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Pilla SJ, Meza KA, Beach MC, Long JA, Gordon HS, Bates JT, Washington DL, Bokhour BG, Tuepker A, Saha S, Maruthur NM. Assessment and prevention of hypoglycaemia in primary care among U.S. Veterans: a mixed methods study. LANCET REGIONAL HEALTH. AMERICAS 2023; 28:100641. [PMID: 38076413 PMCID: PMC10701452 DOI: 10.1016/j.lana.2023.100641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 02/12/2024]
Abstract
Background Hypoglycaemia from diabetes treatment causes morbidity and lower quality of life, and prevention should be routinely addressed in clinical visits. Methods This mixed methods study evaluated how primary care providers (PCPs) assess for and prevent hypoglycaemia by analyzing audio-recorded visits from five Veterans Affairs medical centres in the US. Two investigators independently coded visit dialogue to classify discussions of hypoglycaemia history, anticipatory guidance, and adjustments to hypoglycaemia-causing medications according to diabetes guidelines. Findings There were 242 patients (one PCP visit per patient) and 49 PCPs. Two thirds of patients were treated with insulin and 40% with sulfonylureas. Hypoglycaemia history was discussed in 78/242 visits (32%). PCPs provided hypoglycaemia anticipatory guidance in 50 visits (21%) that focused on holding diabetes medications while fasting and carrying glucose tabs; avoiding driving and glucagon were not discussed. Hypoglycaemia-causing medications were de-intensified or adjusted more often (p < 0.001) when the patient reported a history of hypoglycaemia (15/51 visits, 29%) than when the patient reported no hypoglycaemia or it was not discussed (6/191 visits, 3%). Haemoglobin A1c (HbA1c) was not associated with diabetes medication adjustment, and only 5/12 patients (42%) who reported hypoglycaemia with HbA1c <7.0% had medications de-intensified or adjusted. Interpretation PCPs discussed hypoglycaemia in one-third of visits for at-risk patients and provided limited hypoglycaemia anticipatory guidance. De-intensifying or adjusting hypoglycaemia-causing medications did not occur routinely after reported hypoglycaemia with HbA1c <7.0%. Routine hypoglycaemia assessment and provision of diabetes self-management education are needed to achieve guideline-concordant hypoglycaemia prevention. Funding U.S. Department of Veterans Affairs and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
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Affiliation(s)
- Scott J. Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Kayla A. Meza
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mary Catherine Beach
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Judith A. Long
- Corporal Michael J. Cresenz VA Medical Center, Philadelphia, PA, USA
- Division of General Internal Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Howard S. Gordon
- Jesse Brown VA Medical Center, Chicago, IL, USA
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA
| | - Jeffrey T. Bates
- Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Donna L. Washington
- VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Barbara G. Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Anais Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Somnath Saha
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Nisa M. Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Deardorff WJ, Jing B, Growdon ME, Yaffe K, Boscardin WJ, Boockvar KS, Steinman MA. Medication misuse and overuse in community-dwelling persons with dementia. J Am Geriatr Soc 2023; 71:3086-3098. [PMID: 37272899 PMCID: PMC10592653 DOI: 10.1111/jgs.18463] [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: 02/21/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD. METHODS We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative. RESULTS Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively. CONCLUSION Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.
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Affiliation(s)
- W. James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Matthew E. Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California
- Department of Neurology, University of California, San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Kenneth S. Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, Alabama
| | - Michael A. Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Ma JE, Berkowitz TS, Olsen MK, Smith B, Lorenz KA, Bowling CB. Phenotypes of Symptom, Function, and Medication Burden in Older Adults with Nondialysis Advanced Kidney Disease. KIDNEY360 2023; 4:1430-1436. [PMID: 37682550 PMCID: PMC10615372 DOI: 10.34067/kid.0000000000000241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/31/2023] [Indexed: 09/09/2023]
Abstract
Key Points There are three distinct classes of symptoms, functional impairment, and medication burden among older adults with advanced kidney disease. One class with Complex Needs with pain and psychological symptoms, functional difficulties, and polypharmacy may benefit from tailored multidisciplinary care. Background Older adults with advanced CKD (stages 4 and 5) have significant symptoms, polypharmacy, and functional difficulties, and previous studies evaluated these burdens separately. Identifying subgroups with similar patterns of burdens could help clinicians optimize care for these individuals. Methods We conducted a secondary analysis of 377 older participants (70 years and older) with stage 4 and 5 CKD at high risk of hospitalization enrolled in a national Veterans Affairs prospective cohort study. Adults on dialysis or with prior kidney transplant were excluded. We used latent class analysis to identify participants with similar patterns across symptoms, medication burden, and function. Sixteen variables were included: symptoms (anxiety, depression, appetite, pain, shortness of breath, fatigue, dizziness, leg weakness, constipation, and stiffness using the Symptom Burden Score), polypharmacy (≥10 medications and potentially inappropriate medications), and function (activities of daily living [ADLs], physical and cognitive instrumental ADLs [IADLs], and falls in the past year). We also compared 12-month hospitalization and mortality rates between the three classes. Results Three classes of participants with similar functional impairment, medication burden, and symptom phenotypes were identified. The largest participant class (N =208) primarily had difficulties with physical IADLs and polypharmacy. The second participant class (N =99) had shortness of breath, constipation, and dizziness. The third participant class (N =70) had complex needs with daily pain, psychological symptoms (anxiety and depression), functional limitations (ADLs and physical and cognitive IADLs), and polypharmacy. The three classes had significantly different levels of comorbidities, financial stress, and social support. There were no significant differences in mortality and hospitalization among the three classes. Conclusion There are distinct classes of older adults with advanced CKD who have physical and psychological symptoms, functional impairment, and medication burden. Tailoring care for this population should include a multidisciplinary team to address these overlapping symptoms, medication, and functional needs.
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Affiliation(s)
- Jessica E. Ma
- Geriatric Research Education and Clinical Center, Durham VA Health System, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Theodore S.Z. Berkowitz
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina
| | - Maren K. Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Battista Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina
| | - Karl A. Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - C. Barrett Bowling
- Geriatric Research Education and Clinical Center, Durham VA Health System, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Center for the Study of Aging, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Troy AL, Herzig SJ, Trivedi S, Anderson TS. Initiation of oral anticoagulation in US older adults newly diagnosed with atrial fibrillation during hospitalization. J Am Geriatr Soc 2023; 71:2748-2758. [PMID: 37092856 PMCID: PMC10523931 DOI: 10.1111/jgs.18375] [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: 12/27/2022] [Revised: 03/09/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Atrial fibrillation is a common cause of stroke among older adults and is often first detected during hospitalization, given frequent use of cardiac telemetry. METHODS In a 20% national sample of Medicare fee-for-service beneficiaries, we identified patients aged 65-or-older newly diagnosed with atrial fibrillation while hospitalized in 2016. Our primary outcome was an oral anticoagulant claim within 7-days of discharge. Multivariable logistic regression analyses assessed relationships between anticoagulation initiation and thromboembolic and bleeding risk scores while controlling for demographics, frailty, comorbidities, and hospitalization characteristics. RESULTS Among 38,379 older adults newly diagnosed with atrial fibrillation while hospitalized (mean age 78.2 [SD 8.4]; 51.8% female; 83.3% white), 36,633 (95.4%) had an indication for anticoagulation and 24.6% (9011) of those initiated an oral anticoagulant following discharge. Higher CHA2 DS2 -VASc score was associated with a small increase in oral anticoagulant initiation (predicted probability 20.5% [95% CI, 18.7%-22.3%] for scores <2 and 24.9% [CI, 24.4%-25.4%] for ≥4). Elevated HAS-BLED score was associated with a small decrease in probability of anticoagulant initiation (25.4% [CI, 24.4%-26.4%] for score <2 and 23.1% [CI, 22.5%-23.8%] for ≥3). Frailty was associated with decreased likelihood of oral anticoagulant initiation (24.7% [CI, 23.2%-26.2%] for non-frail and 18.1% [CI, 16.6%-19.6%] for moderately-severely frail). Anticoagulant initiation varied by primary reason for hospitalization, with predicted probability highest among patients with a primary diagnosis of atrial fibrillation (46.1% [CI, 45.0%-47.3%]) and lowest among those with non-cardiovascular conditions (13.8% [CI, 13.3%-14.3%]) and bleeds (3.6% [CI, 2.4%-4.8%]). CONCLUSIONS Oral anticoagulant initiation is uncommon among older adults newly diagnosed with atrial fibrillation during hospitalization, even among patients hospitalized primarily for atrial fibrillation and patients with high thromboembolic risk. Clinicians should discuss risks and benefits of oral anticoagulants with all inpatients found to have atrial fibrillation.
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Affiliation(s)
- Aaron L. Troy
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shrunjal Trivedi
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA
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Anderson TS, Herzig SJ, Jing B, Boscardin WJ, Fung K, Marcantonio ER, Steinman MA. Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults. JAMA Intern Med 2023; 183:715-723. [PMID: 37252732 PMCID: PMC10230372 DOI: 10.1001/jamainternmed.2023.1667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/24/2023] [Indexed: 05/31/2023]
Abstract
Importance Asymptomatic blood pressure (BP) elevations are common in hospitalized older adults, and widespread heterogeneity in the clinical management of elevated inpatient BPs exists. Objective To examine the association of intensive treatment of elevated inpatient BPs with in-hospital clinical outcomes of older adults hospitalized for noncardiac conditions. Design, Setting, and Participants This retrospective cohort study examined Veterans Health Administration data between October 1, 2015, and December 31, 2017, for patients aged 65 years or older hospitalized for noncardiovascular diagnoses and who experienced elevated BPs in the first 48 hours of hospitalization. Interventions Intensive BP treatment following the first 48 hours of hospitalization, defined as receipt of intravenous antihypertensives or oral classes not used prior to admission. Main Outcome and Measures The primary outcome was a composite of inpatient mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation. Data were analyzed between October 1, 2021, and January 10, 2023, with propensity score overlap weighting used to adjust for confounding between those who did and did not receive early intensive treatment. Results Among 66 140 included patients (mean [SD] age, 74.4 [8.1] years; 97.5% male and 2.6% female; 17.4% Black, 1.7% Hispanic, and 75.9% White), 14 084 (21.3%) received intensive BP treatment in the first 48 hours of hospitalization. Patients who received early intensive treatment vs those who did not continued to receive a greater number of additional antihypertensives during the remainder of their hospitalization (mean additional doses, 6.1 [95% CI, 5.8-6.4] vs 1.6 [95% CI, 1.5-1.8], respectively). Intensive treatment was associated with a greater risk of the primary composite outcome (1220 [8.7%] vs 3570 [6.9%]; weighted odds ratio [OR], 1.28; 95% CI, 1.18-1.39), with the highest risk among patients receiving intravenous antihypertensives (weighted OR, 1.90; 95% CI, 1.65-2.19). Intensively treated patients were more likely to experience each component of the composite outcome except for stroke and mortality. Findings were consistent across subgroups stratified by age, frailty, preadmission BP, early hospitalization BP, and cardiovascular disease history. Conclusions and Relevance The study's findings indicate that among hospitalized older adults with elevated BPs, intensive pharmacologic antihypertensive treatment was associated with a greater risk of adverse events. These findings do not support the treatment of elevated inpatient BPs without evidence of end organ damage, and they highlight the need for randomized clinical trials of inpatient BP treatment targets.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - W. John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Edward R. Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael A. Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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Growdon ME, Gan S, Yaffe K, Lee AK, Anderson TS, Muench U, Boscardin WJ, Steinman MA. New psychotropic medication use among Medicare beneficiaries with dementia after hospital discharge. J Am Geriatr Soc 2023; 71:1134-1144. [PMID: 36514208 PMCID: PMC10089969 DOI: 10.1111/jgs.18161] [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: 07/06/2022] [Revised: 10/21/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hospitalizations among people with dementia (PWD) may precipitate behavioral changes, leading to the psychotropic medication use despite adverse outcomes and limited efficacy. We sought to determine the incidence of new psychotropic medication use among community-dwelling PWD after hospital discharge and, among new users, the proportion with prolonged use. METHODS This was a retrospective cohort study using a 20% random sample of Medicare claims in 2017, including hospitalized PWD with traditional and Part D Medicare who were 68 years or older. The primary outcome was incident prescribing at discharge of psychotropics including antipsychotics, sedative-hypnotics, antiepileptics, and antidepressants. This was defined as new prescription fills (i.e., from classes not used in 180 days preadmission) within 7 days of hospital or skilled nursing facility discharge. Prolonged use was defined as the proportion of new users who continued to fill newly prescribed medications beyond 90 days of discharge. RESULTS The cohort included 117,022 hospitalized PWD with a mean age of 81 years; 63% were female. Preadmission, 63% were using at least 1 psychotropic medication; 10% were using medications from ≥3 psychotropic classes. These included antidepressants (44% preadmission), antiepileptics (29%), sedative-hypnotics (21%), and antipsychotics (11%). The proportion of PWD discharged from the hospital with new psychotropics ranged from 1.9% (antipsychotics) to 2.9% (antiepileptics); 6.6% had at least one new class started. Among new users, prolonged use ranged from 36% (sedative-hypnotics) to 63% (antidepressants); across drug classes, prolonged use occurred in 51%. Predictors of newly initiated psychotropics included length of stay (≥median vs. CONCLUSIONS Hospitalized PWD have a high prevalence of preadmission psychotropic medication use; against this baseline, discharge from the hospital with new psychotropics is relatively uncommon. Nevertheless, prolonged use of newly initiated psychotropics occurs in a substantial proportion of this population.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, California, USA
- Northern California Institute for Research and Education, San Francisco, California, USA
| | - Kristine Yaffe
- Mental Health, San Francisco VA Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Departments of Neurology and Psychiatry, University of California, San Francisco, California, USA
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
| | - Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ulrike Muench
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
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Havnes K, Svendsen K, Johansen JS, Granas AG, Garcia BH, Halvorsen KH. Is anticholinergic and sedative drug burden associated with postdischarge institutionalization in community-dwelling older patients acutely admitted to hospital? A Norwegian registry-based study. Pharmacoepidemiol Drug Saf 2022; 32:607-616. [PMID: 36585814 DOI: 10.1002/pds.5590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/03/2022] [Accepted: 12/22/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE Investigate the association between anticholinergic (AC) and sedative (SED) drug burden before hospitalization and postdischarge institutionalization (PDI) in community-dwelling older patients acutely admitted to hospital. METHODS A cross-sectional study using data from the Norwegian Patient Registry and the Norwegian Prescription Database. We studied acutely hospitalized community-dwelling patients ≥70 years during 2013 (N = 86 509). Patients acutely admitted to geriatric wards underwent subgroup analyses (n = 1715). We calculated drug burden by the Drug Burden Index (DBI), use of AC/SED drugs, and the number of AC/SED drugs. Piecewise linearity of DBI versus PDI and a knot point (DBI = 2.45) was identified. Statistical analyses included an adjusted multivariable logistic regression model. RESULTS In the total population, 45.4% were exposed to at least one AC/SED drug, compared to 52.5% in the geriatric subgroup. AC/SED drugs were significantly associated with PDI. The DBI with odds ratios (ORs) of 1.11 (95% CI 1.07-1.15) for DBI < 2.45 and 1.08 (95% CI 1.04-1.13) for DBI ≥ 2.45. The number of AC/SED drugs with OR of 1.07 (95% CI 1.05-1.09). The AC component of DBI with OR 1.23 and the number of AC drugs with OR 1.13. In the subgroup, ORs were closer to 1 for AC drugs. CONCLUSIONS The use of AC/SED drugs was highly prevalent in older patients before acute hospital admissions, and significantly associated with PDI. The number, or just using AC/SED drugs, gave similar associations with PDI compared to applying the DBI. Using AC drugs showed higher sensitivity, indicating that to reduce the risk of PDI, a clinical approach could be to reduce the number of AC drugs.
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Affiliation(s)
- Kjerstin Havnes
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway.,Surgery, Cancer, and Women's Health Clinic, The University Hospital of North Norway, Tromsø, Norway
| | - Kristian Svendsen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Jeanette Schultz Johansen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Anne Gerd Granas
- Department of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Beate Hennie Garcia
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Kjell H Halvorsen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
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8
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Parker JJ, Zhang Y, Fatemi P, Halpern CH, Porter BE, Grant GA. Antiseizure medication use and medical resource utilization after resective epilepsy surgery in children in the United States: A contemporary nationwide cross-sectional cohort analysis. Epilepsia 2022; 63:824-835. [PMID: 35213744 DOI: 10.1111/epi.17180] [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] [Received: 07/17/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Antiseizure drug (ASD) therapy can significantly impact quality of life for pediatric patients whose epilepsy remains refractory to medications and who experience neuropsychological side effects manifested by impaired cognitive and social development. Contemporary patterns of ASD reduction after pediatric epilepsy surgery across practice settings in the United States are sparsely reported outside of small series. We assessed timing and durability of ASD reduction after pediatric epilepsy surgery and associated effects on health care utilization. METHODS We performed a retrospective analysis of 376 pediatric patients who underwent resective epilepsy surgery between 2007 and 2016 in the United States using the Truven MarketScan database. Filled ASD prescriptions during the pre- and postoperative periods were compared. Univariate and multivariate analyses identified factors associated with achieving a stable discontinuation of or reduction in number of ASDs. Health care utilization and costs were systematically compared. RESULTS One hundred seventy-one patients (45.5%) achieved a >90-day ASD-free period after surgery, and 84 (22.3%) additional patients achieved a stable reduction in number of ASDs. Achieving ASD freedom was more common in patients undergoing total hemispherectomy (n = 21, p = .002), and less common in patients with tuberous sclerosis (p = .003). A higher number of preoperative ASDs was associated with a greater likelihood of achieving ASD reduction postoperatively (hazard ratio [HR]: 1.85, 95% confidence interval [CI]: 1.50-2.28), but was not associated with a significant difference in the likelihood of achieving ASD freedom (0.83, 95% CI: 0.49-1.39). Achieving an ASD-free period was associated with fewer hospital readmissions within the first year after surgery. SIGNIFICANCE Patterns of ASD use and discontinuation after pediatric epilepsy surgery provide an unbiased surgical outcome endpoint extractable from administrative databases, where changes in seizure frequency are not captured. This quantitative measure can augment traditional surgical outcome scales, incorporating a significant clinical parameter associated with improved quality of life.
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Affiliation(s)
- Jonathon J Parker
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Parastou Fatemi
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brenda E Porter
- Department of Neurology, Stanford University School of Medicine, Palo Alto, California, USA.,Division of Child Neurology, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA.,Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, California, USA
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9
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Herzig SJ, Anderson TS, Jung Y, Ngo LH, McCarthy EP. Risk factors for opioid-related adverse drug events among older adults after hospital discharge. J Am Geriatr Soc 2022; 70:228-234. [PMID: 34528242 PMCID: PMC10911129 DOI: 10.1111/jgs.17453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/18/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although opioids are initiated on hospital discharge in millions of older adults each year, there are no studies examining patient- and prescribing-related risk factors for opioid-related adverse drug events (ADEs) after hospital discharge among medical patients. METHODS A retrospective cohort study of a national sample of Medicare beneficiaries aged 65 years and older, hospitalized for a medical reason, with at least one claim for an opioid within 2 days of hospital discharge. We excluded patients receiving hospice care and patients admitted from or discharged to a facility. We used administrative billing codes and medication claims to define potential opioid-related ADEs within 30 days of hospital discharge, and competing risks regression to identify risk factors for these events. RESULTS Among 22,879 medical hospitalizations (median age 74, 36.9% female) with an opioid claim within 2 days of hospital discharge, a potential opioid-related ADE occurred in 1604 (7.0%). Independent risk factors included age of 80 years and older (HR 1.18, 95% CI 1.05-1.33); clinical conditions, including kidney disease (HR 1.22, 95% CI 1.08-1.37), dementia/delirium (HR 1.38, 95% CI 1.22-1.56), anxiety disorder (HR 1.20, 95% CI 1.06-1.36), opioid use disorder (HR 1.20, 95% CI 1.03-1.39), intestinal disorders (HR 1.31, 95% CI 1.15-1.49), pancreaticobiliary disorders (HR 1.32, 95% CI 1.09-1.61), and musculoskeletal and nervous system injuries (HR 1.35, 95% CI 1.17-1.54); red flags for opioid misuse (HR 1.37, 95% CI 1.04-1.80); opioid use in the 30 days before hospitalization (HR 1.20, 95% CI 1.08-1.34); and prescription of long-acting opioids (HR 1.34, 95% CI 1.06-1.70). CONCLUSIONS Potential opioid-related ADEs occurred within 30 days of hospital discharge in 7.0% of older adults discharged from a medical hospitalization with an opioid prescription. Identified risk factors can be used to inform physician decision-making, conversations with older adults about risk, and development and targeting of harm reduction strategies.
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Affiliation(s)
- Shoshana J. Herzig
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy S. Anderson
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Yoojin Jung
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Long H. Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ellen P. McCarthy
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
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10
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Anderson TS, Lee AK, Jing B, Lee S, Herzig SJ, Boscardin WJ, Fung K, Rizzo A, Steinman MA. Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System. JAMA Netw Open 2021; 4:e2128998. [PMID: 34673963 PMCID: PMC8531994 DOI: 10.1001/jamanetworkopen.2021.28998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization. OBJECTIVE To investigate outcomes associated with intensification of outpatient diabetes medications at discharge. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021. EXPOSURE Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications. MAIN OUTCOMES AND MEASURES Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge. RESULTS The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled. CONCLUSIONS AND RELEVANCE In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Alexandra K. Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sei Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - W. John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Anael Rizzo
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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11
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Self-reported medication use among coronary heart disease patients showed high validity compared with dispensing data. J Clin Epidemiol 2021; 135:115-124. [PMID: 33640414 DOI: 10.1016/j.jclinepi.2021.02.015] [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: 10/30/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To validate self-reported use of medications for secondary prevention of coronary heart disease (CHD) in a population-based health study by comparing self-report with pharmacy dispensing data, and explore different methods for defining medication use in prescription databases. STUDY DESIGN AND SETTING Self-reported medication use among participants with CHD (n = 1483) from the seventh wave of the Tromsø Study was linked with the Norwegian Prescription Database (NorPD). Cohen's kappa, sensitivity, specificity, and positive and negative predictive values were calculated, using NorPD as the reference standard. Medication use in NorPD was defined in three ways; fixed-time window of 180 days, and legend-time method assuming a daily dose of one dosage unit or one defined daily dose (DDD). RESULTS Kappa-values for antihypertensive drugs, lipid-lowering drugs and acetylsalicylic acid all showed substantial agreement (kappa ≥0.61). Validity varied depending on the method used for defining medication use in NorPD. Applying a fixed-time window gave higher agreement, positive predictive values and specificity compared with the legend-time methods. CONCLUSION Self-reported use of medication for secondary prevention of CHD shows high validity when compared with pharmacy dispensing data. For CHD medications, fixed-time window appears to be the most appropriate method for defining medication use in prescription databases.
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12
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Anderson TS, Lee S, Jing B, Fung K, Ngo S, Silvestrini M, Steinman MA. Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA Netw Open 2020; 3:e201511. [PMID: 32207832 PMCID: PMC7093767 DOI: 10.1001/jamanetworkopen.2020.1511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/24/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. Objective To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. Design, Setting, and Participants This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. Main Outcomes and Measures Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. Results Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. Conclusions and Relevance In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sei Lee
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sarah Ngo
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Molly Silvestrini
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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13
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Fukai K, Nagata T, Mori K, Ohtani M, Fujimoto K, Nagata M, Fujino Y. Validation of self-reported medication use for hypertension, diabetes, and dyslipidemia among employees of large-sized companies in Japan. J Occup Health 2020; 62:e12138. [PMID: 32710699 PMCID: PMC7382304 DOI: 10.1002/1348-9585.12138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/25/2020] [Accepted: 05/30/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the validity of self-reported medication use for hypertension, diabetes, and dyslipidemia by comparison with health insurance claims among employees of large-sized companies in Japan. METHODS Participants were 61 676 participants of 13 large-sized companies in Japan. Self-reports on medication use were obtained through web- or paper-based questionnaires conducted at the annual health checkup in fiscal year 2016. Health insurance claims for medication were obtained from corporate health insurance associations from April 1, 2016, to March 31, 2017. Agreement rate, sensitivity, specificity, positive and negative predictive values (PPV and NPV), and kappa statistics of self-reporting were examined for different reference periods (1-, 2-, and 3- months, and 1-year). Subgroup analysis was conducted stratified by sex, age, body mass index, smoking, alcohol drinking, blood pressure, hemoglobin A1c, and low-density lipoprotein cholesterol. RESULTS Agreement, sensitivity, specificity, PPV, and NPV were 0.98, 0.90, 0.98, 0.87, and 0.99 for hypertension, 0.99, 0.89, 1.00, 0.89, and 1.00 for diabetes, and 0.98, 0.86, 0.99, 0.83, and 0.99 for dyslipidemia, respectively, between self-reports and claims data for 3 months. Kappa statistics were highest with the 3-month reference period of claims data for hypertension, diabetes, and dyslipidemia. No major concordance was observed between the subgroups. CONCLUSION This validation of self-reported medication use for hypertension, diabetes, and dyslipidemia showed almost perfect reliability among employees of large-sized companies in Japan.
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Affiliation(s)
- Kota Fukai
- Department of Preventive MedicineTokai University School of MedicineIsehara CityJapan
| | - Tomohisa Nagata
- Department of Occupational Health Practice and ManagementInstitute of Industrial Ecological SciencesUniversity of Occupational and Environmental HealthKitakyushuJapan
| | - Koji Mori
- Department of Occupational Health Practice and ManagementInstitute of Industrial Ecological SciencesUniversity of Occupational and Environmental HealthKitakyushuJapan
| | - Makoto Ohtani
- Data Science Center for Occupational HealthUniversity of Occupational and Environmental HealthKitakyushuJapan
| | - Kenji Fujimoto
- Department of Public HealthUniversity of Occupational and Environmental HealthKitakyushuJapan
| | - Masako Nagata
- Department of Occupational Health Practice and ManagementInstitute of Industrial Ecological SciencesUniversity of Occupational and Environmental HealthKitakyushuJapan
- Data Science Center for Occupational HealthUniversity of Occupational and Environmental HealthKitakyushuJapan
| | - Yoshihisa Fujino
- Department of Environmental EpidemiologyInstitute of Industrial Ecological SciencesUniversity of Occupational and Environmental HealthKitakyushuJapan
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