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Pundi K, Fan J, Kabadi S, Din N, Blomström-Lundqvist C, Camm AJ, Kowey P, Singh JP, Rashkin J, Wieloch M, Turakhia MP, Sandhu AT. Dronedarone Versus Sotalol in Antiarrhythmic Drug-Naive Veterans With Atrial Fibrillation. Circ Arrhythm Electrophysiol 2023; 16:456-467. [PMID: 37485722 DOI: 10.1161/circep.123.011893] [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: 02/06/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Sotalol and dronedarone are both used for maintenance of sinus rhythm for patients with atrial fibrillation. However, while sotalol requires initial monitoring for QT prolongation and proarrhythmia, dronedarone does not. These treatments can be used in comparable patients, but their safety and effectiveness have not been compared head to head. Therefore, we retrospectively evaluated the effectiveness and safety using data from a large health care system. METHODS Using Veterans Health Administration data, we identified 11 296 antiarrhythmic drug-naive patients with atrial fibrillation prescribed dronedarone or sotalol in 2012 or later. We excluded patients with prior conduction disease, pacemakers or implantable cardioverter-defibrillators, ventricular arrhythmia, cancer, renal failure, liver disease, or heart failure. We used natural language processing to identify and compare baseline left ventricular ejection fraction between treatment arms. We used 1:1 propensity score matching, based on patient demographics, comorbidities, and medications, and Cox regression to compare strategies. To evaluate residual confounding, we performed falsification analysis with nonplausible outcomes. RESULTS The matched cohort comprised 6212 patients (3106 dronedarone and 3106 sotalol; mean [±SD] age, 71±10 years; 2.5% female; mean [±SD] CHA2DS2-VASC, 2±1.3). The mean (±SD) left ventricular ejection fraction was 55±11 and 58±10 for dronedarone and sotalol users, correspondingly. Dronedarone, compared with sotalol, did not demonstrate a significant association with risk of cardiovascular hospitalization (hazard ratio, 1.03 [95% CI, 0.88-1.21]) or all-cause mortality (hazard ratio, 0.89 [95% CI, 0.68-1.16]). However, dronedarone was associated with significantly lower risk of ventricular proarrhythmic events (hazard ratio, 0.53 [95% CI, 0.38-0.74]) and symptomatic bradycardia (hazard ratio, 0.56 [95% CI, 0.37-0.87]). The primary findings were stable across sensitivity analyses. Falsification analyses were not significant. CONCLUSIONS Dronedarone, compared with sotalol, was associated with a lower risk of ventricular proarrhythmic events and conduction disorders while having no difference in risk of incident cardiovascular hospitalization and mortality. These observational data provide the basis for prospective efficacy and safety trials.
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Affiliation(s)
- Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | | | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden (C.B.-L.)
| | - A John Camm
- St. George's University of London, United Kingdom (A.J.C.)
| | - Peter Kowey
- Lankenau Heart Institute, Wynnewood, PA (P.K.)
| | | | | | - Mattias Wieloch
- Department of Coagulation Disorders, Skåne University Hospital, Lund University, Malmö, Sweden (M.W.)
- Sanofi, Stockholm, Sweden (M.W.)
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | - Alexander T Sandhu
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
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Pundi K, Perino AC, Fan J, Din N, Szummer K, Heidenreich P, Turakhia MP. Association of CHA 2DS 2-VASc and HAS-BLED to frailty and frail outcomes: From the TREAT-AF study. Am Heart J 2023; 261:85-94. [PMID: 37024025 DOI: 10.1016/j.ahj.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Morbidity and mortality associated with high CHA2DS2-VASc and HAS-BLED scores is not specific to atrial fibrillation (AF). Frailty could be an important contributor to this morbidity and mortality while being mechanistically independent from AF. We sought to evaluate the association of stroke and bleeding risk to noncardiovascular frail events and the association of stroke prevention therapy to outcomes in frail patients with AF. METHODS Using the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, we identified patients with newly diagnosed AF from 2004 to 2014. Baseline frailty was identified using a previously validated claims-based index requiring ≥2 of 12 ICD-9 diagnoses. Logistic regressions modeled the association between CHA2DS2-VASc and modified HAS-BLED and frailty. Cox proportional hazard regressions were used to evaluate the association between CHA2DS2-VASc and modified HAS-BLED and a composite of noncardiovascular frail events (fractures, urinary tract infections, bacterial pneumonia, or dehydration). We also evaluated the association of oral anticoagulant (OAC) use with stroke, bleeding, and 1-year mortality in frail patients and non-frail patients. RESULTS In 213,435 patients (age 70 ± 11; 98% male; CHA2DS2-VASc 2.4 ± 1.7) with AF, 8,498 (4%) were frail. CHA2DS2-VASc > 0 and HAS-BLED > 0 were strongly associated with frailty (odds ratio [OR] 13.3 (95% CI: 11.6-15.2) for CHA2DS2-VASc 4+ and OR 13.4 (10.2-17.5) for HAS-BLED 3+). After adjusting for covariates, CHA2DS2-VASc, and HAS-BLED > 0 were associated with higher risk of non-cardiovascular frail events (hazard ratio [HR] 2.1 (95% CI: 2.0-2.2) for CHA2DS2-VASc 4+ and HR 1.4 (95% CI: 1.3-1.5) for HAS-BLED 3+). In frail patients, OAC use was associated with significantly lower risk of 1-year mortality (HR 0.82; 95% CI 0.72-0.94, P = .0031) but did not reach significance for risk of stroke (HR 0.80; 95% CI 0.55-1.18, P = .26) or major bleeding (HR 1.08; 95% CI 0.93-1.25, P = .34). CONCLUSIONS High CHA2DS2-VASc and HAS-BLED scores are strongly associated with frailty. However, in frail patients, OAC use was associated with reduction in 1-year mortality. For this challenging clinical population with competing risks of frailty and frail events, focused prospective studies are needed to support clinical decision-making. Until then, careful evaluation of frailty should inform shared decision-making.
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Affiliation(s)
- Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Digital Health, Stanford University School of Medicine, Stanford, CA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Karolina Szummer
- Karolinska University Hospital, Theme Heart and Vessel; Karolinska Institutet, Stockholm, Sweden
| | - Paul Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Digital Health, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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Din N, Fan J, Schmitt S, Guo JD, Hlavacek P, Pundi K, Russ C, Emir B, Turakhia MP, Perino AC. Warfarin Time in Therapeutic INR Range and Direct Oral Anticoagulant Adherence for Venous Thromboembolism Across the Spectrum of Weight and Body Mass Index: Findings from Veterans Health Administration. Clin Appl Thromb Hemost 2023; 29:10760296231152474. [PMID: 36694957 PMCID: PMC9893071 DOI: 10.1177/10760296231152474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The evidence of direct oral anticoagulants (DOACs) usage for venous thromboembolism (VTE) in patients at extremes of body weight or mass index is limited. In such situations, warfarin may be more frequently used. We investigated warfarin time in the therapeutic international normalized ratio range (TTR) and DOAC adherence based on the calculated proportion of days covered (PDC) by pill coverage from a DOAC prescription in patients with VTE across all body sizes. Using data from the Veterans Health Administration (VA), we identified first-time patients with VTE between 2013 and 2018 treated with warfarin or DOACs. We analyzed 28,245 patients with warfarin TTR (N = 10,167) or DOAC PDC(N = 18,078). For warfarin-treated patients after index VTE, mean TTR was lower over shorter treatment durations (TTR 30 vs TTR 180 [mean ± SD]: 43.8% ± 33.5% vs 58.8% ± 23.5%). Mean TTR over 180 days after VTE was lowest for patients <60 kg (TTR 180 [mean ± SD]: <60kg: 49.3% ± 24.2% vs ≥60 to <100 kg: 57.8% ± 23.4%; P < .0001). For DOAC-treated patients over 180 days after index VTE, mean PDC was lowest for patients <60 kg (PDC 180 [mean ± SD]: < 60kg: 76.9% ± 33.2% vs ≥ 60 to <100 kg: 83.6% ± 27.7%; P < .0001).Most DOAC-treated patients attained sufficient adherence across the body size spectrum while warfarin-treated patients <60kg were at risk for low TTR.
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Affiliation(s)
- Natasha Din
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA,Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jennifer D. Guo
- Bristol Myers Squibb, Lawrenceville, NJ, USA former employee at the time the study was conducted
| | | | - Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Mintu P. Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA,Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA,Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Alexander C. Perino
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA,Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA,Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA,Alexander C. Perino, Center for Academic Medicine, Department of Medicine/Division of Cardiovascular Medicine, Mail Code 5687, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304, USA.
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Buta E, Gordon KS, Gueorguieva R, Becker WC, Heapy A, Bathulapalli H, Zeng Q, Redd D, Brandt C, Goulet J. Joint longitudinal trajectories of pain intensity and opioid prescription in veterans with back pain. Pharmacoepidemiol Drug Saf 2022; 31:1262-1271. [PMID: 35996825 DOI: 10.1002/pds.5531] [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: 11/03/2021] [Revised: 07/15/2022] [Accepted: 08/15/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE We describe pain intensity and opioid prescription jointly over time in Veterans with back pain to better understand their relationship. METHODS We performed a retrospective cohort study on electronic health record data from 117 126 Veterans (mean age 49.2 years) diagnosed with back pain in 2015. We used latent class growth analysis to jointly model pain intensity (0-10 scores) and opioid prescriptions over 2 years to identify classes of individuals similar in their trajectory of pain and opioid over time. Multivariable multinomial logit models assessed sociodemographic and clinical predictors of class membership. RESULTS We identified six trajectory classes: a "no pain/no opioid" class (22.2%), a "mild pain/no opioid" class (45.0%), a "moderate pain/no opioid" class (24.6%), a "moderate, decreasing pain/decreasing opioid" class (3.3%), a "moderate pain/high opioid" class (2.6%), and a "moderate, increasing pain/increasing opioid" class (2.3%). Among those in moderate pain classes, being white (vs. non-white) and older were associated with higher odds of being prescribed opioids. Veterans with mental health diagnoses had increased odds of being in the painful classes versus "no pain/no opioid" class. CONCLUSION We found distinct patterns in the long-term joint course of pain and opioid prescription in Veterans with back pain. Understanding these patterns and associated predictors may help with development of targeted interventions for patients with back pain.
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Affiliation(s)
- Eugenia Buta
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA.,Research Department, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Kirsha S Gordon
- Research Department, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Ralitza Gueorguieva
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - William C Becker
- Research Department, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Alicia Heapy
- Research Department, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Harini Bathulapalli
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA.,Research Department, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Qing Zeng
- Biomedical Informatics Center, George Washington University, Washington, District of Columbia, USA
| | - Doug Redd
- Biomedical Informatics Center, George Washington University, Washington, District of Columbia, USA
| | - Cynthia Brandt
- Research Department, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Joseph Goulet
- Research Department, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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Perino AC, Fan J, Pundi K, Schmitt S, Kothari M, Din N, Heidenreich PA, Turakhia MP. Atrial fibrillation bleeding risk and prediction while treated with direct oral anticoagulants in warfarin-naïve or warfarin-experienced patients. Clin Cardiol 2022; 45:960-969. [PMID: 35946047 PMCID: PMC9451662 DOI: 10.1002/clc.23887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 06/08/2022] [Accepted: 06/23/2022] [Indexed: 11/20/2022] Open
Abstract
Background In patients with atrial fibrillation (AF) treated with direct oral anticoagulants (DOAC), bleeding risk scores provide only modest discrimination for major or intracranial bleeding. However, warfarin experience may impact HAS‐BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly) score performance in patients evaluated for DOACs, as HAS‐BLED was derived and validated in warfarin cohorts. Methods We performed a retrospective cohort study of patients prescribed DOAC for AF in the Veterans Health Administration between 2010 and 2017. We determined modified HAS‐BLED score discrimination and calibration for bleeding, for patients treated with DOAC, stratified by prior warfarin exposure. We also determined the association between DOAC–warfarin‐naïve status to bleeding (nonintracranial and intracranial) with DOAC–warfarin‐experienced patients as reference. Results The DOAC analysis cohort included 100, 492 patients with AF (age [mean ± SD]: 72.9 ± 9.6 years; 1.7% female; 90.1% White), of which 26, 760 patients (26.6%) and 73, 732 patients (73.4%) were warfarin experienced or naïve, respectively. HAS‐BLED discrimination for bleeds was modest for patients treated with DOAC, regardless of prior warfarin experience (concordance statistics: 0.53–0.59). For DOAC–warfarin‐naïve patients, as compared to DOAC–warfarin‐experienced patients, adjusted risk of intracranial bleeding was lower, while risk of nonintracranial bleeding was higher (intracranial bleeding propensity adjusted with inverse probability of treatment weights [IPTWs]: hazard ratio [HR]: 0.86, 95% confidence interval [CI]: 0.78–0.95, p = .0040) (nonintracranial bleeding propensity adjusted with IPTW: HR: 1.15, 95% CI: 1.11–1.19, p < .0001). Conclusion Patients’ modified HAS‐BLED score at the time of DOAC initiation, regardless of prior warfarin use, provided only modest discrimination for intracranial and nonintracranial bleeds. These data argue against maintaining DOAC eligible patients on warfarin therapy regardless of modified HAS‐BLED score.
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Affiliation(s)
- Alexander C Perino
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Department of Medicine, Stanford University, Stanford, California, USA.,Center for Digital Health, Stanford University, Stanford, California, USA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Krishna Pundi
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Mitra Kothari
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Center for Digital Health, Stanford University, Stanford, California, USA
| | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Department of Medicine, Stanford University, Stanford, California, USA
| | - Mintu P Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Department of Medicine, Stanford University, Stanford, California, USA.,Center for Digital Health, Stanford University, Stanford, California, USA
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Pundi KN, Perino AC, Fan J, Schmitt S, Kothari M, Szummer K, Askari M, Heidenreich PA, Turakhia MP. Direct Oral Anticoagulant Adherence of Patients With Atrial Fibrillation Transitioned from Warfarin. J Am Heart Assoc 2021; 10:e020904. [PMID: 34779243 PMCID: PMC9075386 DOI: 10.1161/jaha.121.020904] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Reduced time in international normalized ratio therapeutic range (TTR) limits warfarin safety and effectiveness. In patients switched from warfarin to direct oral anticoagulants (DOACs), patient factors associated with low TTR could also increase risk of DOAC nonadherence. We investigated the relationship between warfarin TTR and DOAC adherence in warfarin‐treated patients with atrial fibrillation switched to DOAC. Methods and Results Using data from the Veterans Health Administration, we identified patients with atrial fibrillation switched from warfarin to DOAC (switchers) or treated with warfarin alone (non‐switchers). Logistic regression was used to evaluate association between warfarin TTR and DOAC adherence. We analyzed 128 605 patients (age, 71±9; 1.6% women; CHA2DS2‐VASc 3.5±1.6); 32 377 switchers and 96 228 non‐switchers. In 8016 switchers with international normalized ratio data to calculate 180‐day TTR before switch, TTR was low (median 0.45; IQR, 0.26–0.64). Patients with TTR <0.5 were more likely to be switched to DOAC (odds ratio [OR],1.68 [95% CI,1.62–1.74], P<0.0001), as were those with TTR <0.6 or TTR <0.7. Proportion of days covered ≥0.8 was achieved by 76% of switchers at 365 days. In low‐TTR individuals, proportion of days covered ≥0.8 was achieved by 70%, 72%, and 73% of switchers with TTR <0.5, 0.6, and 0.7, respectively. After multivariable adjustment, TTR <0.5 decreased odds of achieving 365‐day proportion of days covered ≥0.8 (OR, 0.49; 0.43–0.57, P<0.0001), with similar relationships for TTR <0.6 and TTR <0.7. In non‐switchers with TTR <0.5, long‐term TTR remained low. Conclusions In patients with atrial fibrillation switched from warfarin to DOAC, most achieved adequate DOAC adherence despite low pre‐switch TTRs. However, TTR trajectories remained low in non‐switchers. Patients with low warfarin TTR more consistently achieved treatment targets after switching to DOACs, although adherence‐oriented interventions may be beneficial.
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Affiliation(s)
- Krishna N Pundi
- Department of Medicine Stanford University School of Medicine Stanford CA
| | - Alexander C Perino
- Department of Medicine Stanford University School of Medicine Stanford CA.,Center for Digital Health Stanford University School of Medicine Stanford CA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Mitra Kothari
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Karolina Szummer
- Department of Medicine Stanford University School of Medicine Stanford CA.,Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Paul A Heidenreich
- Department of Medicine Stanford University School of Medicine Stanford CA.,Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Mintu P Turakhia
- Department of Medicine Stanford University School of Medicine Stanford CA.,Center for Digital Health Stanford University School of Medicine Stanford CA.,Veterans Affairs Palo Alto Health Care System Palo Alto CA
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Castro VM, Gainer V, Wattanasin N, Benoit B, Cagan A, Ghosh B, Goryachev S, Metta R, Park H, Wang D, Mendis M, Rees M, Herrick C, Murphy SN. The Mass General Brigham Biobank Portal: an i2b2-based data repository linking disparate and high-dimensional patient data to support multimodal analytics. J Am Med Inform Assoc 2021; 29:643-651. [PMID: 34849976 PMCID: PMC8922162 DOI: 10.1093/jamia/ocab264] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/20/2021] [Accepted: 11/16/2021] [Indexed: 01/07/2023] Open
Abstract
Objective Integrating and harmonizing disparate patient data sources into one consolidated data portal enables researchers to conduct analysis efficiently and effectively. Materials and Methods We describe an implementation of Informatics for Integrating Biology and the Bedside (i2b2) to create the Mass General Brigham (MGB) Biobank Portal data repository. The repository integrates data from primary and curated data sources and is updated weekly. The data are made readily available to investigators in a data portal where they can easily construct and export customized datasets for analysis. Results As of July 2021, there are 125 645 consented patients enrolled in the MGB Biobank. 88 527 (70.5%) have a biospecimen, 55 121 (43.9%) have completed the health information survey, 43 552 (34.7%) have genomic data and 124 760 (99.3%) have EHR data. Twenty machine learning computed phenotypes are calculated on a weekly basis. There are currently 1220 active investigators who have run 58 793 patient queries and exported 10 257 analysis files. Discussion The Biobank Portal allows noninformatics researchers to conduct study feasibility by querying across many data sources and then extract data that are most useful to them for clinical studies. While institutions require substantial informatics resources to establish and maintain integrated data repositories, they yield significant research value to a wide range of investigators. Conclusion The Biobank Portal and other patient data portals that integrate complex and simple datasets enable diverse research use cases. i2b2 tools to implement these registries and make the data interoperable are open source and freely available.
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Affiliation(s)
- Victor M Castro
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Vivian Gainer
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Nich Wattanasin
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Barbara Benoit
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Andrew Cagan
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Bhaswati Ghosh
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Sergey Goryachev
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Reeta Metta
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Heekyong Park
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - David Wang
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Michael Mendis
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Martin Rees
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Christopher Herrick
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA
| | - Shawn N Murphy
- Research Information Science and Computing, Mass General Brigham, Somerville, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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8
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Perino AC, Fan J, Schmitt S, Guo JD, Hlavacek P, Din N, Kothari M, Pundi K, Russ C, Emir B, Turakhia MP. Anticoagulation Treatment and Outcomes of Venous Thromboembolism by Weight and Body Mass Index: Insights From the Veterans Health Administration. Circ Cardiovasc Qual Outcomes 2021; 14:e008005. [PMID: 34724801 DOI: 10.1161/circoutcomes.121.008005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Consensus statements have recommended against the use of direct oral anticoagulants (DOACs) in venous thromboembolism (VTE) for patients ≥120 kg and ≥40 kg/m2. We sought to determine use and outcomes of DOACs for VTE across weight and body mass index (BMI). METHODS We performed a retrospective cohort study of patients with first-time VTE 2013 to 2018 that were treated with DOAC or warfarin in the Veterans Health Administration. The Veterans Health Administration has implemented system-wide guidance for patient selection and shared decision-making for use of DOACs in VTE at extremes of weight. We stratified patients by weight and BMI and assessed (1) association of weight and BMI category to outcomes in those prescribed DOAC; and (2) association of DOAC, as compared to warfarin, to outcomes by weight and BMI categories. Outcomes of interest included major bleeding, clinically relevant nonmajor bleeding, and recurrent VTE. RESULTS The analysis cohort included 51 871 patients prescribed DOAC or warfarin within 30 days of index VTE diagnosis (age 64.5±13.1 years; 6.0% female; median weight 93.4 kg [25th-75th: 80.5-108.6 kg]). For patients ≥120 kg (N=6934 patients), 38.4% were treated with DOAC, as compared to 45.4% of those ≥60 to <100 kg (N=30 645; P<0.0001). DOAC prescription was not associated with major bleeds, clinically relevant nonmajor bleeds, or recurrent VTE for those in higher weight and BMI categories as compared to those in average weight and BMI categories. DOAC prescription, as compared to warfarin, was not associated with increased recurrent VTE in any weight or BMI category. CONCLUSIONS Patients ≥120 kg and ≥40 kg/m2 with VTE are frequently prescribed DOAC by the Veterans Health Administration, without an increase in bleeding or recurrent VTE. These findings suggest DOACs can be safe and effective in this population and may argue for broader adoption of pharmacy policies that promote careful patient selection and shared decision making.
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Affiliation(s)
- Alexander C Perino
- Department of Medicine (A.C.P., K.P., M.P.T.) and Center for Digital Health (A.C.P., N.D., M.P.T.), Stanford University School of Medicine, CA
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | | | | | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | - Mitra Kothari
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
| | - Krishna Pundi
- Department of Medicine (A.C.P., K.P., M.P.T.) and Center for Digital Health (A.C.P., N.D., M.P.T.), Stanford University School of Medicine, CA
| | | | | | - Mintu P Turakhia
- Department of Medicine (A.C.P., K.P., M.P.T.) and Center for Digital Health (A.C.P., N.D., M.P.T.), Stanford University School of Medicine, CA
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., S.S., N.D., M.K., M.P.T.)
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9
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Faselis C, Zeng-Treitler Q, Cheng Y, Kerr GS, Nashel DJ, Liappis AP, Weintrob AC, Karasik PE, Arundel C, Boehm D, Heimall MS, Connell LB, Taub DD, Shao Y, Redd DF, Sheriff HM, Zhang S, Fletcher RD, Fonarow GC, Moore HJ, Ahmed A. Cardiovascular Safety of Hydroxychloroquine in US Veterans With Rheumatoid Arthritis. Arthritis Rheumatol 2021; 73:1589-1600. [PMID: 33973403 DOI: 10.1002/art.41803] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 05/04/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Hydroxychloroquine (HCQ) may prolong the QT interval, a risk factor for torsade de pointes, a potentially fatal ventricular arrhythmia. This study was undertaken to examine the cardiovascular safety of HCQ in patients with rheumatoid arthritis (RA). METHODS We conducted an active comparator safety study of HCQ in a propensity score-matched cohort of 8,852 US veterans newly diagnosed as having RA between October 1, 2001 and December 31, 2017. Patients were started on HCQ (n = 4,426) or another nonbiologic disease-modifying antirheumatic drug (DMARD; n = 4,426) after RA diagnosis, up to December 31, 2018, and followed up for 12 months after therapy initiation, up to December 31, 2019. RESULTS Patients had a mean ± SD age of 64 ± 12 years, 14% were women, and 28% were African American. The treatment groups were balanced with regard to 87 baseline characteristics. There were 3 long QT syndrome events (0.03%), 2 of which occurred in patients receiving HCQ. Of the 56 arrhythmia-related hospitalizations (0.63%), 30 occurred in patients in the HCQ group (hazard ratio [HR] associated with HCQ 1.16 [95% confidence interval (95% CI) 0.68-1.95]). All-cause mortality occurred in 144 (3.25%) and 136 (3.07%) of the patients in the HCQ and non-HCQ groups, respectively (HR associated with HCQ 1.06 [95% CI, 0.84-1.34]). During the first 30 days of follow-up, there were no long QT syndrome events, 2 arrhythmia-related hospitalizations (none in the HCQ group), and 13 deaths (6 in the HCQ group). CONCLUSION Our findings indicate that the incidence of long QT syndrome and arrhythmia-related hospitalization is low in patients with RA during the first year after the initiation of HCQ or another nonbiologic DMARD. We found no evidence that HCQ therapy is associated with a higher risk of adverse cardiovascular events or death.
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Affiliation(s)
- Charles Faselis
- Washington DC VA Medical Center, George Washington University, and Uniformed Services University, Washington, DC
| | - Qing Zeng-Treitler
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | - Yan Cheng
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | - Gail S Kerr
- Washington DC VA Medical Center, Georgetown University, and Howard University, Washington, DC
| | - David J Nashel
- Washington DC VA Medical Center and Georgetown University, Washington, DC
| | - Angelike P Liappis
- Washington DC VA Medical Center, George Washington University, and Uniformed Services University, Washington, DC
| | - Amy C Weintrob
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | - Pamela E Karasik
- Washington DC VA Medical Center, Georgetown University, George Washington University, and Uniformed Services University, Washington, DC
| | - Cherinne Arundel
- Washington DC VA Medical Center, George Washington University, and Uniformed Services University, Washington, DC
| | | | | | | | - Daniel D Taub
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | - Yijun Shao
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | | | - Helen M Sheriff
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | | | | | | | - Hans J Moore
- Washington DC VA Medical Center, George Washington University, Uniformed Services University, Georgetown University, and US Department of Veterans Affairs, Washington, DC
| | - Ali Ahmed
- Washington DC VA Medical Center, George Washington University, and Georgetown University, Washington, DC
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10
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Günak MM, Barnes DE, Yaffe K, Li Y, Byers AL. Risk of Suicide Attempt in Patients With Recent Diagnosis of Mild Cognitive Impairment or Dementia. JAMA Psychiatry 2021; 78:659-666. [PMID: 33760039 PMCID: PMC7992018 DOI: 10.1001/jamapsychiatry.2021.0150] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Little is known about the association between mild cognitive impairment (MCI) and suicide. Most studies have focused on dementia and suicidal behavior, with inconsistent results. OBJECTIVES To examine the association between diagnoses of MCI and dementia and suicide attempt and explore potential psychiatric moderators and to assess whether the association differs based on recency of diagnosis. DESIGN, SETTING, AND PARTICIPANTS This nationwide cohort study integrated 5 national databases from the Department of Veterans Affairs (VA) and Centers for Medicare & Medicaid Services and included all VA medical centers in the US. US veterans 50 years or older with MCI diagnoses at baseline (October 1, 2011, to September 30, 2013) or earlier (October 1, 2007, to September 30, 2011) were propensity matched 1:3 with (1) patients with dementia diagnoses and (2) patients without either diagnosis based on demographic characteristics and the Charlson Comorbidity Index. Diagnoses of MCI or dementia were defined as recent if there were no diagnosis codes before baseline. Data were analyzed from March 16, 2020, to January 15, 2021. MAIN OUTCOMES AND MEASURES Information on suicide attempts through December 31, 2016, provided by the National Suicide Prevention Applications Network (nonfatal) and Mortality Data Repository (fatal). RESULTS The study population of 147 595 participants included 21 085 patients with MCI, 63 255 with dementia, and 63 255 in the propensity-matched comparison group. Participants had a mean (SD) age of 74.7 (10.3) years, 143 353 (97.1%) were men, 4242 (2.9%) were women, and 127 065 (86.1%) were non-Hispanic White. A total of 138 patients with MCI (0.7%) and 400 patients with dementia (0.6%) attempted suicide during follow-up, compared with 253 patients without MCI or dementia (0.4%). Exploratory analyses revealed that no psychiatric comorbidity moderated the association between MCI or dementia and suicide attempt. After adjustment for demographic details and medical and psychiatric comorbidities, risk of suicide attempt was consistently highest for patients with a recent MCI or dementia diagnosis, with adjusted hazard ratios (HRs) of 1.73 (95% CI, 1.34-2.22; P < .001) for recent MCI and 1.44 (95% CI, 1.17-1.77; P = .001) for recent dementia. Risk associated with prior diagnosis was not significant (HR for prior MCI, 1.03 [95% CI, 0.78-1.36; P = .84]; HR for prior dementia, 1.14 [95% CI, 0.95-1.36; P = .15]). CONCLUSIONS AND RELEVANCE This study found that older adults with recent MCI or dementia diagnoses were at increased risk of attempting suicide. These findings suggest that involvement of supportive services at the time of or soon after diagnoses of MCI or dementia may help mitigate risk of suicide attempts.
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Affiliation(s)
- Mia Maria Günak
- Department of Clinical Psychology, Leiden University, Leiden, the Netherlands
| | - Deborah E. Barnes
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco,San Francisco Veterans Affairs Health Care System, San Francisco, California,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kristine Yaffe
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco,San Francisco Veterans Affairs Health Care System, San Francisco, California,Department of Epidemiology and Biostatistics, University of California, San Francisco,Department of Neurology, University of California, San Francisco
| | - Yixia Li
- Northern California Institute for Research and Education, The Veterans Health Research Institute, San Francisco, California
| | - Amy L. Byers
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco,San Francisco Veterans Affairs Health Care System, San Francisco, California,Department of Medicine, Division of Geriatrics, University of California, San Francisco
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11
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Williams EC, McGinnis KA, Rubinsky AD, Matson TE, Bobb JF, Lapham GT, Edelman EJ, Satre DD, Catz SL, Richards JE, Bryant KJ, Marshall BDL, Kraemer KL, Crystal S, Gordon AJ, Skanderson M, Fiellin DA, Justice AC, Bradley KA. Alcohol Use and Antiretroviral Adherence Among Patients Living with HIV: Is Change in Alcohol Use Associated with Change in Adherence? AIDS Behav 2021; 25:203-214. [PMID: 32617778 DOI: 10.1007/s10461-020-02950-x] [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: 01/30/2023]
Abstract
Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p < 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions.
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Affiliation(s)
- Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA.
- Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Kathleen A McGinnis
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Anna D Rubinsky
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
- Kidney Health Research Collaborative, University of California, San Francisco and VA San Francisco Health Care System, San Francisco, CA, USA
| | - Theresa E Matson
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Gwen T Lapham
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - E Jennifer Edelman
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Derek D Satre
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Sheryl L Catz
- Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, CA, USA
| | - Julie E Richards
- Department of Health Services, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Kendall J Bryant
- National Institute On Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kevin L Kraemer
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Stephen Crystal
- Health Services Research, Rutgers University, New Brunswick, NJ, USA
| | - Adam J Gordon
- Division of Epidemiology, Department of Internal Medicine, Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Melissa Skanderson
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - David A Fiellin
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Amy C Justice
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Katharine A Bradley
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veteran Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way, S-152, Seattle, WA, 98108, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Healthcare System-Seattle Division, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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12
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Gordon KS, Manhapra A, Crystal S, Dziura J, Edelman EJ, Skanderson M, Kerns RD, Justice AC, Tate J, Becker WC. All-cause mortality among males living with and without HIV initiating long-term opioid therapy, and its association with opioid dose, opioid interruption and other factors. Drug Alcohol Depend 2020; 216:108291. [PMID: 33011662 PMCID: PMC7644145 DOI: 10.1016/j.drugalcdep.2020.108291] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/28/2020] [Accepted: 09/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND While the relationship between long-term opioid therapy (LTOT) dose and overdose is well-established, LTOT's association with all-cause mortality is less understood, especially among people living with HIV (PLWH). There is also limited information regarding the association of LTOT cessation or interruption with mortality. METHODS Among PLWH and matched uninfected male veterans in care, we identified those who initiated LTOT. Using time-updated cox regression, we examined the association between all-cause mortality, unnatural death, and overdose, and opioid use categorized as 1-20 (reference group), 21-50, 51-90, and ≥ 91 mg morphine equivalent daily dose (MEDD). RESULTS There were 22,996 patients on LTOT, 6,578 (29 %) PLWH and 16,418 (71 %) uninfected. Among 5,222 (23 %) deaths, 12 % were unnatural deaths and 6 % overdoses. MEDD was associated with risk of all 3 outcomes; compared to patients on 1-20 mg MEDD, adjusted risk for all-cause mortality monotonically increased (Hazard Ratios (HR) [95 % CI] for 21-50 mg MEDD = 1.36 [1.21, 1.52], 51-90 mg MEDD = 2.06 [1.82, 2.35], and ≥ 91 mg MEDD = 3.03 [2.71, 3.39]). Similar results were seen in models stratified by HIV. LTOT interruption was also associated with all-cause, unnatural, and overdose mortality (HR [95 % CI] 2.30 [2.09, 2.53], 1.47 [1.13, 1.91] and 1.52 [1.04, 2.23], respectively). CONCLUSIONS Among PLWH and uninfected patients on LTOT we observed a strong dose-response relationship with all 3 mortality outcomes. Opioid risk mitigation approaches should be expanded to address the potential effects of higher dose on all-cause mortality in addition to unnatural and overdose fatalities.
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Affiliation(s)
- K S Gordon
- VA Connecticut Healthcare System, West Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.
| | - A Manhapra
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States; Integrative Pain Recovery Service, Hampton VA Medical Center, Hampton, VA, United States; Departments of Physical Medicine & Rehabilitation and Psychiatry, Eastern Virginia Medical School, Norfolk, VA, United States
| | - S Crystal
- Rutgers University, New Brunswick, NJ, United States
| | - J Dziura
- Yale School of Public Health, New Haven, CT, United States
| | - E J Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - M Skanderson
- VA Connecticut Healthcare System, West Haven, CT, United States
| | - R D Kerns
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States; Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - A C Justice
- VA Connecticut Healthcare System, West Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States; Yale School of Public Health, New Haven, CT, United States
| | - J Tate
- VA Connecticut Healthcare System, West Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - W C Becker
- VA Connecticut Healthcare System, West Haven, CT, United States; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
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13
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Perino AC, Kaiser DW, Lee RJ, Fan J, Askari M, Schmitt SK, Turakhia MP. Incidence and outcomes of patients with atrial fibrillation and major bleeding complications: from the TREAT-AF study. J Interv Card Electrophysiol 2020; 62:133-142. [PMID: 32986177 DOI: 10.1007/s10840-020-00873-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Optimal stroke prevention strategies for patients with atrial fibrillation (AF) who experience a major bleed are poorly defined. We sought to estimate the effectiveness and safety of oral anticoagulation (OAC) represcription after an OAC contraindication. METHODS TREAT-AF is a retrospective cohort study of patients with newly diagnosed AF (2004-2012), treated in the Veterans Health Administration. From this cohort, we identified patients with a contraindication to OAC after AF diagnoses, defined as incident intracranial bleeding, non-intracranial bleeding requiring hospitalization, or unrepaired cerebral aneurysm or aortic dissection. We used multivariate Cox proportional hazards to estimate the association of OAC prescription in the 90 days following OAC contraindication to ischemic stroke and rebleeding. RESULTS Among 167,190 patients with newly diagnosed AF (70 ± 11 years, 1.7% female, CHA2DS2-VASc 2.7 ± 1.7), 19,285 patients (11.5%) had an incident bleed (n = 18,342) or an unrepaired cerebral aneurysm or aortic dissection (n = 943). For OAC-contraindicated patients with a CHA2DS2-VASc ≥2 (N = 16,194), OAC was represcribed in 4075 patients (25%) and was associated with a higher risk of non-intracranial bleeding (HR 1.49; 95% CI 1.37-1.61; p < 0.0001) but no difference in intracranial bleeding. There was a trend toward decreased stroke risk (HR 0.85; 95% CI 0.71-1.02; p 0.09). CONCLUSIONS Development of contraindication to OAC after diagnosis of AF is common (11.5%), with most events requiring hospitalization. OAC reinitiation was associated with non-intracranial bleeding risk, with a trend toward reduced stroke risk. These data suggest that stroke prevention approaches after major bleeding events could be beneficial if bleeding risk can be successfully mitigated.
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Affiliation(s)
- Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Daniel W Kaiser
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Randall J Lee
- Department of Medicine and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Susan K Schmitt
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. .,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA. .,Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA.
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14
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Oldfield BJ, McGinnis KA, Edelman EJ, Williams EC, Gordon AJ, Akgün K, Crystal S, Fiellin LE, Gaither JR, Goulet JL, Korthuis PT, Marshall BDL, Justice AC, Bryant K, Fiellin DA, Kraemer KL. Predictors of initiation of and retention on medications for alcohol use disorder among people living with and without HIV. J Subst Abuse Treat 2019; 109:14-22. [PMID: 31856946 DOI: 10.1016/j.jsat.2019.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Infrequent use of and poor retention on evidence-based medications for alcohol use disorder (MAUD) represent a treatment gap, particularly among people living with HIV (PLWH). We examined predictors of MAUD initiation and retention across HIV status. METHODS From Veterans Aging Cohort Study (VACS) data, we identified new alcohol use disorder (AUD) diagnoses from 1998 to 2015 among 163,339 individuals (50,826 PLWH and 112,573 uninfected, matched by age, sex, and facility). MAUD initiation was defined as a prescription fill for naltrexone, acamprosate or disulfiram within 30 days of a new diagnosis. Among those who initiated, retention was defined as filling medication for ≥80% of days over the following six months. We used multivariable logistic regression to assess patient- and facility-level predictors of AUD medication initiation across HIV status. RESULTS Among 10,603 PLWH and 24,424 uninfected individuals with at least one AUD episode, 359 (1.0%) initiated MAUD and 49 (0.14%) were retained. The prevalence of initiation was lower among PLWH than those without HIV (adjusted odds ratio [AOR] 0.66, 95% confidence interval [CI] 0.51-0.85). Older age (for PLWH: AOR 0.78, 95% CI 0.61-0.99; for uninfected: AOR 0.70, 95% CI 0.61-0.80) and black race (for PLWH: AOR 0.63, 95% CI 0.0.49-0.1.00; for uninfected: AOR 0.63, 95% CI 0.48-0.83), were associated with decreased odds of initiation for both groups. The low frequency of retention precluded multivariable analyses for retention. CONCLUSIONS For PLWH and uninfected individuals, targeted implementation strategies to expand MAUD are needed, particularly for specific subpopulations (e.g. black PLWH).
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Affiliation(s)
- Benjamin J Oldfield
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America.
| | - Kathleen A McGinnis
- Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - E Jennifer Edelman
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Emily C Williams
- School of Public Health, University of Washington, Seattle, WA, United States of America; Health Services Research and Development, VA Puget Sound Healthcare Services, Seattle, WA, United States of America
| | - Adam J Gordon
- Department of Medicine, University of Utah, Salt Lake City, UT, United States of America; Department of Medicine, Salt Lake City VA Health Care System, Salt Lake City, UT, United States of America
| | - Kathleen Akgün
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Stephen Crystal
- School of Social Work, Rutgers University, New Brunswick, NJ, United States of America
| | - Lynn E Fiellin
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Julie R Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States of America
| | - Joseph L Goulet
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - P Todd Korthuis
- Department of Medicine, Oregon Health Sciences University, Portland, OR, United States of America
| | - Brandon D L Marshall
- School of Public Health, Brown University, Providence, RI, United States of America
| | - Amy C Justice
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States of America
| | - David A Fiellin
- Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Kevin L Kraemer
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
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15
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Perino AC, Fan J, Askari M, Heidenreich PA, Keung E, Raitt MH, Piccini JP, Ziegler PD, Turakhia MP. Practice Variation in Anticoagulation Prescription and Outcomes After Device-Detected Atrial Fibrillation. Circulation 2019; 139:2502-2512. [PMID: 30880434 DOI: 10.1161/circulationaha.118.038988] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Device-detected atrial fibrillation (AF) is associated with increased risk of stroke; however, there are no clearly defined thresholds of AF burden at which to initiate oral anticoagulation (OAC). We sought to describe OAC prescription practice variation in response to new device-detected AF and the association with outcomes. METHODS We performed a retrospective cohort study using data from the Veterans Health Administration linked to remote monitoring data that included day-level AF burden. We included patients with cardiac implantable electronic devices and remote monitoring from 2011 to 2014, CHA2DS2-VASc score ≥2, and no prior stroke or OAC receipt in the preceding 2 years. We determined the proportion of patients prescribed OAC within 90 days after new device-detected AF across a range of AF thresholds (≥6 minutes to >24 hours) and examined site variation in OAC prescription. We used multivariable Cox proportional hazards regressions to determine the association of OAC prescription with stroke by device-detected AF burden. RESULTS Among 10 212 patients with cardiac implantable electronic devices, 4570 (45%), 3969 (39%), 3263 (32%), and 2469 (24%) had device-detected AF >6 minutes, >1 hour, >6 hours, and >24 hours, respectively. For device-detected AF >1 hour, 1712 patients met inclusion criteria (72±10 years; 1.5% female; CHA2DS2-VASc score 4.0±1.4; HAS-BLED score 2.6±1.1). The proportion receiving OAC varied based on device-detected AF burden (≥6 minutes: 272/2101 [13%]; >1 hour: 273/1712 [16%]; >6 hours: 263/1279 [21%]; >24 hours: 224/818 [27%]). Across 52 sites (N=1329 patients), there was substantial site-level variation in OAC prescription after device-detected AF >1 hour (median, 16%; range, 3%-67%; median odds ratio, 1.56 [95% credible interval, 1.49-1.71]). In adjusted models, OAC prescription after device-detected AF >24 hours was associated with reduced stroke risk (hazard ratio, 0.28; 95% CI, 0.10-0.81; P=0.02), although the propensity-adjusted model was significant when AF lasted at least 6 minutes. CONCLUSIONS Among veterans with cardiac implantable electronic devices, device-detected AF is common. There is large practice variation in 90-day OAC initiation after new device-detected AF, with low rates of treatment overall, even for episodes that last >24 hours. The strongest association of OAC with reduction in stroke was observed after device-detected AF >24 hours. Randomized trials are needed to confirm these observational findings.
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Affiliation(s)
- Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, CA (A.C.P., P.A.H., M.P.T.).,Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., M.A., P.A.H., M.P.T.)
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., M.A., P.A.H., M.P.T.)
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., M.A., P.A.H., M.P.T.)
| | - Paul A Heidenreich
- Department of Medicine, Stanford University School of Medicine, CA (A.C.P., P.A.H., M.P.T.).,Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., M.A., P.A.H., M.P.T.)
| | | | | | | | | | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, CA (A.C.P., P.A.H., M.P.T.).,Veterans Affairs Palo Alto Health Care System, CA (A.C.P., J.F., M.A., P.A.H., M.P.T.).,Center for Digital Health, Stanford University School of Medicine, CA (M.P.T.)
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Wilcox MA, Coppola D, Bailey N, Wilson A, Kamauu AWC, Alba PR, Patterson OV, Viernes B, Denhalter DW, Solomon ID, DuVall SL. Risperdal ® CONSTA ® Needle Detachment. Incidence Rates Before and After Kit Redesign: A Retrospective Study using Electronic Health Records and Natural Language Processing in the Department of Veterans Affairs. Neurol Ther 2019; 8:95-108. [PMID: 30847767 PMCID: PMC6534640 DOI: 10.1007/s40120-019-0130-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Indexed: 11/27/2022] Open
Abstract
Introduction Janssen received reports of needle detachments for Risperdal® CONSTA® and, in response, redesigned the kit. Objective The study objective was to estimate the rate of Risperdal® CONSTA® needle detachments prior to and after the introduction of a redesigned kit. Methods This retrospective study used record abstraction in the US Department of Veterans Affairs (VA). The 3 phases included: (1) a pilot study for methods evaluation in a sample of 6 hospitals with previously reported detachments; (2) a baseline study to ascertain the baseline detachment rate; and (3) a follow-up study to ascertain the rate for the redesigned kit. Administrative codes and natural language processing with clinical review were used to identify detachments. Results Pilot: we identified a subset of spontaneously reported detachments and several previously unreported events. In the baseline study (original device), from January through December 2013, 22 needle detachments were identified among 47,934 administrations of the drug in a census of administrations in the VA; an incidence of 0.0459%. In the follow-up study (redesigned device), from December 2015 through December 2016, there were 14 reported detachments in 41,819 injections, 0.0335%. This represents a reduction of 27% from the baseline. Conclusion This approach enabled us to identify needle detachments we would not have otherwise found (“solicited”). However, it likely resulted in incomplete outcome ascertainment. While this may have resulted in lower overall rates, it did not bias the comparison of the baseline and follow-up studies. The results showed that the redesigned Risperdal® CONSTA® kit reduced the incidence of needle detachment events in the VA. Funding Janssen Pharmaceuticals, Inc.
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Affiliation(s)
- Marsha A Wilcox
- Epidemiology, Janssen Pharmaceutical Research and Development, LLC, 1125 Trenton-Harbourton Rd., Titusville, NJ, 08560, USA.
| | - Danielle Coppola
- Therapy Area Safety Head Immunology, Janssen Pharmaceutical Research and Development, LLC, 1125 Trenton-Harbourton Rd., Titusville, NJ, 08560, USA
| | - Nicole Bailey
- Epidemiology, Anolinx, Inc., 428 E 2400 S, # 202, Salt Lake City, UT, 84107, USA
| | - Andrew Wilson
- Anolinx, Inc., 428 E 2400 S, # 202, Salt Lake City, UT, 84107, USA
| | - Aaron W C Kamauu
- Anolinx, Inc., 428 E 2400 S, # 202, Salt Lake City, UT, 84107, USA
| | - Patrick R Alba
- Department of Veterans Affairs, Salt Lake City Health Care System, VA Informatics and Computing Infrastructure, Salt Lake City, 500 Foothill Blvd, Salt Lake City, UT, 84148, USA
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Olga V Patterson
- Department of Veterans Affairs, Salt Lake City Health Care System, VA Informatics and Computing Infrastructure, Salt Lake City, 500 Foothill Blvd, Salt Lake City, UT, 84148, USA
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Benjamin Viernes
- Department of Veterans Affairs, Salt Lake City Health Care System, VA Informatics and Computing Infrastructure, Salt Lake City, 500 Foothill Blvd, Salt Lake City, UT, 84148, USA
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Daniel W Denhalter
- Department of Veterans Affairs, Salt Lake City Health Care System, VA Informatics and Computing Infrastructure, Salt Lake City, 500 Foothill Blvd, Salt Lake City, UT, 84148, USA
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Ira D Solomon
- Established Products, CNS Portfolio, Janssen Pharmaceutical Research and Development, LLC, 1125 Trenton-Harbourton Rd., Titusville, NJ, 08560, USA
| | - Scott L DuVall
- Department of Veterans Affairs, Salt Lake City Health Care System, VA Informatics and Computing Infrastructure, Salt Lake City, 500 Foothill Blvd, Salt Lake City, UT, 84148, USA
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA
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17
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Edelman EJ, Gordon KS, Crothers K, Akgün K, Bryant KJ, Becker WC, Gaither JR, Gibert CL, Gordon AJ, Marshall BDL, Rodriguez-Barradas MC, Samet JH, Justice AC, Tate JP, Fiellin DA. Association of Prescribed Opioids With Increased Risk of Community-Acquired Pneumonia Among Patients With and Without HIV. JAMA Intern Med 2019; 179:297-304. [PMID: 30615036 PMCID: PMC6439696 DOI: 10.1001/jamainternmed.2018.6101] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Some opioids are known immunosuppressants; however, the association of prescribed opioids with clinically relevant immune-related outcomes is understudied, especially among people living with HIV. OBJECTIVE To assess the association of prescribed opioids with community-acquired pneumonia (CAP) by opioid properties and HIV status. DESIGN, SETTING, AND PARTICIPANTS This nested case-control study used data from patients in the Veterans Aging Cohort Study (VACS) from January 1, 2000, through December 31, 2012. Participants in VACS included patients living with and without HIV who received care in Veterans Health Administration (VA) medical centers across the United States. Patients with CAP requiring hospitalization (n = 4246) were matched 1:5 with control individuals without CAP (n = 21 146) by age, sex, race/ethnicity, length of observation, and HIV status. Data were analyzed from March 15, 2017, through August 8, 2018. EXPOSURES Prescribed opioid exposure during the 12 months before the index date was characterized by a composite variable based on timing (none, past, or current); low (<20 mg), medium (20-50 mg), or high (>50 mg) median morphine equivalent daily dose; and opioid immunosuppressive properties (yes vs unknown or no). MAIN OUTCOME AND MEASURE CAP requiring hospitalization based on VA and Centers for Medicare & Medicaid data. RESULTS Among the 25 392 VACS participants (98.9% male; mean [SD] age, 55 [10] years), current medium doses of opioids with unknown or no immunosuppressive properties (adjusted odds ratio [AOR], 1.35; 95% CI, 1.13-1.62) and immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and current high doses of opioids with unknown or no immunosuppressive properties (AOR, 2.07; 95% CI, 1.50-2.86) and immunosuppressive properties (AOR, 3.18; 95% CI, 2.44-4.14) were associated with the greatest CAP risk compared with no prescribed opioids or any past prescribed opioid with no immunosuppressive (AOR, 1.24; 95% CI, 1.09-1.40) and immunosuppressive properties (AOR, 1.42; 95% CI, 1.21-1.67), especially with current receipt of immunosuppressive opioids. In stratified analyses, CAP risk was consistently greater among people living with HIV with current prescribed opioids, especially when prescribed immunosuppressive opioids (eg, AORs for current immunosuppressive opioids with medium dose, 1.76 [95% CI, 1.20-2.57] vs 2.33 [95% CI, 1.60-3.40]). CONCLUSIONS AND RELEVANCE Prescribed opioids, especially higher-dose and immunosuppressive opioids, are associated with increased CAP risk among persons with and without HIV.
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Affiliation(s)
- E Jennifer Edelman
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - Kirsha S Gordon
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Veterans Affairs Connecticut Healthcare System, West Haven
| | | | - Kathleen Akgün
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Veterans Affairs Connecticut Healthcare System, West Haven
| | - Kendall J Bryant
- HIV/AIDS Program, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - William C Becker
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Veterans Affairs Connecticut Healthcare System, West Haven
| | - Julie R Gaither
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Cynthia L Gibert
- DC Veterans Affairs Medical Center, Washington, DC.,Department of Medicine, George Washington University, Washington, DC
| | - Adam J Gordon
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah.,Department of Medicine, University of Utah, Salt Lake City
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | | | - Jeffrey H Samet
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.,Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Amy C Justice
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut.,Veterans Affairs Connecticut Healthcare System, West Haven
| | - Janet P Tate
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Veterans Affairs Connecticut Healthcare System, West Haven
| | - David A Fiellin
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
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18
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Leef GC, Perino AC, Askari M, Fan J, Ho PM, Olivier CB, Longo L, Mahaffey KW, Turakhia MP. Appropriateness of Direct Oral Anticoagulant Dosing in Patients With Atrial Fibrillation: Insights From the Veterans Health Administration. J Pharm Pract 2019; 33:647-653. [PMID: 30791808 DOI: 10.1177/0897190019828270] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have strict dosing guidelines, but recent studies indicate that inappropriate dosing is common, particularly in chronic kidney disease (CKD), for which it has been reported to be as high as 43%. Since 2011, the Veterans Health Administration (VA) has implemented anticoagulation management programs for DOACs, generally led by pharmacists, which has previously been shown to improve medication adherence. OBJECTIVE We investigated the prevalence of overdosing and underdosing of DOACs in the VA. METHODS Using data from the TREAT-AF cohort study (The Retrospective Evaluation and Assessment of Therapies in AF), we identified VA patients with newly diagnosed atrial fibrillation (AF) and receipt of a DOAC between 2003 and 2015. We classified dosing as correct, overdosed, or underdosed based on the Food and Drug Administration-approved dosing criteria. RESULTS Of 230 762 patients, 5060 received dabigatran (77.3%) or rivaroxaban (22.7%) within 90 days of AF diagnosis (age 69 [10[ years; CHA2DS2-VASc 1.6 [1.4]), of which 1312 (25.9%) had CKD based on estimated glomerular filtration rate <60. Overall, 93.6% of patients, 83.2% with CKD, received appropriate DOAC dosing. Incorrect dosing increased with worsening renal function. CONCLUSION Compared to recent studies of commercial payers and health-care systems, incorrect dosing of DOACs is less common across the VA. Pharmacist-led DOAC management or similar anticoagulation management interventions may reduce the risk of incorrect dosing across health-care systems.
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Affiliation(s)
- George C Leef
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - P Michael Ho
- Veterans Affairs Eastern Colorado Health Care System, Denver, CO, USA.,University of Colorado School of Medicine, Denver, CO, USA
| | - Christoph B Olivier
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Longo
- Department of Veteran Affairs, Pharmacy Benefits Management Services, USA
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.,Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA
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19
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Wood PR, Manning E, Baker JF, England B, Davis L, Cannon GW, Mikuls TR, Caplan L. Blood glucose changes surrounding initiation of tumor-necrosis factor inhibitors and conventional disease-modifying anti-rheumatic drugs in veterans with rheumatoid arthritis. World J Diabetes 2018; 9:53-58. [PMID: 29531640 PMCID: PMC5840570 DOI: 10.4239/wjd.v9.i2.53] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/15/2018] [Accepted: 03/07/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To determine the scope of acute hypoglycemic effects for certain anti-rheumatic medications in a large retrospective observational study.
METHODS Patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry were selected who, during follow-up, initiated treatment with tumor necrosis factor inhibitors (TNFi’s, including etanercept, adalimumab, infliximab, golimumab, or certolizumab), prednisone, or conventional disease-modifying anti-rheumatic drugs (DMARDs), and for whom proximate random blood glucose (RBG) measurements were available within a window 2-wk prior to, and 6 mo following, medication initiation. Similar data were obtained for patients with proximate values available for glycosylated hemoglobin A1C values within a window 2 mo preceding, and 12 mo following, medication initiation. RBG and A1C measurements were compared before and after initiation events using paired t-tests, and multivariate regression analysis was performed including established comorbidities and demographics.
RESULTS Two thousands one hundred and eleven patients contributed at least one proximate measurement surrounding the initiation of any examined medication. A significant decrease in RBG was noted surrounding 653 individual hydroxychloroquine-initiation events (-3.68 mg/dL, P = 0.04), while an increase was noted for RBG surrounding 665 prednisone-initiation events (+5.85 mg/dL, P < 0.01). A statistically significant decrease in A1C was noted for sulfasalazine initiation, as measured by 49 individual initiation events (-0.70%, P < 0.01). Multivariate regression analyses, using methotrexate as the referent, suggest sulfasalazine (β = -0.58, P = 0.01) and hydroxychloroquine (β = -5.78, P = 0.01) use as predictors of lower post-medication-initiation RBG and A1C values, respectively. Analysis by drug class suggested prednisone (or glucocorticoids) as predictive of higher medication-initiation event RBG among all start events as compared to DMARDs, while this analysis did not show any drug class-level effect for TNFi. A diagnosis of congestive heart failure (β = 4.69, P = 0.03) was predictive for higher post-initiation RBG values among all medication-initiation events.
CONCLUSION No statistically significant hypoglycemic effects surrounding TNFi initiation were observed in this large cohort. Sulfasalazine and hydroxychloroquine may have epidemiologically significant acute hypoglycemic effects.
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Affiliation(s)
- Patrick R Wood
- Denver Veterans Affairs Medical Center, Division of Rheumatology, University of Colorado, Aurora, CO 80045, United States
| | - Evan Manning
- Denver Veterans Affairs Medical Center, Division of Rheumatology, University of Colorado, Aurora, CO 80045, United States
| | - Joshua F Baker
- Philadelphia Veterans Affairs Medical Center, Division of Rheumatology, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Bryant England
- Omaha Veterans Affairs Medical Center, Division of Rheumatology, University of Nebraska, Omaha, NE 68198, United States
| | - Lisa Davis
- Denver Health and Hospital, Division of Rheumatology, University of Colorado, Aurora, CO 80045, United States
| | - Grant W Cannon
- George Wahlen Veterans Affairs Medical Center, Division of Rheumatology, University of Utah, Salt Lake City, UT 84148, United States
| | - Ted R Mikuls
- Omaha Veterans Affairs Medical Center, Division of Rheumatology, University of Nebraska, Omaha, NE 68198, United States
| | - Liron Caplan
- Denver Veterans Affairs Medical Center, Division of Rheumatology, University of Colorado, Aurora, CO 80045, United States
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20
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Hum J, Jou JH, Green PK, Berry K, Lundblad J, Hettinger BD, Chang M, Ioannou GN. Improvement in Glycemic Control of Type 2 Diabetes After Successful Treatment of Hepatitis C Virus. Diabetes Care 2017; 40:1173-1180. [PMID: 28659309 DOI: 10.2337/dc17-0485] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/02/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hepatitis C virus (HCV) infection is associated with diabetes and may worsen glycemic control in patients with diabetes. We aimed to investigate whether eradication of HCV infection with direct-acting antiviral (DAA) agents is associated with improved glycemic control in patients with diabetes. RESEARCH DESIGN AND METHODS We identified 2,435 patients with diabetes who underwent interferon-free and ribavirin-free DAA-based antiviral treatment for HCV in the national Veterans Affairs health care system. Changes in average hemoglobin A1c (HbA1c) level and use of antidiabetic medications 1 year before and after antiviral treatment were compared between patients who achieved sustained virologic response (SVR) and those who did not. RESULTS Among patients with elevated baseline HbA1c, the drop in HbA1c associated with antiviral treatment was greater in those who achieved SVR (0.98%) than in those who sustained treatment failure (0.65%) (adjusted mean difference 0.34, P = 0.02). Use of antidiabetic medications decreased more in patients who achieved SVR than in those who sustained treatment failure, especially for the use of insulin, which dropped significantly from 41.3% to 38% in patients achieving SVR compared with a slight increase from 49.8% to 51% in those who sustained treatment failure. CONCLUSIONS DAA-based eradication of HCV is associated with improved glycemic control in patients with diabetes as evidenced by decreased mean HbA1c and decreased insulin use. These endocrine benefits of SVR provide additional justification for considering antiviral treatment in all patients with diabetes.
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Affiliation(s)
- Justine Hum
- Division of Gastroenterology, Portland Veterans Affairs Medical Center, Portland, OR
| | - Janice H Jou
- Division of Gastroenterology, Portland Veterans Affairs Medical Center, Portland, OR
| | - Pamela K Green
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - James Lundblad
- Division of Endocrinology, Portland Veterans Affairs Medical Center, Portland, OR
| | - Barbara D Hettinger
- Division of Endocrinology, Portland Veterans Affairs Medical Center, Portland, OR
| | - Michael Chang
- Division of Gastroenterology, Portland Veterans Affairs Medical Center, Portland, OR
| | - George N Ioannou
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA .,Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
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21
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Treating Specialty and Outcomes in Newly Diagnosed Atrial Fibrillation: From the TREAT-AF Study. J Am Coll Cardiol 2017; 70:78-86. [PMID: 28662810 DOI: 10.1016/j.jacc.2017.04.054] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/13/2017] [Accepted: 04/28/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) occurs in many clinical contexts and is diagnosed and treated by clinicians across many specialties. This approach has resulted in treatment variations. OBJECTIVES The goal of this study was to evaluate the association between treating specialty and AF outcomes among patients newly diagnosed with AF. METHODS Using data from the TREAT-AF (Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, patients with newly diagnosed, nonvalvular AF between 2004 and 2012 were identified who had at least 1 outpatient encounter with primary care or cardiology within 90 days of the AF diagnosis. Cox proportional hazards regression was used to evaluate the association between treating specialty and AF outcomes. RESULTS Among 184,161 patients with newly diagnosed AF (age 70 ± 11 years; 1.7% women; CHA2DS2-VASc score 2.6 ± 1.7), 40% received cardiology care and 60% received primary care only. After adjustment for covariates, cardiology care was associated with reductions in stroke (hazard ratio [HR]: 0.91; 95% confidence interval [CI]: 0.86 to 0.96; p < 0.001) and death (HR: 0.89; 95% CI: 0.88 to 0.91; p < 0.0001) and increases in hospitalizations for AF/supraventricular tachycardia (HR: 1.38; 95% CI: 1.35 to 1.42; p < 0.0001) and myocardial infarction (HR: 1.03; 95% CI: 1.00 to 1.05; p < 0.04). The propensity-matched cohort had similar results. In mediation analysis, oral anticoagulation prescription within 90 days of diagnosis may have mediated reductions in stroke but did not mediate reductions in survival. CONCLUSIONS In patients with newly diagnosed AF, cardiology care was associated with improved outcomes, potentially mediated by early prescription of oral anticoagulation therapy. Although hypothesis-generating, these data warrant serious consideration and study of health care system interventions at the time of new AF diagnosis.
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22
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Arif FM, Sumida K, Molnar MZ, Potukuchi PK, Lu JL, Hassan F, Thomas F, Siddiqui OA, Gyamlani GG, Kalantar-Zadeh K, Kovesdy CP. Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease. Nephron Clin Pract 2017; 137:15-22. [PMID: 28445893 DOI: 10.1159/000473704] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/27/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Mortality in the immediate post-hemodialysis transition period is extremely high. Many end-stage renal disease (ESRD) patients in the US start dialysis in an inpatient setting, but the characteristics of patients starting dialysis as inpatients, and the association of inpatient hemodialysis transition with mortality remain unclear. METHODS We examined 48,261 US veterans who transitioned to hemodialysis between October 2007 and September 2011. Associations of inpatient hemodialysis starting with all-cause mortality were examined in Cox proportional hazard models, with adjustments for demographics, comorbidities, vascular access type, pre-dialysis nephrology care and medication use, and last pre-ESRD estimated glomerular filtration rate and hemoglobin. RESULTS A total of 22,338 (46.3%) patients received the first hemodialysis treatment in an inpatient setting. Inpatient hemodialysis transition was associated with older age, presence of a tunneled catheter, higher comorbidity burden, and lack of pre-dialysis nephrology care. A total of 8,674 patients died (mortality rate 405/1,000 patient-years, 95% CI 397-413) during the first 6 months after transition to hemodialysis. The starting of inpatient vs. outpatient hemodialysis was associated with significantly higher crude all-cause mortality, but this association was attenuated after multivariable adjustments. CONCLUSIONS Transition to hemodialysis in an inpatient setting is more common in older and sicker individuals, and in patients without pre-dialysis nephrology care and those who used a catheter for vascular access. Future studies are needed to determine if a higher proportion of patients could start hemodialysis treatment in outpatient clinics, through interventions targeting modifiable risk factors such as timely vascular access placement or earlier nephrology referrals.
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Affiliation(s)
- Faisal M Arif
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Howell BA, Long JB, Edelman EJ, McGinnis KA, Rimland D, Fiellin DA, Justice AC, Wang EA. Incarceration History and Uncontrolled Blood Pressure in a Multi-Site Cohort. J Gen Intern Med 2016; 31:1496-1502. [PMID: 27619934 PMCID: PMC5130961 DOI: 10.1007/s11606-016-3857-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 06/02/2016] [Accepted: 08/18/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Incarceration is associated with increased risk of hypertension and cardiovascular disease mortality. We used data from the Veterans Aging Cohort Study (VACS) to explore the impact of incarceration on blood pressure (BP) control. METHODS Among hypertensive VACS participants, we measured the association between self-reported recent incarceration or past (not recent) history of incarceration and BP control in the year following the survey. To analyze the association between incarceration and BP control, we used logistic regression models adjusted for sociodemographic characteristics, clinical factors (HIV status and body mass index), and behavioral factors (history of smoking, unhealthy alcohol use, illicit drug use). We explored potential mediators including post-traumatic stress disorder (PTSD), depression, primary care engagement, and adherence to antihypertensive medications. RESULTS Among the 3515 eligible VACS participants, 2304 participants met the inclusion criteria. Of these, 163 (7 %) reported recent incarceration, and 904 (39 %) reported a past history of incarceration. Participants with recent or past history of incarceration were more likely to have uncontrolled BP than those without a history of incarceration (67 % vs. 56 % vs. 51 %, p < 0.001). In multivariable analysis, recent incarceration (adjusted odds ratio [AOR] = 1.57 95 % confidence interval [CI]: 1.09-2.26), but not a past history of incarceration (AOR = 1.08 95 % CI: 0.90-1.30), was associated with uncontrolled BP compared with those who were never incarcerated. CONCLUSIONS Among patients with a history of hypertension, recent incarceration is associated with having uncontrolled BP following release. Interventions are needed for recently released individuals to improve hypertension outcomes.
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Affiliation(s)
- Benjamin A Howell
- Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208030, New Haven, CT, 06520, USA.
| | - Jessica B Long
- Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208030, New Haven, CT, 06520, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208030, New Haven, CT, 06520, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
| | | | - David Rimland
- Atlanta VA Medical Center, Atlanta, GA, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - David A Fiellin
- Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208030, New Haven, CT, 06520, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
| | - Amy C Justice
- Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208030, New Haven, CT, 06520, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
- Veterans Administration Connecticut Healthcare System, West Haven, CT, USA
| | - Emily A Wang
- Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208030, New Haven, CT, 06520, USA
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Yang F, Hellyer JA, Than C, Ullal AJ, Kaiser DW, Heidenreich PA, Hoang DD, Winkelmayer WC, Schmitt S, Frayne SM, Phibbs CS, Turakhia MP. Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease. Heart 2016; 103:818-826. [PMID: 27852694 DOI: 10.1136/heartjnl-2016-309266] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 10/11/2016] [Accepted: 10/14/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD). METHODS We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD. RESULTS Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years. CONCLUSIONS There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.
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Affiliation(s)
- Felix Yang
- Maimonides Medical Center, Brooklyn, New York, USA
| | - Jessica A Hellyer
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Claire Than
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Aditya J Ullal
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
| | - Daniel W Kaiser
- Stanford University School of Medicine, Stanford, California, USA
| | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
| | - Donald D Hoang
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Wolfgang C Winkelmayer
- Stanford University School of Medicine, Stanford, California, USA.,Baylor College of Medicine, Houston, Texas, USA
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Susan M Frayne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
| | - Ciaran S Phibbs
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
| | - Mintu P Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.,Stanford University School of Medicine, Stanford, California, USA
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25
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Edelman EJ, Gordon KS, Tate JP, Becker WC, Bryant K, Crothers K, Gaither JR, Gibert CL, Gordon AJ, Marshall B, Rodriguez-Barradas MC, Samet JH, Skanderson M, Justice AC, Fiellin DA. The impact of prescribed opioids on CD4 cell count recovery among HIV-infected patients newly initiating antiretroviral therapy. HIV Med 2016; 17:728-739. [PMID: 27186715 PMCID: PMC5053822 DOI: 10.1111/hiv.12377] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied. METHODS Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (< 90 days) and long-term (≥ 90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity [ascertained with the Veterans Aging Cohort Study (VACS) Index]. Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e. dose and known immunosuppressive properties). RESULTS Compared to those with none, patients with short-term opioids had a similar increase in CD4 cell count (mean rise per year: 74 vs. 68 cells/μL; P = 0.11), as did those with long-term prescribed opioids (mean rise per year: 74 vs. 75 cells/μL; P = 0.98). In sensitivity analysis, compared with no opioids, the effects of short-term prescribed opioids were statistically significant among those with a baseline CD4 cell count ≥ 500 cells/μL (mean rise per year: 52 cells/μL for no opioids vs. 20 cells/μL for short-term opioids; P = 0.04); findings were otherwise unchanged. CONCLUSIONS Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating ART.
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Affiliation(s)
- E J Edelman
- Yale University School of Medicine, New Haven, CT, USA.
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA.
| | - K S Gordon
- VA Connecticut Health Care System, West Haven, CT, USA
| | - J P Tate
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - W C Becker
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - K Bryant
- National Institute on Alcohol Abuse and Alcoholism, HIV/AIDS Program, Bethesda, MD, USA
| | - K Crothers
- University of Washington, Seattle, WA, USA
| | - J R Gaither
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
- Yale University School of Public Health, New Haven, CT, USA
| | - C L Gibert
- DC Veterans Affairs Medical Center and George Washington University, Washington, DC, USA
| | - A J Gordon
- Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA
| | - Bdl Marshall
- Brown University School of Public Health, Providence, RI, USA
| | - M C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - J H Samet
- Boston University Schools of Medicine and Public Health, Boston, MA, USA
| | - M Skanderson
- VA Connecticut Health Care System, West Haven, CT, USA
| | - A C Justice
- Yale University School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
- VA Connecticut Health Care System, West Haven, CT, USA
| | - D A Fiellin
- Yale University School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA
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26
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Gosmanova EO, Mikkelsen MK, Molnar MZ, Lu JL, Yessayan LT, Kalantar-Zadeh K, Kovesdy CP. Association of Systolic Blood Pressure Variability With Mortality, Coronary Heart Disease, Stroke, and Renal Disease. J Am Coll Cardiol 2016; 68:1375-1386. [PMID: 27659458 PMCID: PMC5117818 DOI: 10.1016/j.jacc.2016.06.054] [Citation(s) in RCA: 199] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 06/13/2016] [Accepted: 06/21/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Intraindividual blood pressure (BP) fluctuates dynamically over time. Previous studies suggested an adverse link between greater visit-to-visit variability in systolic blood pressure (SBP) and various outcomes. However, these studies have significant limitations, such as a small size, inclusion of selected populations, and restricted outcomes. OBJECTIVES This study investigated the association of increased visit-to-visit variability and all-cause mortality, cardiovascular events, and end-stage renal disease (ESRD) in a large cohort of U.S. veterans. METHODS From among 3,285,684 U.S. veterans with and without hypertension and normal estimated glomerular filtration rates (eGFR) during 2005 and 2006, we identified 2,865,157 patients who had 8 or more outpatient BP measurements. Systolic blood pressure variability (SBPV) was measured using the SD of all SBP values (normally distributed) in 1 individual. Associations of SD quartiles (<10.3, 10.3 to 12.7, 12.7 to 15.6, and ≥15.6 mm Hg) with all-cause mortality, incident coronary heart disease (CHD), stroke, and ESRD was examined using Cox models adjusted for sociodemographic characteristics, baseline eGFR, comorbidities, body mass index, SBP, diastolic BP, and antihypertensive medication use. RESULTS Several sociodemographic variables (older age, male sex, African-American race, divorced or widowed status) and clinical characteristics (lower baseline eGFR, higher SBP and diastolic BP), and comorbidities (presence of diabetes, hypertension, cardiovascular disease, and lung disease) were all associated with higher intraindividual SBPV. The multivariable adjusted hazard ratios and 95% confidence intervals for SD quartiles 2 through 4 (compared with the first quartile) associated with all-cause mortality, CHD, stroke, and ESRD were incrementally higher. CONCLUSIONS Higher SBPV in individuals with and without hypertension was associated with increased risks of all-cause mortality, CHD, stroke, and ESRD. Further studies are needed to determine interventions that can lower SBPV and their impact on adverse health outcomes.
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Affiliation(s)
- Elvira O Gosmanova
- Nephrology Section, Stratton Veterans Affairs (VA) Medical Center, Albany, New York; Division of Nephrology, Albany Medical College, Albany, New York
| | | | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jun L Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Lenar T Yessayan
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, California
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee.
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27
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Cannon GW, DuVall SL, Haroldsen CL, Caplan L, Curtis JR, Michaud K, Mikuls TR, Reimold A, Collier DH, Joseph GJ, Harrison DJ, Sauer BC. Clinical Outcomes and Biologic Costs of Switching Between Tumor Necrosis Factor Inhibitors in US Veterans with Rheumatoid Arthritis. Adv Ther 2016; 33:1347-59. [PMID: 27352377 PMCID: PMC4969320 DOI: 10.1007/s12325-016-0371-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Indexed: 11/26/2022]
Abstract
Introduction The purpose of this study was to evaluate clinical outcomes and drug/administration costs of treatment with tumor necrosis factor inhibitor (TNFi) agents in US veterans with rheumatoid arthritis (RA) initiating TNFi therapy. The analysis compared patients initiating and continuing a single TNFi with patients who subsequently switched to a different TNFi. Methods Data from patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry who initiated treatment with adalimumab, etanercept, or infliximab from 2003 to 2010 were analyzed. Outcomes included duration of therapy, Disease Activity Score based on 28 joints (DAS28), and direct drug and drug administration costs. Results Of 563 eligible patients, 262 initiated a single TNFi therapy, 142 restarted their initial TNFi after a ≥90-day gap in treatment (interrupted therapy), and 159 switched to a different TNFi. Patients who switched had higher mean DAS28 before starting TNFi therapy than patients with single or interrupted therapy: 5.3 vs 4.5 or 4.6, respectively. Mean duration of the first course was 34.3 months for single therapy, 18.3 months for interrupted therapy, and 17.7 months for switched therapy. Mean post-treatment DAS28 was highest for patients who switched TNFi. Mean annualized costs for first course were $13,800 for single therapy, $13,200 for interrupted therapy, and $14,200 for switched therapy; mean annualized costs for second course were $12,800 for interrupted therapy and $15,100 for switched therapy. Conclusion Patients who switched TNFi had higher pre-treatment DAS28 and higher overall costs than patients who received the same TNFi as either single or interrupted therapy. Funding This research was funded by Immunex Corp., a fully owned subsidiary of Amgen Inc., and by VA HSR&D Grant SHP 08-172.
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Affiliation(s)
- Grant W Cannon
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Scott L DuVall
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Candace L Haroldsen
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Liron Caplan
- Denver VA and University of Colorado School of Medicine, Denver, CO, USA
| | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE, USA
- National Data Bank for Rheumatic Diseases, Wichita, KS, USA
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, NE, USA
| | - Andreas Reimold
- Dallas VA and University of Texas Southwestern, Dallas, TX, USA
| | | | | | | | - Brian C Sauer
- Veterans Affairs Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
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28
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Mudumbai SC, Oliva EM, Lewis ET, Trafton J, Posner D, Mariano ER, Stafford RS, Wagner T, Clark JD. Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System. PAIN MEDICINE 2016; 17:1732-43. [DOI: 10.1093/pm/pnw015] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Becker WC, Gordon K, Edelman EJ, Kerns RD, Crystal S, Dziura JD, Fiellin LE, Gordon AJ, Goulet JL, Justice AC, Fiellin DA. Trends in Any and High-Dose Opioid Analgesic Receipt Among Aging Patients With and Without HIV. AIDS Behav 2016; 20:679-86. [PMID: 26384973 PMCID: PMC5006945 DOI: 10.1007/s10461-015-1197-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Harms of opioid analgesics, especially high-dose therapy among individuals with comorbidities and older age, are increasingly recognized. However, trends in opioid receipt among HIV-infected patients are not well characterized. We examined trends, from 1999 to 2010, in any and high-dose (≥120 mg/day) opioid receipt among patients with and without HIV, by age strata, controlling for demographic and clinical correlates. Of 127,216 patients, 64 % received at least one opioid prescription. Opioid receipt increased substantially among HIV-infected and uninfected patients over the study; high-dose therapy was more prevalent among HIV-infected patients. Trends in high-dose receipt stratified by three age groups revealed an increasing trend in each age strata, higher among HIV-infected patients. Correlates of any opioid receipt included HIV, PTSD and major depression. Correlates of high-dose receipt included HIV, PTSD, major depression and drug use disorders. These findings suggest a need for appropriate balance of risks and benefits, especially as these populations age.
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Affiliation(s)
- William C Becker
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Kirsha Gordon
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - E Jennifer Edelman
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert D Kerns
- Psychology, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen Crystal
- Center for Health Services Research, Rutgers University, New Brunswick, NJ, USA
| | - James D Dziura
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Lynn E Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Adam J Gordon
- University of Pittsburgh and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joseph L Goulet
- Psychology, VA Connecticut Healthcare System, West Haven, CT, USA
- Psychology, Yale University School of Medicine, New Haven, CT, USA
| | - Amy C Justice
- Internal Medicine, West Haven VA Medical Center, VA Connecticut Healthcare System, Mail Stop 151B, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - David A Fiellin
- Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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30
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Ullal AJ, Than CT, Fan J, Schmitt S, Perino AC, Kaiser DW, Heidenreich PA, Frayne SM, Phibbs CS, Turakhia MP. Amiodarone and risk of death in contemporary patients with atrial fibrillation: Findings from The Retrospective Evaluation and Assessment of Therapies in AF study. Am Heart J 2015; 170:1033-1041.e1. [PMID: 26542514 PMCID: PMC4800972 DOI: 10.1016/j.ahj.2015.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 07/15/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are limited data on mortality outcomes associated with use of amiodarone in atrial fibrillation and flutter (AF). METHODS We evaluated the association of amiodarone use with mortality in patients with newly diagnosed AF using complete data from the Department of Veterans Affairs national health care system. We included patients seen in an outpatient setting within 90 days of a new diagnosis for nonvalvular AF between Veterans Affairs fiscal years 2004 and 2008. Multivariate analysis and propensity-matched Cox proportional hazards regression were used to evaluate the association of amiodarone use to death. RESULTS Of 122,465 patients (353,168 person-years of follow-up, age 72.1 ± 10.3 years, 98.4% males), amiodarone was prescribed in 11,655 (9.5%). Cumulative, unadjusted mortality rates were higher for amiodarone recipients than for nonrecipients (87 vs 73 per 1,000 person-years, P < .001). However, in multivariate and propensity-matched survival analyses, there was no significant difference in mortality (multivariate hazard ratio 1.01, 95% CI 0.97-1.05, P = .51, and propensity-matched hazard ratio 1.02, 95% CI 0.97-1.07, P = .45). The hazard of death was not modified by age, sex, heart failure, kidney function, β-blocker use, or warfarin use, but there was evidence of effect modification among patients diagnosed with AF as an inpatient versus outpatient. CONCLUSION In a national health care system population of newly diagnosed AF, overall use of amiodarone as an early treatment strategy was not associated with mortality.
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Affiliation(s)
- Aditya J Ullal
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford University School of Medicine, Stanford, CA
| | - Claire T Than
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | | | | | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford University School of Medicine, Stanford, CA
| | - Susan M Frayne
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford University School of Medicine, Stanford, CA
| | - Ciaran S Phibbs
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford University School of Medicine, Stanford, CA
| | - Mintu P Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford University School of Medicine, Stanford, CA.
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Lee SJ, Stijacic-Cenzer I, Barnhart C, McClymont K, Steinman MA. Changing Patterns of Glucose-Lowering Medication Use in VA Nursing Home Residents With Diabetes, 2005 to 2011. J Am Med Dir Assoc 2015; 16:898.e9-14. [PMID: 26272298 PMCID: PMC4593744 DOI: 10.1016/j.jamda.2015.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/24/2015] [Accepted: 06/24/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Although nursing home (NH) residents make up a large and growing proportion of Americans with diabetes mellitus, little is known about how glucose-lowering medications are used in this population. We sought to examine glucose-lowering medication use in Veterans Affairs (VA) NH residents with diabetes between 2005 and 2011. RESEARCH DESIGN AND METHODS Retrospective cohort study, using linked laboratory, pharmacy, administrative, and NH Minimum Dataset (MDS) 2.0 databases in 123 VA NHs. A total of 9431 long-stay (>90 days) VA NH residents older than 65 followed for 52,313 person-quarters. We identified receipt of glucose-lowering medications, including insulin, metformin, sulfonylureas, thiazolidinediones, and others (alpha-glucosidase inhibitors, meglitinides, glucagonlike peptide-1 analogs, dipeptidyl peptidase-4 inhibitors and amylin analogs) per quarter. RESULTS The rates of sulfonylurea use in long-stay NH residents dropped dramatically from 24% in 2005 to 12% in 2011 (P < .001), driven in large part by the dramatic decrease in glyburide use (10% to 2%, P < .001). There was sharp drop in thiazolidinedione use in 2007 (4% to <1%, P < .001). Metformin use was stable, ranging between 7% and 9% (P = .24). Insulin use increased slightly from 30% to 32% (P < .001). Use of other classes of glucose-lowering medications was stable (P = .22) and low, remaining below 1.3%. CONCLUSIONS AND RELEVANCE Between 2005 and 2011, there were dramatic declines in use of sulfonylureas and thiazolidinediones in VA NH residents, suggesting that prescribing practices can be quickly changed in this setting.
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Affiliation(s)
- Sei J Lee
- Division of Geriatrics, San Francisco VA and University of California San Francisco, San Francisco, CA.
| | - Irena Stijacic-Cenzer
- Division of Geriatrics, San Francisco VA and University of California San Francisco, San Francisco, CA
| | - Caroline Barnhart
- Division of Geriatrics, San Francisco VA and University of California San Francisco, San Francisco, CA
| | - Keelan McClymont
- Division of Geriatrics, San Francisco VA and University of California San Francisco, San Francisco, CA
| | - Michael A Steinman
- Division of Geriatrics, San Francisco VA and University of California San Francisco, San Francisco, CA
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Calculations of Financial Incentives for Providers in a Pay-for-Performance Program: Manual Review Versus Data From Structured Fields in Electronic Health Records. Med Care 2015; 53:901-7. [PMID: 26340661 DOI: 10.1097/mlr.0000000000000418] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospital report cards and financial incentives linked to performance require clinical data that are reliable, appropriate, timely, and cost-effective to process. Pay-for-performance plans are transitioning to automated electronic health record (EHR) data as an efficient method to generate data needed for these programs. OBJECTIVE To determine how well data from automated processing of structured fields in the electronic health record (AP-EHR) reflect data from manual chart review and the impact of these data on performance rewards. RESEARCH DESIGN Cross-sectional analysis of performance measures used in a cluster randomized trial assessing the impact of financial incentives on guideline-recommended care for hypertension. SUBJECTS A total of 2840 patients with hypertension assigned to participating physicians at 12 Veterans Affairs hospital-based outpatient clinics. Fifty-two physicians and 33 primary care personnel received incentive payments. MEASURES Overall, positive and negative agreement indices and Cohen's kappa were calculated for assessments of guideline-recommended antihypertensive medication use, blood pressure (BP) control, and appropriate response to uncontrolled BP. Pearson's correlation coefficient was used to assess how similar participants' calculated earnings were between the data sources. RESULTS By manual chart review data, 72.3% of patients were considered to have received guideline-recommended antihypertensive medications compared with 65.0% by AP-EHR review (κ=0.51). Manual review indicated 69.5% of patients had controlled BP compared with 66.8% by AP-EHR review (κ=0.87). Compared with 52.2% of patients per the manual review, 39.8% received an appropriate response by AP-EHR review (κ=0.28). Participants' incentive payments calculated using the 2 methods were highly correlated (r≥0.98). Using the AP-EHR data to calculate earnings, participants' payment changes ranged from a decrease of $91.00 (-30.3%) to an increase of $18.20 (+7.4%) for medication use (interquartile range, -14.4% to 0%) and a decrease of $100.10 (-31.4%) to an increase of $36.40 (+15.4%) for BP control or appropriate response to uncontrolled BP (interquartile range, -11.9% to -6.1%). CONCLUSIONS Pay-for-performance plans that use only EHR data should carefully consider the measures and the structure of the EHR before data collection and financial incentive disbursement. For this study, we feel that a 10% difference in the total amount of incentive earnings disbursed based on AP-EHR data compared with manual review is acceptable given the time and resources required to abstract data from medical records.
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Weisberg DF, Gordon KS, Barry DT, Becker WC, Crystal S, Edelman EJ, Gaither J, Gordon AJ, Goulet J, Kerns RD, Moore BA, Tate J, Justice AC, Fiellin DA. Long-term Prescription of Opioids and/or Benzodiazepines and Mortality Among HIV-Infected and Uninfected Patients. J Acquir Immune Defic Syndr 2015; 69:223-33. [PMID: 26009831 PMCID: PMC4446730 DOI: 10.1097/qai.0000000000000591] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Increased long-term prescription of opioids and/or benzodiazepines necessitates evaluating risks associated with their receipt. We sought to evaluate the association between long-term opioids and/or benzodiazepines and mortality in HIV-infected patients receiving antiretroviral therapy and uninfected patients. METHODS Prospective analysis of all-cause mortality using multivariable methods and propensity score matching among HIV-infected patients receiving antiretroviral therapy and uninfected patients. RESULTS Of 64,602 available patients (16,989 HIV-infected and 47,613 uninfected), 27,128 (exposed and unexposed to long-term opioids and/or benzodiazepines) were 1:1 matched by propensity score. The hazard ratio for death was 1.40 [95% confidence interval (CI): 1.22 to 1.61] for long-term opioid receipt, 1.26 (95% CI: 1.08 to 1.48) for long-term benzodiazepine receipt, and 1.56 (95% CI: 1.26 to 1.92) for long-term opioid and benzodiazepine receipt. There was an interaction (P = 0.01) between long-term opioid receipt and HIV status with mortality. For long-term opioid receipt, the hazard ratio was 1.46 (95% CI: 1.15 to 1.87) among HIV-infected patients, and 1.25 (95% CI: 1.05 to 1.49) among uninfected patients. Mortality risk was increased for patients receiving both long-term opioids and benzodiazepines when opioid doses were ≥ 20 mg morphine-equivalent daily dose and for patients receiving long-term opioids alone when doses were ≥ 50 mg morphine-equivalent daily dose. CONCLUSIONS Long-term opioid receipt was associated with an increased risk of death; especially with long-term benzodiazepine receipt, higher opioid doses, and among HIV-infected patients. Long-term benzodiazepine receipt was associated with an increased risk of death regardless of opioid receipt. Strategies to mitigate risks associated with these medications, and caution when they are coprescribed, are needed particularly in HIV-infected populations.
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Affiliation(s)
- Daniel F Weisberg
- *Yale University School of Medicine, New Haven, CT; †VA Connecticut Healthcare System, West Haven, CT; Departments of ‡Psychiatry; §Internal Medicine, Yale University School of Medicine, New Haven, CT; ‖Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ; ¶Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT; #Yale University School of Public Health, New Haven, CT; **Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; ††VA Pittsburgh Healthcare System, Pittsburgh, PA; and ‡‡Pain Research, Informatics, Multi-morbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT
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Kizilbash QF, Petersen NJ, Chen GJ, Naik AD, Trautner BW. Bacteremia and Mortality with Urinary Catheter–Associated Bacteriuria. Infect Control Hosp Epidemiol 2015; 34:1153-9. [DOI: 10.1086/673456] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective.Although catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU) are clinically distinct conditions, most literature describing the risks of bacteriuria does not distinguish between them. We studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU. Second, we investigated whether the presence or absence of urinary symptoms in catheterized patients with bacteriuria was associated with bacteremia from any source or mortality. Finally, we explored the effect of antimicrobial treatment of bacteriuria on subsequent bacteremia from any source and mortality.Design.We performed a retrospective cohort study with 30 days of follow-up after an initial positive urine culture. CAUTI and CAABU were defined by Infectious Diseases Society of America guidelines.Setting. A large tertiary care facility.Patients.All inpatients with a urinary catheter (external or indwelling) and a positive urine culture between October 2010 and June 2011.Results.We captured 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality. Use of antimicrobial agents to treat bacteriuria was not associated with either bacteremia from any source or mortality.Conclusions.Bacteremia from a urinary source was infrequent, and there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria in this population. Antibiotic treatment of bacteriuria did not affect outcomes.
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Nelson SD, Lu CC, Teng CC, Leng J, Cannon GW, He T, Zeng Q, Halwani A, Sauer B. The use of natural language processing of infusion notes to identify outpatient infusions. Pharmacoepidemiol Drug Saf 2014; 24:86-92. [PMID: 25402257 DOI: 10.1002/pds.3720] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 07/25/2014] [Accepted: 09/05/2014] [Indexed: 11/10/2022]
Abstract
PURPOSE Outpatient infusions are commonly missing in Veterans Health Affairs (VHA) pharmacy dispensing data sets. Currently, Healthcare Common Procedure Coding System (HCPCS) codes are used to identify outpatient infusions, but concerns exist if they correctly capture all infusions and infusion-related data such as dose and date of administration. We developed natural language processing (NLP) software to extract infusion information from medical text infusion notes. The objective was to compare the sensitivity of three approaches to identify infliximab administration dates and infusion doses against a reference standard established from the Veterans Affairs rheumatoid arthritis (VARA) registry. METHODS We compared the sensitivity and positive predictive value (PPV) of NLP to that of HCPCS codes in identifying the correct date and dose of infliximab infusions against a human extracted reference standard. RESULTS The sensitivity was 0.606 (0.585-0.627) for HCPCS alone, 0.858 (0.842-0.873) for NLP alone, and 0.923 (0.911-0.934) for the two methods combined, with a PPV of 0.735 (0.716-0.754), 0.976 (0.969-0.983), and 0.957 (0.948-0.965) for each method, respectively. The mean dose of infliximab was 433 mg in the reference standard, 337 mg from HCPCS, 434 mg from NLP, and 426 mg from the combined method. CONCLUSIONS HCPCS codes alone are not sufficient to accurately identify infliximab infusion dates and doses in the VHA system. The use of NLP significantly improved the sensitivity and PPV for estimating infusion dates and doses, especially when combined with HCPCS codes.
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Affiliation(s)
- Scott D Nelson
- George E. Whalen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA; University of Utah, Salt Lake City, UT, USA
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Increased mortality associated with digoxin in contemporary patients with atrial fibrillation: findings from the TREAT-AF study. J Am Coll Cardiol 2014; 64:660-8. [PMID: 25125296 DOI: 10.1016/j.jacc.2014.03.060] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 03/26/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite endorsement of digoxin in clinical practice guidelines, there exist limited data on its safety in atrial fibrillation/flutter (AF). OBJECTIVES The goal of this study was to evaluate the association of digoxin with mortality in AF. METHODS Using complete data of the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the U.S. Department of Veterans Affairs (VA) healthcare system, we identified patients with newly diagnosed, nonvalvular AF seen within 90 days in an outpatient setting between VA fiscal years 2004 and 2008. We used multivariate and propensity-matched Cox proportional hazards to evaluate the association of digoxin use with death. Residual confounding was assessed by sensitivity analysis. RESULTS Of 122,465 patients with 353,168 person-years of follow-up (age 72.1 ± 10.3 years, 98.4% male), 28,679 (23.4%) patients received digoxin. Cumulative mortality rates were higher for digoxin-treated patients than for untreated patients (95 vs. 67 per 1,000 person-years; p < 0.001). Digoxin use was independently associated with mortality after multivariate adjustment (hazard ratio [HR]: 1.26, 95% confidence interval [CI]: 1.23 to 1.29, p < 0.001) and propensity matching (HR: 1.21, 95% CI: 1.17 to 1.25, p < 0.001), even after adjustment for drug adherence. The risk of death was not modified by age, sex, heart failure, kidney function, or concomitant use of beta-blockers, amiodarone, or warfarin. CONCLUSIONS Digoxin was associated with increased risk of death in patients with newly diagnosed AF, independent of drug adherence, kidney function, cardiovascular comorbidities, and concomitant therapies. These findings challenge current cardiovascular society recommendations on use of digoxin in AF.
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Cannon GW, DuVall SL, Haroldsen CL, Caplan L, Curtis JR, Michaud K, Mikuls TR, Reimold A, Collier DH, Harrison DJ, Joseph GJ, Sauer BC. Persistence and dose escalation of tumor necrosis factor inhibitors in US veterans with rheumatoid arthritis. J Rheumatol 2014; 41:1935-43. [PMID: 25128516 DOI: 10.3899/jrheum.140164] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Limited evidence exists comparing the persistence, effectiveness, and costs of biologic therapies for rheumatoid arthritis in clinical practice. Comparative effectiveness studies are needed to understand real-world experience with these agents. We evaluated treatment patterns, costs, and effectiveness of tumor necrosis factor inhibitor (TNFi) agents in patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry. METHODS Observational data from the VARA registry and linked administrative databases were analyzed. Longitudinal data from VARA patients initiating adalimumab (ADA), etanercept (ETN), or infliximab (IFX) from 2003 (the date all agents were available within the Veteran Affairs) to 2010 were analyzed. Outcomes included Disease Activity Score using 28 joints (DAS28), treatment persistence, dose escalation, and direct costs of drugs and drug administration. RESULTS For 563 eligible patients, baseline DAS28, DAS28 improvements, and persistence on initial treatment were similar across agents. Fewer patients receiving ETN (n = 5/290; 2%) underwent dose escalation than did patients taking ADA (n = 32/204; 16%) or IFX (n = 44/69; 64%). Annual costs for first course of TNFi therapy were lower for injectable ADA ($13,100 US) and ETN ($13,500 US) than for intravenously administered IFX ($16,900 US). CONCLUSION Despite similar persistence and clinical disease activity for these TNFi agents, rates of dose escalation were highest with ADA and IFX. Higher overall costs were noted for IFX without increases in effectiveness.
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Affiliation(s)
- Grant W Cannon
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc.
| | - Scott L DuVall
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - Candace L Haroldsen
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - Liron Caplan
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - Jeffrey R Curtis
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - Kaleb Michaud
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - Ted R Mikuls
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - Andreas Reimold
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - David H Collier
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - David J Harrison
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - George J Joseph
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
| | - Brian C Sauer
- From the Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, Utah; Denver Veterans Affairs (VA); University of Colorado, Denver, Colorado; University of Alabama at Birmingham, Birmingham, Alabama; the University of Nebraska Medical Center; Omaha VA, Omaha, Nebraska; the National Data Bank for Rheumatic Diseases, Wichita, Kansas; Dallas VA; University of Texas Southwestern, Dallas, Texas; Amgen Inc., Thousand Oaks, California, USA.G.W. Cannon, MD, Associate Chief of Staff of Academic Affiliations; S.L. DuVall, PhD, Associate Director, VA Informatics and Computing Infrastructure and Research Assistant Professor; C.L. Haroldsen, MSPH, Senior Programmer/Analyst; B.C. Sauer, PhD, MS, Associate Professor, Veterans Affairs Salt Lake City Health Care System, University of Utah School of Medicine; L. Caplan, MD, PhD, Associate Professor of Medicine/Rheumatology, Denver VA, University of Colorado; J.R. Curtis, MD, MS, MPH, William J. Koopman Endowed Professor in Rheumatology and Immunology, Director, University of Alabama Birmingham (UAB) Arthritis Clinical Intervention Program, Co-director, UAB Center for Education and Research on Therapeutics, Co-director, UAB PharmacoEpidemiology and Economic Research Group, University of Alabama at Birmingham; K. Michaud, PhD, Assistant Professor of Medicine, Co-director, University of Nebraska Medical Center, National Data Bank for Rheumatic Diseases; T.R. Mikuls, MD, Staff Physician and Researcher, Professor of Internal Medicine and Rheumatology, Omaha VA, University of Nebraska Medical Center; A. Reimold, MD, Chief, Rheumatology Section, Associate Professor of Medicine, Dallas VA, University of Texas Southwestern; D.H. Collier, MD, Clinical Research Medical Director; D.J. Harrison, PhD, Health Economics Director, Amgen Inc.; G.J. Joseph, PhD, Health Economics Senior Manager, former employee of Amgen Inc
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Thiazide Use Is Associated With Reduced Risk for Incident Lower Extremity Fractures in Men With Spinal Cord Injury. Arch Phys Med Rehabil 2014; 95:1015-20. [DOI: 10.1016/j.apmr.2013.12.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 01/01/2023]
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Mudumbai SC, Takemoto S, Cason BA, Au S, Upadhyay A, Wallace AW. Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System. J Hosp Med 2014; 9:289-96. [PMID: 24799360 DOI: 10.1002/jhm.2182] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 02/04/2014] [Accepted: 02/13/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I. OBJECTIVE To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I. DESIGN A retrospective cohort study. SETTING Veterans Affairs (VA) Healthcare System. PATIENTS A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE-I who underwent inpatient surgery from calendar years 1999 to 2012. INTERVENTION None. MEASUREMENTS We classified surgical admissions based upon the timing of postoperative resumption of an ACE-I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30-day mortality data. We evaluated the relationship between 30-day mortality and the nonresumption of an ACE-I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient- and hospital-level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models. RESULTS Twenty-five percent of our cohort did not resume an ACE-I during the 14 days following surgery. Nonresumption of an ACE-I within postoperative day 0 to 14 was independently associated with increased 30-day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30-3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship. CONCLUSIONS Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated.
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Affiliation(s)
- Seshadri C Mudumbai
- Anesthesia Service, Veterans Affairs Palo Alto Health Care System, Palo Alto and Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California
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Motzkus-Feagans C, Pakyz AL, Ratliff SM, Bajaj JS, Lapane KL. Statin use and infections in Veterans with cirrhosis. Aliment Pharmacol Ther 2013; 38:611-8. [PMID: 23889738 DOI: 10.1111/apt.12430] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/04/2012] [Accepted: 07/05/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence about the beneficial effects of statins on reducing infections is accumulating. Identifying ways to reduce infection risk in patients with cirrhosis is important because of increased mortality risk and costs associated with infections. AIM To estimate the extent to which statin use prolongs time to infection among patients with cirrhosis. METHODS We identified Veterans with cirrhosis, but without decompensation (n = 19 379) using US Veterans Health Administration data from 2001 to 2009. New users of statins were identified and propensity matched to non-users and users of other cholesterol-lowering medications (1:1 matching). The cohort was followed up for hospitalisations with infections. Cox regression models with time-varying exposures provided estimates of adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS New statin use was present among 13% of VA patients with cirrhosis without decompensation. Overall, 12.4% of patients developed a serious infection, and 0.1% of patients died. In the propensity-matched sample, statin users experienced hospitalisations with infections at a rate 0.67 less than non-users (95% Confidence Interval: 0.47-0.95). CONCLUSIONS Infections are a major concern among cirrhotic patients and have the potential to seriously impact both life expectancy and quality of life. Statin use may potentially reduce the risk of infections among patients with cirrhosis.
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Affiliation(s)
- C Motzkus-Feagans
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Bajaj JS, Ratliff SM, Heuman DM, Lapane KL. Non-selective beta-blockers are not associated with serious infections in veterans with cirrhosis. Aliment Pharmacol Ther 2013; 38:407-14. [PMID: 23786291 PMCID: PMC3725127 DOI: 10.1111/apt.12382] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 05/20/2013] [Accepted: 06/03/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Studies evaluating outcomes associated with non-selective beta-blockers (NSBB) in cirrhosis have yielded mixed results. A major cause of death in decompensated cirrhosis is infection. AIM To determine the effect of NSBB use on serious infections (requiring hospitalisation) in compensated and decompensated cirrhosis. METHODS Using data from the US Veterans Health Administration from 2001-2009, we identified two cohorts: compensated cirrhotics (n = 12,656) and decompensated cirrhotics (n = 4834). From each cohort, we identified new NSBB users and propensity-matched them 1:1 to non-users (n = 1836 each in compensated users/non-users and n = 1462 each in decompensated users/non-users). They were followed up for serious infections (median time: 3.1 years), death and transplant. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) from Cox regression models. RESULTS Death or transplantation occurred in 0.7% compensated and 2.7% of decompensated patients. Among decompensated cirrhotics, death (P = 0.0061) and transplantation (P = 0.0086) occurred earlier in NSBB users compared with non-users. Serious infections were observed in 4.8% of compensated cirrhotics and in 13.7% of decompensated cirrhotics. There was no difference in the rate of serious infection development in new NSBB users compared with non-users in the compensated (adjusted HR: 0.90, CI: 0.59-1.36) or in the decompensated group (adjusted HR: 1.10, CI: 0.96-1.25). CONCLUSION The use of non-selective beta-blockers in U.S. veterans is not associated with an increased rate of serious infections in compensated or decompensated cirrhosis.
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Affiliation(s)
- J S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, VA 23249, USA.
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Risks and benefits of bladder antimuscarinics among elderly residents of Veterans Affairs Community Living Centers. J Am Med Dir Assoc 2013; 14:749-60. [PMID: 23639715 DOI: 10.1016/j.jamda.2013.03.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 03/12/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To evaluate risks and benefits of bladder antimuscarinics (BAMs) among elderly long term care nursing home residents. DESIGN Retrospective cohort study using a new user design and propensity score matching. SETTING Veterans Affairs (VA) Community Living Centers (Nursing Homes). PARTICIPANTS Older adults (65 and older) admitted for long term care between October 1, 2002, and September 30, 2009. MEASUREMENTS The study used multiple VA data sources (Minimum Data Set [MDS], inpatient, outpatient, and pharmacy prescriptions administrative files). The following outcomes were evaluated: (1) fractures (hip fracture and "any" fracture) identified from inpatient and/or outpatient data (ICD-9-CM codes) and from MDS; (2) cognitive performance measured using the validated MDS Cognitive Performance Scale; (3) improvement in urinary incontinence measured from MDS; (4) quality of life measured from MDS using 2 validated instruments: Index of Social Engagement and Health Status Index. Covariates included demographic characteristics, baseline continence status (bladder and bowel) and continence management, preexistent urinary tract infections, body mass index, comorbidities, other medication use, cognitive status, and mobility at baseline. These variables were used to calculate the predicted probability (propensity score) of being initiated on a BAM; the resulting propensity scores were used to match new users and nonusers. Outcomes were compared with Cox proportional hazards regression and generalized estimating equations methodology. RESULTS BAMs were used by 9.8% of the residents 65 years and older admitted for long term care; 44% (1195) were new users. Of these, all but 53 received nonselective immediate release preparations, predominantly oxybutynin chloride (75%). BAM initiation resulted in improved urinary continence status (odds ratio = 1.27, 95% confidence interval [CI] 1.07-1.5) and better social engagement (difference in mean index of social engagement score = 0.2074, 95% CI 0.055-0.3598). The risk of fractures was significantly increased in new users as compared to nonusers (hip fracture: hazard ratio [HR] = 3.67, 95% CI 1.46-9.34; "any" fracture: HR = 2.64, 95% CI 1.37-5.10). The number needed to treat (NNT) to obtain improvement in urinary incontinence after 90 days of treatment (NNT = 32, 95% CI 17-125) was similar to the number needed to harm (NNH) at 90 days in the hip fracture analysis (NNH = 36, 95% CI 12-209). There were no differences in cognitive performance or overall quality of life scores associated with BAM use. CONCLUSION These results question the continued use of BAMs, particularly immediate-release oxybutynin chloride in elderly nursing home residents.
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Carbone LD, Chin AS, Lee TA, Burns SP, Svircev JN, Hoenig HM, Akhigbe T, Weaver FM. The association of opioid use with incident lower extremity fractures in spinal cord injury. J Spinal Cord Med 2013; 36:91-6. [PMID: 23809522 PMCID: PMC3595973 DOI: 10.1179/2045772312y.0000000060] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE To determine the association between opioid use and lower extremity fracture risk in men with spinal cord injury (SCI). DESIGN Retrospective cohort study. SETTING Veterans Affairs Healthcare System. PARTICIPANTS In total, 7447 male Veterans with a history of a traumatic SCI identified from the Veterans Affairs (VA) Spinal Cord Dysfunction Registry (SCD) from September 2002 through October 2007 and followed through October 2010. OUTCOME MEASURES Incident lower extremity fractures by use of opioids. RESULTS In individuals identified from the VA SCD Registry 2002-2007, opioid use was quite common, with approximately 70% of the cohort having received a prescription for an opioid. Overall, there were 892 incident lower extremity fractures over the time period of this study (597 fractures in the opioid users and 295 fractures in the non-opioid users). After adjusting for covariates, there was a statistically significant relationship between opioid use and increased risk for lower extremity fractures (hazard ratio 1.82 (95% confidence interval 1.59-2.09)). Shorter duration of use (<6 months) and higher doses were positively related to fracture risk (P < 0.0001). CONCLUSIONS Opioid use is quite common in SCI and is associated with an increased risk for lower extremity fractures. Careful attention to fracture prevention is warranted in patients with SCI, particularly upon initiation of an opioid prescription and when higher doses are used.
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Affiliation(s)
- Laura D. Carbone
- Department of Research, Veterans Affairs Medical Center, Memphis, TN, USA; and Department of Medicine, Division of Connective Tissues Disorders, University of Tennessee Health Science Center, Memphis, TN, USA,Correspondence to: Laura Carbone, University of Tennessee Health Science Center, 956 Court Avenue, Rm G326, Memphis, TN 38163-0001, USA.
| | - Amy S. Chin
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr VA Hospital, Hines, IL, USA
| | - Todd A. Lee
- University of Illinois at Chicago, Chicago, IL, USA
| | - Stephen P. Burns
- VA Puget Sound Health Care System & Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jelena N. Svircev
- VA Puget Sound Health Care System & Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | | | - Titilola Akhigbe
- Department of Research, Veterans Affairs Medical Center, Memphis, TN, USA; and Department of Medicine, Division of Connective Tissues Disorders, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Frances M. Weaver
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr VA Hospital, Hines, IL, USA
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Turakhia MP, Hoang DD, Xu X, Frayne S, Schmitt S, Yang F, Phibbs CS, Than CT, Wang PJ, Heidenreich PA. Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study. Am Heart J 2013; 165:93-101.e1. [PMID: 23237139 DOI: 10.1016/j.ahj.2012.10.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 10/05/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND Atrial fibrillation and flutter (AF, collectively) cause stroke. We evaluated whether treating specialty influences warfarin prescription in patients with newly diagnosed AF. METHODS In the TREAT-AF study, we used Veterans Health Administration health record and claims data to identify patients with newly diagnosed AF between October 2004 and November 2008 and at least 1 internal medicine/primary care or cardiology outpatient encounter within 90 days after diagnosis. The primary outcome was prescription of warfarin. RESULTS In 141,642 patients meeting the inclusion criteria, the mean age was 72.3 ± 10.2 years, 1.48% were women, and 25.8% had cardiology outpatient care. Cardiology-treated patients had more comorbidities and higher mean CHADS2 scores (1.8 vs 1.6, P < .0001). Warfarin use was higher in cardiology-treated vs primary care only-treated patients (68.6% vs 48.9%, P < .0001). After covariate and site-level adjustment, cardiology care was significantly associated with warfarin use (odds ratio [OR] 2.05, 95% CI 1.99-2.11). These findings were consistent across a series of adjusted models (OR 2.05-2.20), propensity matching (OR 1.98), and subgroup analyses (OR 1.58-2.11). Warfarin use in primary-care-only patients declined from 2004 to 2008 (51.6%-44.0%, P < .0001), whereas the adjusted odds of warfarin receipt with cardiology care (vs primary care) increased from 2004 to 2008 (1.88-2.24, P < .0001). CONCLUSION In patients with newly diagnosed AF, we found large differences in anticoagulation use by treating specialty. A divergent 5-year trend of risk-adjusted warfarin use was observed. Treating specialty influences stroke prevention care and may impact clinical outcomes.
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Affiliation(s)
- Mintu P Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford University School of Medicine, Palo Alto, CA 94304, USA.
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Receipt of opioid analgesics by HIV-infected and uninfected patients. J Gen Intern Med 2013; 28:82-90. [PMID: 22895747 PMCID: PMC3539026 DOI: 10.1007/s11606-012-2189-z] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 07/02/2012] [Accepted: 07/23/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Opioids are increasingly prescribed, but there are limited data on opioid receipt by HIV status. OBJECTIVES To describe patterns of opioid receipt by HIV status and the relationship between HIV status and receiving any, high-dose, and long-term opioids. DESIGN Cross-sectional analysis of the Veterans Aging Cohort Study. PARTICIPANTS HIV-infected (HIV+) patients receiving Veterans Health Administration care, and uninfected matched controls. MAIN MEASURES Pain-related diagnoses were determined using ICD-9 codes. Any opioid receipt was defined as at least one opioid prescription; high-dose was defined as an average daily dose ≥ 120 mg of morphine equivalents; long-term opioids was defined as ≥ 90 consecutive days, allowing a 30 day refill gap. Multivariable models were used to assess the relationship between HIV infection and the three outcomes. KEY RESULTS Among the HIV+ (n = 23,651) and uninfected (n = 55,097) patients, 31 % of HIV+ and 28 % of uninfected (p < 0.001) received opioids. Among patients receiving opioids, HIV+ patients were more likely to have an acute pain diagnosis (7 % vs. 4 %), but less likely to have a chronic pain diagnosis (53 % vs. 69 %). HIV+ patients received a higher mean daily morphine equivalent dose than uninfected patients (41 mg vs. 37 mg, p = 0.001) and were more likely to receive high-dose opioids (6 % vs. 5 %, p < 0.001). HIV+ patients received fewer days of opioids than uninfected patients (median 44 vs. 60, p < 0.001), and were less likely to receive long-term opioids (31 % vs. 34 %, p < 0.001). In multivariable analysis, HIV+ status was associated with receipt of any opioids (AOR 1.40, 95 % CI 1.35, 1.46) and high-dose opioids (AOR 1.22, 95 % CI 1.07, 1.39), but not long-term opioids (AOR 0.94, 95 % CI 0.88, 1.01). CONCLUSIONS Patients with HIV infection are more likely to be prescribed opioids than uninfected individuals, and there is a variable association with pain diagnoses. Efforts to standardize approaches to pain management may be warranted in this highly complex and vulnerable patient population.
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Bajaj JS, Ratliff SM, Heuman DM, Lapane KL. Proton pump inhibitors are associated with a high rate of serious infections in veterans with decompensated cirrhosis. Aliment Pharmacol Ther 2012; 36:866-74. [PMID: 22966967 PMCID: PMC3524366 DOI: 10.1111/apt.12045] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 08/06/2012] [Accepted: 08/22/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is increasing evidence that proton pump inhibitors (PPIs) increase the rate of infections in patients with decompensated cirrhosis. AIMS To estimate the extent to which proton pump inhibitors (PPIs) increase the rate of infections among patients with decompensated cirrhosis. METHODS We conducted a retrospective propensity-matched new user design using US Veterans Health Administration data. Only decompensated cirrhotic patients from 2001 to 2009 were included. New PPI users after decompensation (n = 1268) were 1:1 matched to those who did not initiate gastric acid suppression. Serious infections, defined as infections associated with a hospitalisation, were the outcomes. These were separated into acid suppression-related (SBP, bacteremia, Clostridium difficile and pneumonia) and non-acid suppression-related. Time-varying Cox models were used to estimate adjusted hazard ratios (HR) and 95% CIs of serious infections. Parallel analyses were conducted with H2 receptor antagonists (H2RA). RESULTS More than half of persons with decompensated cirrhosis were new users of gastric acid suppressants, with most using PPIs (45.6%) compared with H2RAs (5.9%). In the PPI propensity-matched analysis, 25.3% developed serious infections and 25.9% developed serious infections in the H2RA analysis. PPI users developed serious infections faster than nongastric acid suppression users (adjusted HR: 1.66; 95% CI: 1.31–2.12). For acid suppression-related serious infections, PPI users developed the outcome at a rate 1.75 times faster than non-users (95% CI: 1.32–2.34). The H2RA findings were not statistically significant (HR serious infections: 1.59; 95% CI: 0.80–3.18; HR acid suppression-related infections: 0.92; 95% CI: 0.31–2.73). CONCLUSION Among patients with decompensated cirrhosis, proton pump inhibitors but not H2 receptor antagonists increase the rate of serious infections.
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Affiliation(s)
- J S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, Richmond, VA, USA.
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Lavigne JE, Au A, Jiang R, Wang Y, Good CP, Glassman P, Cunningham F. Utilization of prescription drugs with warnings of suicidal thoughts and behaviours in the USA and the US Department of Veterans Affairs, 2009. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2012. [DOI: 10.1111/j.1759-8893.2012.00093.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Abstract
Objectives
To develop a list of prescription medications labelled with warnings for adverse effects of suicidal ideation or behaviour and to describe utilization in the USA and in the Department of Veterans Affairs (VA) in 2009.
Methods
A systematic search of US Food and Drug Administration and other references using ‘suicide’, ‘suicidal’ and ‘suicidality’ was used to identify prescription drugs labelled for risk of suicidal ideation or behaviour. Prescription medications sold in the USA by sales volume are reported alongside VA utilization as determined from national electronic pharmacy records.
Key findings
One hundred and twenty-five prescription drugs were labelled for potential adverse effects of suicidal ideation or behaviour. Forty-five of these drugs were among the top 200 prescription medications sold in the USA in 2009 with a total sales volume of 540.8 million prescriptions. Rank-ordered utilization was similar in the VA. VA total fill volume was 5.99 million prescriptions.
Conclusions
The majority of prescriptions with adverse effect warnings of suicidal ideation or behaviour were generic. Relatively high volumes of drugs with warnings for suicidal ideation or behaviour are filled in the USA and in the VA.
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Affiliation(s)
- Jill E. Lavigne
- Pharmacy Practice and Administration, Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York
| | - Anthony Au
- VA MedSAFE, Pharmacy Benefits Management Group, US Department of Veterans Health Affairs, Hines, Illinois
| | - Rong Jiang
- VA MedSAFE, Pharmacy Benefits Management Group, US Department of Veterans Health Affairs, Hines, Illinois
| | - Yu Wang
- VA MedSAFE, Pharmacy Benefits Management Group, US Department of Veterans Health Affairs, Hines, Illinois
| | | | - Peter Glassman
- VA Greater Los Angeles Healthcare System (GLA), Los Angeles, California, USA
| | - Frances Cunningham
- VA MedSAFE, Pharmacy Benefits Management Group, US Department of Veterans Health Affairs, Hines, Illinois
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Lafrance JP, Miller DR. Dispensed Selective and Nonselective Nonsteroidal Anti-inflammatory Drugs and the Risk of Moderate to Severe Hyperkalemia: A Nested Case-Control Study. Am J Kidney Dis 2012; 60:82-9. [DOI: 10.1053/j.ajkd.2012.02.328] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 02/22/2012] [Indexed: 01/25/2023]
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Pergam SA, Forsberg CW, Boeckh MJ, Maynard C, Limaye AP, Wald A, Smith NL, Young BA. Herpes zoster incidence in a multicenter cohort of solid organ transplant recipients. Transpl Infect Dis 2011; 13:15-23. [PMID: 20636480 DOI: 10.1111/j.1399-3062.2010.00547.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Immunosuppressed patients are at increased risk for herpes zoster (HZ), but incidence in solid organ transplant (SOT) recipients has varied in multiple studies. To assess incidence of HZ, we examined patients who underwent SOT and received follow-up care within the large multicenter US Department of Veteran's Affairs healthcare system. METHODS Incident cases of HZ were determined using ICD-9 coding from administrative databases. A multivariable Cox proportional hazards model, adjusted for a priori risk factors, was used to assess demographic factors associated with development of HZ. RESULTS Among the 1077 eligible SOT recipients, the cohort-specific incidence rate of HZ was 22.2 per 1000 patient-years (95% confidence interval [CI], 18.1-27.4). African Americans (37.6 per 1000 [95% CI, 25.0-56.6]) and heart transplants recipients (40.0 per 1000 [95% CI, 23.2-68.9]) had the highest incidence of HZ. Patients transplanted between 2005 and 2007 had the lowest incidence (15.3 per 1000 [95% CI, 8.2-28.3]). In a multivariable model, African Americans (hazard ratio [HR] 1.88; 95% CI: 1.12, 3.17) and older transplant recipients (HR 1.13; 95% CI: 1.01, 1.27 [per 5-year increment]) had increased relative hazards of HZ. CONCLUSIONS These data demonstrate that HZ is a common infectious complication following SOT. Future studies focused on HZ prevention are needed in this high-risk population.
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Affiliation(s)
- S A Pergam
- Department of Medicine, University of Washington, Seattle, Washington 98109, USA.
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Hsu JL, Siroka AM, Smith MW, Holodniy M, Meduri GU. One-year outcomes of community-acquired and healthcare-associated pneumonia in the Veterans Affairs Healthcare System. Int J Infect Dis 2011; 15:e382-7. [PMID: 21393043 DOI: 10.1016/j.ijid.2011.02.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 01/08/2011] [Accepted: 02/01/2011] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND While studies have demonstrated higher medium-term mortality for community-acquired pneumonia (CAP), mortality and costs have not been characterized for healthcare-associated pneumonia (HCAP) over a 1-year period. METHODS We conducted a retrospective cohort study to evaluate mortality rates and health system costs for patients with CAP or HCAP during initial hospitalization and for 1 year after hospital discharge. We selected 50 758 patients admitted to the Veterans Affairs (VA) healthcare system between October 2003 and May 2007. Main outcome measures included hospital, post-discharge, and cumulative mortality rates and cost during initial hospitalization and at 12 months following discharge. RESULTS Hospital and 1-year HCAP mortality were nearly twice that of CAP. HCAP was an independent predictor for hospital mortality (odds ratio (OR) 1.62, 95% confidence interval (CI) 1.49-1.76) and 1-year mortality (OR 1.99, 95% CI 1.87-2.11) when controlling for demographics, comorbidities, pneumonia severity, and factors associated with multidrug-resistant infection, including immune suppression, previous antibiotic treatment, and aspiration pneumonia. HCAP patients consistently had higher mortality in each stratum of the Charlson-Deyo-Quan comorbidity index. HCAP patients incurred significantly greater cost during the initial hospital stay and in the following 12 months. Demographics and comorbid conditions, particularly aspiration pneumonia, accounted for 19-33% of this difference. CONCLUSION HCAP represents a distinct category of pneumonia with particularly poor survival up to 1 year after hospital discharge. While comorbidities, pneumonia severity, and risk factors for multidrug-resistant infection may interact to produce even higher mortality compared to CAP, they alone do not explain the observed differences.
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Affiliation(s)
- Joe L Hsu
- Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305-5236, USA.
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