastricht, the Netherlands
| | - Hans-Joachim Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, 44780, Bochum, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, 79110, Freiburg, Germany; Cochrane Germany, Cochrane Germany Foundation, Breisacher Strasse 153, 79110, Freiburg, Germany
| | - Benno Flaig
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Ghainsom Kom
- Techniker Krankenkasse (TK), 22765, Hamburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Walter E Hafaeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120, Heidelberg, Germany
| | - Paul P Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, QLD, 4226, Australia
| | - Christiane Muth
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld, 33615, Bielefeld, Germany
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29
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Gedeborg R, Garmo H, Robinson D, Stattin P. Prescription-based prediction of baseline mortality risk among older men. PLoS One 2020; 15:e0241439. [PMID: 33119680 PMCID: PMC7595371 DOI: 10.1371/journal.pone.0241439] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/14/2020] [Indexed: 02/03/2023] Open
Abstract
Background Understanding the association between patients’ history of prescribed medications and mortality rate could optimize characterization of baseline risk when the Charlson Comorbidity Index is insufficient. Methods Using a Swedish cohort of men selected randomly as controls to men with prostate cancer diagnosed 2007–2013, we estimated the association between medications prescribed during the previous year and mortality rates, using Cox regression stratified for age. Results Among the 326,450 older men with median age of 69 years included in this study, 73% were categorized as free of comorbidity according to the Charlson Comorbidity Index; however, 84% had received at least one prescription during the year preceding the follow-up. This was associated with a 60% overall increase in mortality rate (hazard ratio [HR] = 1.60, 95% confidence interval [CI] 1.56 to 1.64). Some drugs that were unexpectedly associated with mortality included locally acting antacids (HR = 4.7, 95% CI 4.4 to 5.1), propulsives (HR = 4.7, 95% CI 4.4 to 5.0), vitamin A and D (HR = 4.6, 95% CI 4.3 to 4.9), and loop diuretics, for example furosemide (HR = 3.7; 95% CI 3.6 to 3.8). Thiazide diuretics, however, were only weakly associated with a mortality risk (HR = 1.5; 95% CI 1.4 to 1.5). Surprisingly, only weak associations with mortality were seen for major cardiovascular drug classes. Conclusions A majority of older men had a history of prescribed medications and many drug classes were associated with mortality rate, including drug classes not directly indicated for a specific comorbidity represented in commonly used comorbidity measures. Prescription history can improve baseline risk assessment but some associations might be context-sensitive.
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Affiliation(s)
- Rolf Gedeborg
- Dept. of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Hans Garmo
- Dept. of Surgical Sciences, Urology, Uppsala University, Uppsala, Sweden
- Translational Oncology and Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, King’s College London, Guy’s Hospital, London, United Kingdom
- Regional Cancer Center Uppsala Örebro, Uppsala University Hospital, Uppsala, Sweden
| | - David Robinson
- Department of Urology, Ryhov Hospital, Jönköping, Sweden
| | - Pär Stattin
- Dept. of Surgical Sciences, Urology, Uppsala University, Uppsala, Sweden
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30
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Iommi M, Rosa S, Fusaroli M, Rucci P, Fantini MP, Poluzzi E. Modified-Chronic Disease Score (M-CDS): Predicting the individual risk of death using drug prescriptions. PLoS One 2020; 15:e0240899. [PMID: 33064757 PMCID: PMC7567358 DOI: 10.1371/journal.pone.0240899] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/05/2020] [Indexed: 01/25/2023] Open
Abstract
Background Estimating the morbidity of a population is strategic for health systems to improve healthcare. In recent years administrative databases have been increasingly used to predict health outcomes. In 1992, Von Korff proposed a Chronic Disease Score (CDS) to predict 1-year mortality by only using drug prescription data. Because pharmacotherapy underwent many changes over the last 3 decades, the original version of the CDS has limitations. The aim of this paper is to report on the development of the modified version of the CDS. Methods The modified CDS (M-CDS) was developed using 33 variables (from drug prescriptions within two-year before 01/01/2018) to predict one-year mortality in Bologna residents aged ≥50 years. The population was split into training and testing sets for internal validation. Score weights were estimated in the training set using Cox regression model with LASSO procedure for variables selection. The external validation was carried out on the Imola population. The predictive ability of M-CDS was assessed using ROC analysis and compared with that of the Charlson Comorbidity Index (CCI), that is based on hospital data only, and of the Multisource Comorbidity Score (MCS), which uses hospital and pharmaceutical data. Results The predictive ability of M-CDS was similar in the training and testing sets (AUC 95% CI: training [0.760–0.770] vs. testing [0.750–0.772]) and in the external population (Imola AUC 95% CI [0.756–0.781]). M-CDS was significantly better than CCI (M-CDS AUC = 0.761, 95% CI [0.750–0.772] vs. CCI-AUC = 0.696, 95% CI [0.681–0.711]). No significant difference was found between M-CDS and MCS (MCS AUC = 0.762, 95% CI [0.749–0.775]). Conclusions M-CDS, using only drug prescriptions, has a better performance than the CCI score in predicting 1-year mortality, and is not inferior to the multisource comorbidity score. M-CDS can be used for population risk stratification, for risk-adjustment in association studies and to predict the individual risk of death.
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Affiliation(s)
- Marica Iommi
- Department of Biomedical and Neuromotor Sciences–Hygiene and Biostatistics Unit, University of Bologna, Bologna, Italy
- * E-mail:
| | - Simona Rosa
- Department of Biomedical and Neuromotor Sciences–Hygiene and Biostatistics Unit, University of Bologna, Bologna, Italy
| | - Michele Fusaroli
- Department of Medical and Surgical Sciences–Pharmacology Unit, University of Bologna, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences–Hygiene and Biostatistics Unit, University of Bologna, Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences–Hygiene and Biostatistics Unit, University of Bologna, Bologna, Italy
| | - Elisabetta Poluzzi
- Department of Medical and Surgical Sciences–Pharmacology Unit, University of Bologna, Bologna, Italy
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Lee M, Kurz D, Schwiesow S, Delate T, Campbell S, Rivera K, Olson K. Perceptions of the Value of Clinical Pharmacy Medication Review for Women During Early Pregnancy. J Manag Care Spec Pharm 2020; 26:1301-1308. [PMID: 32996386 PMCID: PMC10391213 DOI: 10.18553/jmcp.2020.26.10.1301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The benefit of continuing medications to prevent or treat illness is often overlooked, since pregnant women tend to overestimate the teratogenic risk of medications. Pharmacists can serve as a resource to prescribers and pregnant women with their knowledge of the appropriate use and management of medications during pregnancy. Little information exists on the value women place on pharmacists' medication management during pregnancy. OBJECTIVE To assess pregnant women's perceptions of an ambulatory care clinical pharmacist (CP) medication review service during early pregnancy that provided education regarding the risks and benefits of medication use during pregnancy. METHODS This was a qualitative study of pregnant women using semistructured telephone interviews performed between December 12, 2018, and January 18, 2019, and conducted in an integrated health care delivery system. Potential participants were identified from CP encounter records. Consented English-speaking women aged ≥ 18 years participated in an up to 30-minute interview within 1 week of the CP encounter. Interviews were professionally transcribed and coded line by line using the constant comparison method with grounded theory used to gain insight into participants' perspectives. RESULTS 62 women were invited to participate in semistructured telephone interviews of whom 24 (39%) completed the interview. Three main themes emerged from the qualitative analysis: satisfaction with the service, comfort with medication use during pregnancy, and connectedness to the health care team. Overall, the CP medication review and education service was perceived positively by the participants. Participants reported satisfaction in the quality, timeliness, and convenience of the service and found it beneficial to have their medications reviewed early during pregnancy to assist in medication use decisions before their first obstetric visit. CONCLUSIONS CP medication review provided a comforting, valuable service for women during early pregnancy when medication-taking decisions can feel exigent. DISCLOSURES This study was funded by Kaiser Permanente. The authors have nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors, May 2019, in Salt Lake City, UT.
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Affiliation(s)
- Minna Lee
- Case Management Department, Sutter Health Palo Alto Medical Foundation, Sunnyvale, California
| | - Deanna Kurz
- Pharmacy Department, Kaiser Permanente Colorado, Aurora
| | | | - Thomas Delate
- Drug Use Management, Kaiser Permanente National Pharmacy, Aurora, Colorado, and Clinical Pharmacy Department, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Stephanie Campbell
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, and Clinical Pharmacy Department, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Kara Rivera
- Pharmacy Department, Kaiser Permanente Colorado, Aurora
| | - Kari Olson
- Pharmacy Department, Kaiser Permanente Colorado, Aurora; Drug Use Management, Kaiser Permanente National Pharmacy, Aurora; and Clinical Pharmacy Department, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
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Packard A, Delate T, Martinez K, Clark NP. Adherence to and persistence with direct oral anticoagulant therapy among patients with new onset venous thromboembolism receiving extended anticoagulant therapy and followed by a centralized anticoagulation service. Thromb Res 2020; 193:40-44. [DOI: 10.1016/j.thromres.2020.05.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/11/2020] [Accepted: 05/25/2020] [Indexed: 12/11/2022]
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Davis J, Lim E, Taira DA, Chen J. Relation of the Networks Formed by Diabetic Patients Sharing Physicians With Emergency Department Visits and Hospitalizations. Med Care 2020; 58:800-804. [PMID: 32826745 PMCID: PMC10697216 DOI: 10.1097/mlr.0000000000001378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate if the networks of diabetic patients sharing physicians are associated with emergency department (ED) visits and hospitalizations. STUDY DESIGN This is a retrospective cohort study. METHODS We used administrative data from a large insurer in Hawaii in 2010. Three types of networks were defined based on patient visits: (1) the total number of links from one patient to other patients sharing a physician; (2) the number of other patients connected by sharing the physician seen the most often; and (3) the number of other patients connected by seeing all the same physicians during the year. The networks were characterized into thirds based on their complexity and analyzed using zero-inflated negative binomial regression models on ED visits and hospitalizations. RESULTS The study included 38,767 diabetes patients with a mean age of 64 years. Patients sharing the most physicians had double the risks of ED visits and hospitalizations. Patients linked by belonging to the largest primary care practices had a 28% reduced odds of ED visits. Patients linked by seeing all of the same physicians during the year had the fewest primary care providers and specialists visits and 25%-50% reductions in ED visits and hospitalizations. CONCLUSIONS Networks of diabetic patients sharing all the same physicians were associated with decreased ED visits and hospitalizations. Encouraging diabetic patients to find a provider they like and trust and to stay in the provider's care may help reduce the risks of adverse events. Physicians building loyalty among their patients may reduce their patients' risks.
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Affiliation(s)
- James Davis
- John A. Burns School of Medicine, Honolulu, HI
| | - Eunjung Lim
- John A. Burns School of Medicine, Honolulu, HI
| | | | - John Chen
- John A. Burns School of Medicine, Honolulu, HI
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Delate T, Hansen ML, Gutierrez AC, Le KN. Indications for Rituximab Use in an Integrated Health Care Delivery System. J Manag Care Spec Pharm 2020; 26:832-838. [PMID: 32584674 PMCID: PMC10391100 DOI: 10.18553/jmcp.2020.26.7.832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rituximab is a top-selling biologic that was first approved by the FDA in 1997 for a non-Hodgkin lymphoma orphan indication. It has since been approved for additional orphan indications, with rheumatoid arthritis as the only FDA-approved, nonorphan indication. Evidence suggests that rituximab is frequently used off-label, but information on its use over time and indications for use in the United States is limited. OBJECTIVE To assess incident rituximab use over time in an integrated health care delivery system. METHODS This was a cross-sectional, retrospective study. Data were collected from administrative databases and manual chart reviews. Patients who received their first rituximab infusion between October 1, 2009, and December 31, 2017, and who were not a part of a clinical trial were included. Indication for use (FDA-approved orphan/nonorphan, off-label) was determined. Proportions of use were assessed over time. Multivariable logistic regression modeling was performed to assess factors associated with receiving rituximab for an FDA-approved indication. RESULTS A total of 1,674 patients were included. The majority (66.4%) of patients had an FDA-approved indication, with lymphoma being the most common approved indication (66.4%). The most common indication for off-label use was neurologic conditions (72.7%), predominantly demyelinating diseases. Off-label indication use increased from 1.2% in 2009 to 55.6% in 2017. Factors associated with rituximab use for an FDA-approved indication included increased age (adjusted odds ratio [AOR] = 1.05, 95% CI = 1.04-1.07) and increased burden of chronic disease (chronic disease score: AOR = 1.07, 95% CI = 1.02-1.12; Charlson Comorbidity Index score: AOR = 3.52, 95% CI = 3.03-4.10). CONCLUSIONS Off-label use of rituximab grew dramatically over the course of the study. With the recent FDA approval of the rituximab biosimilar and its expected lower price, off-label use will likely continue to rise. Opportunities for cost savings and to ensure appropriate use of these medications should be evaluated. DISCLOSURES This study was funded by Kaiser Permanente. All authors except Hansen are employed by Kaiser Permanente. Hansen has nothing to disclose. Preliminary results were presented at the Mountain States Conference for Residents and Preceptors in May 2019 in Salt Lake City, UT, and at an encore presentation October 2019 at the American College of Clinical Pharmacy Annual Meeting in New York, NY.
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Affiliation(s)
- Thomas Delate
- Drug Use Management, Kaiser Permanente National Pharmacy, Aurora, Colorado, and Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Margaret L. Hansen
- Neurology Department, Wexner Medical Center, The Ohio State University, Columbus
| | | | - Kim N. Le
- Drug Use Management, Kaiser Permanente National Pharmacy, Downey, California
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Hoyt MA, Wang AWT, Boggero IA, Eisenlohr-Moul TA, Stanton AL, Segerstrom SC. Emotional approach coping in older adults as predictor of physical and mental health. Psychol Aging 2020; 35:591-603. [PMID: 32271069 PMCID: PMC8199838 DOI: 10.1037/pag0000463] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Emotional approach coping involves active attempts at emotional expression and processing in response to stressful circumstances. This study tested whether dispositional emotional approach coping processes predict changes in physical and mental health in community-dwelling older adults, particularly within the context of higher perceived stress. To test this, older adults (N = 150) completed assessments of emotional expression and emotional processing at study entry. They also completed measures of perceived stress, depressive symptoms, and ill-health (a composite of subjective and objective physical health indicators, which included blood draw for collection of biomarkers), every 6 months over 4.5 years. Emotional processing and emotional expression were not related significantly to ill-health at study entry. However, emotional processing (but not emotional expression) significantly predicted changes in ill-health. At higher levels of emotional processing, ill-health remained low and stable; at lower levels of emotional processing, ill-health increased over time. However, when perceived stress was high, higher emotional processing and emotional expression were related to lower depressive symptoms at study entry, but higher emotional processing was associated with increasing depressive symptoms over time. Emotional approach coping processes evidence prospective relations with health outcomes, which are partially conditioned by stress perceptions. Emotional processing appears to have a protective impact against declining physical health. Predictive relationships for depressive symptoms are more complex. Older adults with chronically high perceived stress might benefit from interventions that target emotion-regulating coping processes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Farrow GS, Delate T, McNeil K, Jones AE, Witt DM, Crowther MA, Clark NP. Vitamin K versus warfarin interruption alone in patients without bleeding and an international normalized ratio > 10. J Thromb Haemost 2020; 18:1133-1140. [PMID: 32073738 DOI: 10.1111/jth.14772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/14/2020] [Accepted: 02/18/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reversal of an international normalized ratio (INR) > 10 with vitamin K is recommended in patients experiencing bleeding; however, information on outcomes with reversal using vitamin K in non-bleeding patients is lacking. OBJECTIVE To compare clinical and safety outcomes between non-bleeding patients receiving warfarin with an INR > 10 who did and did not receive a prescription for vitamin K. PATIENTS/METHODS This was a retrospective cohort study conducted in an integrated health-care delivery system. Adult patients receiving warfarin therapy who experienced an INR > 10 without bleeding between 01/01/2006 and 06/30/2018 were included. Patients were assessed for an outpatient dispensing or in-office administration of vitamin K on the day of or the day after an INR > 10 and then clinically relevant bleeding, thromboembolism, all-cause mortality, and time to INR < 4 within the next 30 days. RESULTS A total of 809 patients was included with 332 and 477 who were and were not dispensed vitamin K, respectively. Overall, mean patient age was 71.7 years, 60.1% were female and the mean INR was 10.4 at presentation. There were no differences between groups in 30-day rates of bleeding or thromboembolism (both P > .05). Patients dispensed vitamin K had a higher likelihood of mortality (15.1% versus 10.1%, P = .032, adjusted odds ratio = 1.63, 95% confidence interval 1.03 to 2.57). Overall, time to an INR < 4 was similar between groups. CONCLUSION Vitamin K administration was not associated with improved clinical outcomes in asymptomatic patients with an INR > 10.
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Affiliation(s)
| | - Thomas Delate
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Kelsey McNeil
- Ambulatory Services, Boulder Community Health, Boulder, CO, USA
| | - Aubrey E Jones
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nathan P Clark
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA
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Freml J, Delate T, Hermosillo-Rodriguez J. Guideline-recommended incorporation of biomarker testing results in metastatic colorectal cancer therapy. Per Med 2020; 17:185-194. [PMID: 32330071 DOI: 10.2217/pme-2019-0107] [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]
Abstract
Aim: To describe pharmacogenomic tumor testing among patients with metastatic colorectal cancer. Methods: This was a retrospective study of patients with metastatic colorectal cancer diagnosed between 1 January 2014 and 30 June 2018. Patients were assessed for pharmacogenomic testing and appropriateness of chemotherapy use. Results: Overall, 112/167 (67.1%) patients had at least one of the three recommended pharmacogenomic tests and 41/167 (24.6%) had all tests. Twenty-four patients were treated with cetuximab with 8/167 (4.7%) identified as being treated with a RAS variant (n = 3) or incomplete testing (n = 5); thus, not in accordance with guidelines. Conclusion: Uptake of testing was variable but increased over time; however, a small proportion of patients received cetuximab with a variant or not all recommended tests being performed.
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Affiliation(s)
- Jared Freml
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO 80011, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80453, USA
| | - Thomas Delate
- Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO 80011, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80453, USA
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Zhan ZW, Chen YA, Dong YH. Comparative Performance of Comorbidity Measures in Predicting Health Outcomes in Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:335-344. [PMID: 32103932 PMCID: PMC7024789 DOI: 10.2147/copd.s229646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/16/2020] [Indexed: 01/15/2023] Open
Abstract
Purpose Multiple studies have suggested that comorbidities pose negative impacts on the survival of patients with chronic obstructive pulmonary disease (COPD); few have applied comorbidity measures driven from health insurance claims databases to predict various health outcomes. We aimed to examine the performance of commonly used comorbidity measures based on diagnosis and pharmacy dispensing claims information in predicting future death and hospitalization in COPD patients. Methods We identified COPD patients in a population-based Taiwanese database. We built logistic regression models with age, sex, and baseline comorbidities measured by either diagnosis or pharmacy claims information as predictors of subsequent-year death or hospitalization in a random 50% sample and validated the discrimination in the other 50%. The diagnosis-based comorbidity measures included the Charlson Index and the Elixhauser comorbidity measure; the pharmacy-based comorbidity measures included the updated Chronic Disease Score (CDS) and the Pharmacy-Based Comorbidity Index (PBDI). Results We identified 428,251 eligible patients. For overall death, the Elixhauser comorbidity measure showed the best predictive performance (c-statistic=0.832), followed by the PBDI (c-statistic=0.822), the Charlson Index (c-statistic=0.815), and the updated CDS (c-statistic=0.808). For overall hospitalization, the PBDI (c-statistics=0.730) and the Elixhauser comorbidity measure (c-statistics=0.724) outperformed the updated CDS (c-statistics=0.714) and the Charlson Index (c-statistics=0.710). For hospitalization due to cardiovascular, cerebrovascular, or respiratory diseases, the comorbidity models showed similar predictive ranks and demonstrated c-statistics higher than 0.75. However, none of the models could adequately predict hospitalization due to other reasons (c-statistics < 0.60). Conclusion Our study comprehensively compared the predictive performance of comorbidity measures. The Elixhauser comorbidity measure and the PBDI are useful tools for describing comorbid conditions and predicting health outcomes in COPD patients.
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Affiliation(s)
- Zhe-Wei Zhan
- Faculty of Pharmacy, School of Pharmaceutical Science, National Yang-Ming University, Taipei 112, Taiwan
| | - Yu-An Chen
- Faculty of Pharmacy, School of Pharmaceutical Science, National Yang-Ming University, Taipei 112, Taiwan.,Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei 112, Taiwan
| | - Yaa-Hui Dong
- Faculty of Pharmacy, School of Pharmaceutical Science, National Yang-Ming University, Taipei 112, Taiwan.,Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei 112, Taiwan
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Homayra F, Hongdilokkul N, Piske M, Pearce LA, Zhou H, Min JE, Krebs E, Nosyk B. Determinants of selection into buprenorphine/naloxone among people initiating opioid agonist treatment in British Columbia. Drug Alcohol Depend 2020; 207:107798. [PMID: 31927163 DOI: 10.1016/j.drugalcdep.2019.107798] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Studies assessing the comparative effectiveness of methadone versus buprenorphine/naloxone for opioid use disorder in real-world settings are rare - challenged by structural differences in delivery across settings and factors influencing treatment selection. We identified determinants of selection into buprenorphine/naloxone and quantified contributions of individual and provider-level covariates in a setting delivering both medications within the same healthcare settings. METHODS Utilizing linked health administrative datasets, we conducted a retrospective cohort study of people with opioid use disorder (PWOUD) receiving opioid agonist treatment (OAT) in British Columbia, Canada, from 2008-2017. Determinants of buprenorphine/naloxone selection were identified using a generalized linear mixed model with random intercept terms for providers and individuals. We determined the influence of individual demographics, clinical history, measures of provider experience and preference, and dates of key policy changes. RESULTS A total of 39,605 individuals experienced 178,976 OAT episodes (methadone:139,439(77.9 %);buprenorphine/naloxone:39,537(22.1 %)). Male sex, less OAT experience, younger age, mental health conditions and chronic pain were associated with higher odds of buprenorphine/naloxone prescription. For providers, higher client-attachment, more complex OAT case-mixes, and higher buprenorphine/naloxone prescribing-preference were also associated with higher odds of buprenorphine/naloxone prescription. Observed individual-level covariates explained 9.7 % of variance in odds of buprenorphine/naloxone selection, while observed provider-level covariates explained 20.0 %. Controlling for covariates, residual unmeasured between-individual variance accounted for 18.5 % of the explained variation in the odds of buprenorphine/naloxone selection, while unmeasured between-provider variance accounted for 28.4 %. CONCLUSION Provider characteristics were more influential in selection of buprenorphine/naloxone over methadone informing subsequent analyses of comparative effectiveness of these regimens.
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Affiliation(s)
- F Homayra
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - N Hongdilokkul
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - M Piske
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - L A Pearce
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - H Zhou
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - J E Min
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - E Krebs
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - B Nosyk
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 9706, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
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Wang SH, Chen WJ, Hsu LY, Chien KL, Wu CS. Use of Spontaneous Reporting Systems to Detect Host-Medication Interactions: Sex Differences in Oral Anti-Diabetic Drug-Associated Myocardial Infarction. J Am Heart Assoc 2019; 7:e008959. [PMID: 30571494 PMCID: PMC6404447 DOI: 10.1161/jaha.118.008959] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Medical treatment should be tailored to an individual's characteristics to optimize treatment benefits. We examined whether case-only analyses from spontaneous reporting systems can detect host-medication interactions in oral antidiabetic drug-associated myocardial infarction. Methods and Results Interaction between sex and use of oral antidiabetic drugs was mined among patients with myocardial infarction in the US Food and Drug Administration Adverse Event Reporting System from 2004 to 2014, including 55 718 males and 42 428 females. The odds ratio ( OR ) of multiplicative interactions was used to estimate sex-drug interaction. Detected signs of these interactions were then validated by a nested case-control study utilizing a healthcare record database, Taiwan's National Health Insurance Research Database, from 2001 to 2014, including 31 585 cases and 126 340 controls. In the US Food and Drug Administration Adverse Event Reporting System, a higher proportion of male than female patients used metformin (10.32% in males versus 7.82% in females) and sulfonylureas (4.75% in males versus 3.43% in females); after adjusting for patients' pharmacy-based chronic disease score, males had a higher risk of metformin-associated ( OR =1.07; 99% confidence interval, 1.00-1.14) and sulfonylureas-associated ( OR =1.21; 99% confidence interval, 1.10-1.33) myocardial infarction than females. Detected signs of sex-drug interactions were validated in the National Health Insurance Research Database ( OR for metformin=1.14; 99% confidence interval, 1.03-1.26; OR for sulfonylureas=1.13; 99% confidence interval, 1.02-1.25). Conclusions Males have a higher risk of metformin- and sulfonylureas-associated myocardial infarction than females, which suggests that sex-drug interactions are a key issue in diabetes mellitus treatment plan development. This case-only approach using information from spontaneous reporting systems may be a potential tool for screening host-medication interactions that cause adverse events.
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Affiliation(s)
- Shi-Heng Wang
- 1 Department of Public Health and Department of Occupational Safety and Health China Medical University Taichung Taiwan
| | - Wei J Chen
- 2 Institute of Epidemiology and Preventive Medicine College of Public Health National Taiwan University Taipei Taiwan
| | - Le-Yin Hsu
- 2 Institute of Epidemiology and Preventive Medicine College of Public Health National Taiwan University Taipei Taiwan
| | - Kuo-Liong Chien
- 2 Institute of Epidemiology and Preventive Medicine College of Public Health National Taiwan University Taipei Taiwan.,3 Department of Internal Medicine National Taiwan University Hospital Taipei Taiwan
| | - Chi-Shin Wu
- 4 Department of Psychiatry College of Medicine and National Taiwan University Hospital National Taiwan University Taipei Taiwan
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Chen S. A new distribution‐free
k
‐sample test: Analysis of kernel density functionals. CAN J STAT 2019. [DOI: 10.1002/cjs.11525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Su Chen
- Department of Mathematical SciencesThe University of MemphisMemphis TN 38152 U.S.A
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Pistoia F, Carolei A, Bodien YG, Greenfield S, Kaplan S, Sacco S, Pistarini C, Casalena A, De Tanti A, Cazzulani B, Bellaviti G, Sarà M, Giacino J. The Comorbidities Coma Scale (CoCoS): Psychometric Properties and Clinical Usefulness in Patients With Disorders of Consciousness. Front Neurol 2019; 10:1042. [PMID: 31681139 PMCID: PMC6812466 DOI: 10.3389/fneur.2019.01042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 09/13/2019] [Indexed: 11/18/2022] Open
Abstract
Although comorbidities have a well-known impact on the functional recovery of patients with disorders of consciousness, including coma, vegetative state (VS), and minimally conscious state (MCS), a specific tool for their assessment in this challenging group of patients is lacking. For this aim, a multistep process was used to develop and validate the Comorbidities Coma Scale (CoCoS) in a sample of 162 patients with a diagnosis of coma, VS or MCS admitted to four Acute Inpatient Rehabilitation Units. To establish the psychometric properties of the scale, content validity, and internal consistency were investigated through Exploratory Factor Analysis in the whole sample (n = 162). Interrater reliability, assessed by the weighted Cohen's kappa (Kw), and concurrent validity of the scale as compared to the Greenfield Scale, assessed by ρ Spearman's correlation coefficient, were investigated in a subsample of patients (n = 52) within two of the above units. Our findings provided evidence of a good content validity of the scale, with the identification of a 12-factor structure representing the different comorbid dimensions of the target population. Inter-rater reliability was excellent in both the rehabilitation units where the assessment was made [Kw 0.98 (95% CI 0.96–0.99)]. CoCoS total scores correlated significantly with total scores of the Greenfield Scale (ρ = 0.932, 95% CI 0.89–0.96; P < 0.0001) indicating that CoCoS has concurrent validity while being more informative about the specific pattern of comorbidities of these challenging patients. The CoCos is a new tool which standardizes the approach to assessment of comorbid conditions and reliably identifies the category and severity of each comorbidity detected. It may be used for both clinical and research applications.
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Affiliation(s)
- Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Boston, MA, United States.,Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Sheldon Greenfield
- Health Policy Research Institute, University of California, Irvine, Irvine, CA, United States
| | - Sherrie Kaplan
- Health Policy Research Institute, University of California, Irvine, Irvine, CA, United States
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Caterina Pistarini
- Salvatore Maugeri Foundation, Scientific Institute of Nervi, Nervi, Italy
| | | | | | | | - Gianluca Bellaviti
- Salvatore Maugeri Foundation, Scientific Institute of Pavia, Pavia, Italy
| | - Marco Sarà
- Post-Coma Rehabilitative Unit, San Raffaele Hospital, Cassino, Italy
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Boston, MA, United States
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Rovner BW, Casten RJ, Hegel MT, Leiby B. Preventing Cognitive Decline in Black Individuals With Mild Cognitive Impairment: A Randomized Clinical Trial. JAMA Neurol 2019; 75:1487-1493. [PMID: 30208380 DOI: 10.1001/jamaneurol.2018.2513] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Mild cognitive impairment (MCI) is a transition state between normal cognitive aging and dementia that increases the risk for progressive cognitive decline. Preventing cognitive decline is a public health priority. Objective To determine whether behavioral activation prevents cognitive and functional decline over 2 years in black individuals with MCI. Design, Setting, and Participants Single-center, single-masked, attention-controlled randomized clinical trial. Participants were enrolled from June 21, 2011, to October 3, 2014, and follow-up ended December 13, 2016. Community-based recruitment and treatment of black individuals older than 65 years with amnestic MCI. Volunteer sample of 1390 persons with memory complaints were screened. Overall, 536 individuals had baseline assessment, and 315 (58.8%) were ineligible, most often owing to normal cognition (205 of 315 [65%]) or dementia (59 of 315 [18.7%]); 221 fully eligible participants were randomized. Analyses were intention to treat. Interventions Participants were randomized to behavioral activation, which aimed to increase cognitive, physical, and social activity (111 [50.2%]), or supportive therapy, an attention control treatment (110 [49.8%]). Main Outcomes and Measures The prespecified primary outcome was a decline of 6 or more recalled words on the total recall score of the Hopkins Verbal Learning Test-Revised assessed at 6, 12, 18, and 24 months. The secondary outcome was functional decline. Results Of 221 randomized participants (mean [SD] age, 75.8 [7.0] years, 175 women [79%]), 77 behavioral activation participants (69.4%) and 87 supportive therapy participants (79.1%) had 2-year outcome assessments. After baseline, behavioral activation participants engaged in significantly more cognitive activities than supportive therapy participants. The 2-year incidence of memory decline was 1.2% (95% CI, 0.2-6.4) for behavioral activation vs 9.3% (95% CI, 5.30-16.4) for supportive therapy (relative risk, 0.12; 95% CI, 0.02-0.74; P = .02). Behavioral activation was associated with stable everyday function, whereas supportive therapy was associated with decline (difference in slopes, 2.71; 95% CI, 0.12-5.30; P = .04). Rates of serious adverse events for behavioral activation and supportive therapy, respectively, were: falls (14 [13%] vs 28 [25%]), emergency department visits (24 [22%] vs 24 [22%]), hospitalizations (36 [32%] vs 31 [28%]), and deaths (7 [5%] vs 3 [4%]). Conclusions and Relevance Behavioral activation prevented cognitive and functional decline, but this finding requires further investigation. Black individuals have almost twice the rate of dementia as white individuals; behavioral activation may reduce this health disparity. Trial Registration ClinicalTrials.gov Identifier: NCT01299766.
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Affiliation(s)
- Barry W Rovner
- Department of Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.,Department Psychiatry, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.,Department Ophthalmology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robin J Casten
- Department of Psychiatry and Human Behavior, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark T Hegel
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Benjamin Leiby
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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Rovner BW, Casten RJ, Leiby B. Memory improvement in African Americans with amnestic mild cognitive impairment. Int J Geriatr Psychiatry 2019; 34:1447-1454. [PMID: 31087388 PMCID: PMC6742531 DOI: 10.1002/gps.5141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Amnestic mild cognitive impairment (aMCI) has an uncertain course. Valid methods to evaluate memory change will best identify predictors of course. This issue is especially relevant to older persons in minority groups, who may have encountered life course factors that adversely affect cognition. METHODS/DESIGN Growth curve mixture models were used to identify trajectories of memory test scores obtained every 6 months over 2 years in 221 African Americans with aMCI. RESULTS Participants sorted into two classes, with clinically and statistically significant differences in memory scores over time. Class 1 (n = 28 [14.7%]) had sustained improved scores. Class 2 (n = 162 [85.3%]) scores remained low, fluctuated, or declined. Class 1 had better baseline cognition and daily function than class 2. CONCLUSIONS The observed rate of improved memory is lower than reported reversion rates from aMCI to normal cognition. Evaluating trajectories of memory test scores rather than changes in categorical diagnoses of aMCI, which may depend on recalling (or not recalling) one or two words, may yield a more valid indicator of cognitive change. These approaches require further study in minority groups.
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Affiliation(s)
- Barry W. Rovner
- Jefferson Hospital for Neuroscience, 900 Walnut Street, Suite 200, Philadelphia, PA 19107
| | - Robin J. Casten
- Jefferson Hospital for Neuroscience, 900 Walnut Street, Suite 200, Philadelphia, PA 19107
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A Pharmaceutical Dispensing–based Index of Mortality Risk From Long-term Conditions Performed as well as Hospital Record–based Indices. Med Care 2019; 58:e9-e16. [DOI: 10.1097/mlr.0000000000001217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Enns B, Min JE, Panagiotoglou D, Montaner JSG, Nosyk B. Geographic variation in the costs of medical care for people living with HIV in British Columbia, Canada. BMC Health Serv Res 2019; 19:626. [PMID: 31481056 PMCID: PMC6724338 DOI: 10.1186/s12913-019-4391-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/01/2019] [Indexed: 12/04/2022] Open
Abstract
Background Regional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery. We aimed to estimate regional variation in medical costs for people living with HIV (PLHIV), adjusting for demographics and case-mix. Methods We conducted a retrospective cohort study using linked health administrative databases of PLHIV, from 2010 to 2014, in British Columbia (BC), Canada. Quarterly health care costs (2018 CAD) were derived from inpatient, outpatient, prescription drugs, antiretroviral therapy (ART), and HIV diagnostics. We used a two-part model with a logit link for the probability of incurring costs, and a log link and gamma distribution for observations with positive costs. We also estimated quarterly utilization rates for hospitalization-, physician billing- and prescription drug-days. Primary variables were indicators of individuals’ Health Service Delivery Area (HSDA). We adjusted cost and utilization estimates for demographic characteristics, HIV-disease progression, and comorbidities. Results Our cohort included 9577 PLHIV (median age 45.5 years, 80% male). Adjusted total quarterly costs for all 16 HSDAs were within 20% of the provincial mean, 8/16 for hospitalization costs, 16/16 for physician billing costs and 10/16 for prescription drug costs. Northern Interior and Northeast HSDAs had 38 and 44% lower quarterly non-ART prescription drug costs, and 2 and 5% higher quarterly inpatient costs, respectively. Conclusions We observed limited variation in medical care costs and utilization among PLHIV in BC. However, lower levels of outpatient care and higher levels of inpatient care indicate possible barriers to accessing care among PLHIV in the most rural regions of the province. Electronic supplementary material The online version of this article (10.1186/s12913-019-4391-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Benjamin Enns
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Jeong Eun Min
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Dimitra Panagiotoglou
- Faculty of Medicine, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.,Division of AIDS, Department of Medicine, University of British Columbia, 667-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Bohdan Nosyk
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada. .,Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
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Wood M, Delate T, Stadler SL, Denham AM, Ruppe LK, Hornak R, Olson KL. Trends in high intensity statin use among secondary prevention patients 76 years and older. Pharm Pract (Granada) 2019; 17:1402. [PMID: 31275492 PMCID: PMC6594424 DOI: 10.18549/pharmpract.2019.2.1402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 04/11/2019] [Indexed: 11/21/2022] Open
Abstract
Background: High intensity statin therapy (HIST) is the gold standard therapy for
decreasing the risk of recurrent atherosclerotic cardiovascular disease
(ASCVD); however, little is known about the use of HIST in older adults with
ASCVD. Objectives: The aim of this cross-sequential study was to determine trends in statin
intensity in older adults over a 10-year timeframe. Methods: The study was conducted in an integrated healthcare delivery system. Patients
were 76 years or older with validated coronary ASCVD. Data were collected
from administrative databases. Statin intensity level was assessed in
eligible patients on January 1st and July 1st from January 1, 2007 to
December 31, 2016. Results: Overall, a total of 5,453 patients were included with 2,119 (38.9%)
and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively.
Included patients had a mean age of 79.8 years and were primarily male and
white and had a cardiac intervention. The rate of HIST use increased from
14.5% to 41.3% over the study period (p<0.001 for
trend). Conversely, the rates of moderate and low intensity statin use
decreased from 61.8% and 9.8% to 41.2% and 4.8%,
respectively (both p<0.001 for trend). Similar trends were identified
for females and males. Conclusions: The percentage of patients with ASCVD 76 years and older who received HIST
substantially increased from 2007 to 2016. This trend was identified in both
females and males. Future comparative effectiveness research should be
conducted in this patient population to examine cardiac-related outcomes
with HIST and Non-HIST use.
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Affiliation(s)
- Michele Wood
- Clinical Pharmacy Specialist. Pharmacy Department, Kaiser Permanente Colorado. Aurora, CO (United States)
| | - Thomas Delate
- Clinical Research Scientist; Pharmacy Department; Kaiser Permanente Colorado. Aurora, CO (United States).
| | - Sheila L Stadler
- Clinical Pharmacy Specialist. Pharmacy Department, Kaiser Permanente Colorado. Aurora, CO (United States).
| | - Anne M Denham
- Clinical Pharmacy Specialist. Pharmacy Department, Kaiser Permanente Colorado. Aurora, CO (United States).
| | - Leslie K Ruppe
- Clinical Pharmacy Specialist. Pharmacy Department, Kaiser Permanente Colorado. Aurora, CO (United States).
| | - Roseanne Hornak
- Clinical Pharmacy Specialist. Pharmacy Department, Kaiser Permanente Colorado. Aurora, CO (United States).
| | - Kari L Olson
- Clinical Pharmacy Supervisor. Pharmacy Department, Kaiser Permanente Colorado. Aurora, CO (United States).
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Reed RG, Al-Attar A, Presnell SR, Lutz CT, Segerstrom SC. A longitudinal study of the stability, variability, and interdependencies among late-differentiated T and NK cell subsets in older adults. Exp Gerontol 2019; 121:46-54. [PMID: 30885717 PMCID: PMC6482456 DOI: 10.1016/j.exger.2019.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/03/2019] [Accepted: 03/14/2019] [Indexed: 12/31/2022]
Abstract
The stability and variability of older adults' late-differentiated peripheral blood T and natural killer (NK) cells over time remains incompletely quantified or understood. We examined the variability and change over time in T and NK cell subsets in a longitudinal sample of older adults; the effects of sex, cytomegalovirus (CMV) serostatus, and chronic disease severity on immune levels and trajectories; and interdependencies among T and NK cell subsets. Older adults (N = 149, age 64-94 years, 42% male) provided blood every 6 months for 2.5 years (up to 5 waves) to evaluate late-differentiated CD8 T cells (CD28-, CD57+) and CD56dimNK cells (CD57+, NKG2C+, FcɛRIγ-). In multilevel models, most of the variance in immune subsets reflected stable differences between people. However, CD56dimNK cell subsets (CD57+ and FcɛRIγ-) also increased with age, whereas T cell subsets did not. Independent of age, all subsets examined were higher in CMV-positive older adults. Men had higher levels of CD56dim CD57+ than women. Chronic disease was not associated with any immune subset investigated. T and NK cell subsets correlated within each cell type, but interdependencies differed by CMV serostatus. Our results suggest the accumulation of these stable cell populations may be driven less by chronological aging, even less by chronic disease severity, and more by CMV, which may differentially skew T and NK cell differentiation.
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Affiliation(s)
- Rebecca G Reed
- Department of Psychology, College of Arts and Sciences, University of Kentucky, Lexington, KY, United States of America; Department of Pathology and Laboratory Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States of America.
| | - Ahmad Al-Attar
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States of America
| | - Steven R Presnell
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States of America
| | - Charles T Lutz
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States of America; Department of Microbiology, Immunology, and Molecular Genetics, College of Medicine, University of Kentucky, Lexington, KY, United States of America.
| | - Suzanne C Segerstrom
- Department of Psychology, College of Arts and Sciences, University of Kentucky, Lexington, KY, United States of America.
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Chau J, Delate T, Ota T, Bhardwaja B. Patient Perspectives on Switching from Infliximab to Infliximab-dyyb in Patients with Rheumatologic Diseases in the United States. ACR Open Rheumatol 2019; 1:52-57. [PMID: 31777780 PMCID: PMC6858025 DOI: 10.1002/acr2.1007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Objective The introduction of biosimilars for rheumatologic diseases (RDs) has provided a potentially lower‐cost therapy compared with their bio‐originator products; however, adoption of biosimilars may be challenged by patient perceptions. The objective of this study was to describe patients’ perspectives of switching from infliximab to infliximab‐dyyb. Methods This was a survey of adult patients with RDs who qualified for switching from infliximab to infliximab‐dyyb therapy between September 1 2017 and January 31 2018. Verbal consent was obtained prior to administration of a telephone survey. Survey questions were focused on the safety, efficacy, and knowledge of biosimilar therapy. Results A total of 108 patients were identified with 52 (48%) patients consenting to study participation. Forty (77%) and 12 (23%) patients reported switching and not switching, respectively, to infliximab‐dyyb. Regarding disease control, most respondents (80%) were satisfied to very satisfied with the switch to infliximab‐dyyb. Major concerns reported for switching included not knowing enough about the medication (38%), potential side effects (35%), and loss of disease activity control (35%). Conclusion Overall, patients reported satisfaction with switching from infliximab to infliximab‐dyyb, but concerns regarding safety and efficacy were expressed. Patient involvement in the switching decision‐making process may allay concerns and enhance biosimilar uptake.
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Affiliation(s)
- Jason Chau
- Kaiser Permanente Washington Tacoma Washington
| | - Thomas Delate
- Kaiser Permanente Colorado, Aurora, Colorado, and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus Aurora Colorado
| | - Taylor Ota
- Kaiser Permanente Colorado, Aurora, Colorado, and Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus Aurora Colorado
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A novel superior medication-based chronic disease score predicted all-cause mortality in independent geriatric cohorts. J Clin Epidemiol 2019; 105:112-124. [DOI: 10.1016/j.jclinepi.2018.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/24/2018] [Accepted: 09/18/2018] [Indexed: 12/26/2022]
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