Burden of migraine in Finland: multimorbidity and phenotypic disease networks in occupational healthcare

The regional disparities in liver disease comorbidity among elderly Chinese based on a health ecological model: the China Health and Retirement Longitudinal Study

PURPOSE

This study aimed to investigate the risk factors for liver disease comorbidity among older adults in eastern, central, and western China, and explored binary, ternary and quaternary co-morbid co-causal patterns of liver disease within a health ecological model.

METHOD

Basic information from 9,763 older adults was analyzed using data from the China Health and Retirement Longitudinal Study (CHARLS). LASSO regression was employed to identify significant predictors in eastern, central, and western China. Patterns of liver disease comorbidity were studied using association rules, and spatial distribution was analyzed using a geographic information system. Furthermore, binary, ternary, and quaternary network diagrams were constructed to illustrate the relationships between liver disease comorbidity and co-causes.

RESULTS

Among the 9,763 elderly adults studied, 536 were found to have liver disease comorbidity, with binary or ternary comorbidity being the most prevalent. Provinces with a high prevalence of liver disease comorbidity were primarily concentrated in Inner Mongolia, Sichuan, and Henan. The most common comorbidity patterns identified were "liver-heart-metabolic", "liver-kidney", "liver-lung", and "liver-stomach-arthritic". In the eastern region, important combination patterns included "liver disease-metabolic disease", "liver disease-stomach disease", and "liver disease-arthritis", with the main influencing factors being sleep duration of less than 6 h, frequent drinking, female, and daily activity capability. In the central region, common combination patterns included "liver disease-heart disease", "liver disease-metabolic disease", and "liver disease-kidney disease", with the main influencing factors being an education level of primary school or below, marriage, having medical insurance, exercise, and no disabilities. In the western region, the main comorbidity patterns were "liver disease-chronic lung disease", "liver disease-stomach disease", "liver disease-heart disease", and "liver disease-arthritis", with the main influencing factors being general or poor health satisfaction, general or poor health condition, severe pain, and no disabilities.

CONCLUSION

The comorbidities associated with liver disease exhibit specific clustering patterns at both the overall and local levels. By analyzing the comorbidity patterns of liver diseases in different regions and establishing co-morbid co-causal patterns, this study offers a new perspective and scientific basis for the prevention and treatment of liver diseases.

Comorbidity Patterns in Patients Newly Diagnosed With Colorectal Cancer: Network-Based Study

BACKGROUND

Patients with colorectal cancer (CRC) often present with multiple comorbidities, and many of these can affect treatment and survival. However, previous comorbidity studies primarily focused on diseases in commonly used comorbidity indices. The comorbid status of CRC patients with respect to the entire spectrum of chronic diseases has not yet been investigated.

OBJECTIVE

This study aimed to systematically analyze all chronic diagnoses and diseases co-occurring, using a network-based approach and large-scale administrative health data, and provide a complete picture of the comorbidity pattern in patients newly diagnosed with CRC from southwest China.

METHODS

In this retrospective observational study, the hospital discharge records of 678 hospitals from 2015 to 2020 in Sichuan Province, China were used to identify new CRC cases in 2020 and their history of diseases. We examined all chronic diagnoses using ICD-10 (International Classification of Diseases, 10th Revision) codes at 3 digits and focused on chronic diseases with >1% prevalence in at least one subgroup (1-sided test, P<.025), which resulted in a total of 66 chronic diseases. Phenotypic comorbidity networks were constructed across all CRC patients and different subgroups by sex, age (18-59, 60-69, 70-79, and ≥80 years), area (urban and rural), and cancer site (colon and rectum), with comorbidity as a node and linkages representing significant correlations between multiple comorbidities.

RESULTS

A total of 29,610 new CRC cases occurred in Sichuan, China in 2020. The mean patient age at diagnosis was 65.6 (SD 12.9) years, and 75.5% (22,369/29,610) had at least one comorbidity. The most prevalent comorbidities were hypertension (8581/29,610, 29.0%; 95% CI 28.5%-29.5%), hyperplasia of the prostate (3816/17,426, 21.9%; 95% CI 21.3%-22.5%), and chronic obstructive pulmonary disease (COPD; 4199/29,610, 14.2%; 95% CI 13.8%-14.6%). The prevalence of single comorbidities was different in each subgroup in most cases. Comorbidities were closely associated, with disorders of lipoprotein metabolism and hyperplasia of the prostate mediating correlations between other comorbidities. Males and females shared 58.3% (141/242) of disease pairs, whereas male-female disparities occurred primarily in diseases coexisting with COPD, cerebrovascular diseases, atherosclerosis, heart failure, or renal failure among males and with osteoporosis or gonarthrosis among females. Urban patients generally had more comorbidities with higher prevalence and more complex disease coexistence relationships, whereas rural patients were more likely to have co-existing severe diseases, such as heart failure comorbid with the sequelae of cerebrovascular disease or COPD.

CONCLUSIONS

Male-female and urban-rural disparities in the prevalence of single comorbidities and their complex coexistence relationships in new CRC cases were not due to simple coincidence. The results reflect clinical practice in CRC patients and emphasize the importance of measuring comorbidity patterns in terms of individual and coexisting diseases in order to better understand comorbidity patterns.

Using artificial intelligence to identify patients with migraine and associated symptoms and conditions within electronic health records

BACKGROUND

Real-world evidence (RWE)-based on information obtained from sources such as electronic health records (EHRs), claims and billing databases, product and disease registries, and personal devices and health applications-is increasingly used to support healthcare decision making. There is variability in the collection of EHR data, which includes "structured data" in predefined fields (e.g., problem list, open claims, medication list, etc.) and "unstructured data" as free text or narrative. Healthcare providers are likely to provide more complete information as free text, but extracting meaning from these fields requires newer technologies and a rigorous methodology to generate higher-quality evidence. Herein, an approach to identify concepts associated with the presence and progression of migraine was developed and validated using the complete patient record in EHR data, including both the structured and unstructured portions.

METHODS

"Traditional RWE" approaches (i.e., capture from structured EHR fields and extraction using structured queries) and "Advanced RWE" approaches (i.e., capture from unstructured EHR data and processing by artificial intelligence [AI] technology, including natural language processing and AI-based inference) were evaluated against a manual chart abstraction reference standard for data collected from a tertiary care setting. The primary endpoint was recall; differences were compared using chi square.

RESULTS

Compared with manual chart abstraction, recall for migraine and headache were 66.6% and 29.6%, respectively, for Traditional RWE, and 96.8% and 92.9% for Advanced RWE; differences were statistically significant (absolute differences, 30.2% and 63.3%; P < 0.001). Recall of 6 migraine-associated symptoms favored Advanced RWE over Traditional RWE to a greater extent (absolute differences, 71.5-88.8%; P < 0.001). The difference between traditional and advanced techniques for recall of migraine medications was less pronounced, approximately 80% for Traditional RWE and ≥ 98% for Advanced RWE (P < 0.001).

CONCLUSION

Unstructured EHR data, processed using AI technologies, provides a more credible approach to enable RWE in migraine than using structured EHR and claims data alone. An algorithm was developed that could be used to further study and validate the use of RWE to support diagnosis and management of patients with migraine.

Evaluation of the pharmacokinetic interactions and safety of atogepant coadministered with esomeprazole

Aim: To investigate potential pharmacokinetic interactions between atogepant and esomeprazole. Methods: Atogepant, esomeprazole, or both were administered to 32 healthy adults in an open-label, nonrandomized, crossover study. Systemic exposure (area under the plasma concentration-time curve [AUC] and peak plasma concentration [Cmax]) for atogepant administered in combination versus alone were compared using a linear mixed effects model. Results: Coadministration with esomeprazole delayed atogepant time to Cmax by ∼1.5 h and reduced Cmax by ∼23% with no statistically significant change in AUC compared with atogepant alone. Administration of atogepant 60 mg alone or in combination with esomeprazole 40 mg was well tolerated in healthy adults. Conclusion: Esomeprazole had no clinically meaningful effect on atogepant pharmacokinetics. Clinical Trial Registration: unregistered phase I study.

Headache and quality of life in Finnish female municipal employees

OBJECTIVES

Migraine and other specific types of chronic headache impair health-related quality of life (HRQoL). However, undefined headache is common in general population and little is known about its impact on QoL. This study addresses the impact of undefined headache symptoms on quality of life in a population of working-age females.

METHODS

This cross-sectional study consisted of 633 female municipal employees. Self-reported headache recurrence was defined by asking whether headache was occasional or recurrent. We assessed quality of life with two different instruments, the generic EUROHIS-QOL 8-item index (EUROHIS-8) and the preference-based instrument EuroQoL (EQ-5D) representing health-related QoL. Anxiety, depressive symptoms and work stress were measured using validated questionnaires. Adjusted hypothesis of linearity was evaluated using bootstrap type analysis of covariance with age, education and number of comorbidities as covariates.

RESULTS

In the study population, 76% (n=481) had experienced headache during the past year, and of those 38% (n=184) had recurrent headache. The EQ-5D index decreased linearly with increasing headache symptoms and four out of five EQ-5D dimensions were lowest in recurrent headache group. Females with headache had lower QoL on every EUROHIS-8 item except for conditions of living place, compared to females without headache. These results remained statistically significant after adjustment with age, education and number of comorbidities. There were no differences in prevalence of musculoskeletal disorders between study groups.

CONCLUSIONS

This cross-sectional, observational study showed that self-reported recurrent headache is common among Finnish women belonging to active work force. Both health-related and general QoL is best in females without headache and lowest in the recurrent headache group. We conclude that recurrent headache, even when the subjects have low anxiety and depressive symptoms scores, is associated with low HRQoL in working-age females. These results underline the importance of headache, a common and neglected symptom deteriorating female employees' wellbeing.

Comorbidity patterns in depression: A disease network analysis using regional hospital discharge records

BACKGROUND

Depression is a psychiatric disorder with a high comorbidity burden; however, previous comorbidity studies predominately focused on a few common diseases and relied on self-reported data. We aimed to investigate the comorbid status of depression concerning the entire spectrum of chronic diseases using network analysis.

METHOD

Totally, 22,872 depressed inpatients and one-to-one matched controls were enrolled in the retrospective study. Hospital discharge records were aggregated to measure the comorbidities, where those with a prevalence ≥ 1% were selected for further analysis. Based on the co-occurrence frequency, sex- and age-specific comorbidity networks in depressed patients were constructed and the results were compared with the controls. Louvain algorithm was used to detect the highly interlinked communities.

RESULTS

Depressed patients had 4 comorbidities on average, and 84.4% had at least one comorbidity. The comorbidity network in depression cases was more complex than controls (connections of 839 vs. 369). Intricate but distinct communities appeared within the comorbidity network in depressed patients, where the largest community included cerebrovascular diseases, chronic ischaemia heart disease, atherosclerosis and osteoporosis. Sex-specific central diseases existed, and cardiovascular diseases were the major central diseases to both gender. The older the depressed patients, the more severe the central diseases in the comorbidity network.

LIMITATIONS

The causality of the observed interactions could not be determined.

CONCLUSIONS

The application of network analysis on longitudinal healthcare datasets to assess comorbidity patterns can supplement the traditional clinical study approaches. The findings would improve our understanding of depression-related comorbidities and enhance the integrated management of depression.

Phenotypic Disease Network Analysis to Identify Comorbidity Patterns in Hospitalized Patients with Ischemic Heart Disease Using Large-Scale Administrative Data

Ischemic heart disease (IHD) exhibits elevated comorbidity. However, few studies have systematically analyzed the comorbid status of IHD patients with respect to the entire spectrum of chronic diseases. This study applied network analysis to provide a complete picture of physical and mental comorbidities in hospitalized patients with IHD using large-scale administrative data. Hospital discharge records from a provincial healthcare database of IHD inpatients (n = 1,035,338) and one-to-one matched controls were included in this retrospective analysis. We constructed the phenotypic disease networks in IHD and control patients and further assessed differences in comorbidity patterns. The community detection method was applied to cluster diagnoses within the comorbidity network. Age- and sex-specific patterns of IHD comorbidities were also analyzed. IHD inpatients showed 50% larger comorbid burden when compared to controls. The IHD comorbidity network consisted of 1941 significant associations between 71 chronic conditions. Notably, the more densely connected comorbidities in IHD patients were not within the highly prevalent ones but the rarely prevalent ones. Two highly interlinked communities were detected in the IHD comorbidity network, where one included hypertension with heart and multi-organ failures, and another included cerebrovascular diseases, cerebrovascular risk factors and anxiety. Males exhibited higher comorbid burden than females, and thus more complex comorbidity relationships were found in males. Sex-specific disease pairs were detected, e.g., 106 and 30 disease pairs separately dominated in males and females. Aging accounts for the majority of comorbid burden, and the complexity of the comorbidity network increased with age. The network-based approach improves our understanding of IHD-related comorbidities and enhances the integrated management of patients with IHD.

Erenumab Decreases Headache-Related Sick Leave Days and Health Care Visits: A Retrospective Real-World Study in Working Patients with Migraine

Introduction

The prevalence of migraine is highest among working age individuals, and this disease is associated with an increased number of sick leaves and health care visits, as well as lost productivity. Erenumab, the first monoclonal antibody targeting the calcitonin gene-related peptide (CGRP) pathway, is effective in decreasing the monthly number of migraine days, but evidence of its impact on the number of sick leave days and health care visits in patients with migraine is limited.

Methods

This retrospective registry study focused on occupationally active patients with migraine treated with erenumab at a Finnish private health care provider, Terveystalo. Erenumab responders, defined as patients who had at least two unique prescriptions of erenumab and no prescription of other CGRP inhibitor (CGRPi), were followed for 12 months prior to and after erenumab treatment initiation (index), and the change in the number of headache-related and all-cause sick leave days, health care visits and prescriptions for other medications during this period were assessed from the registry data. The same outcomes were assessed in an age- and sex-matched control group of migraine patients not receiving CGRPi to control for potential changes in patient behavior and health care practices during the COVID-19 pandemic.

Results

Altogether, 162 patients who were entitled to employer-sponsored health care received erenumab and met the 12-month follow-up requirements. In the responder group (n = 82; 50.1%) headache-related sick leave days were reduced by 73.9% (p = 0.035) and health care visits by 44.6% (p < 0.001) in the 12 months following treatment initiation compared to the period of 12 months prior to treatment. All-cause sick leave days were reduced by 19.4% and all-cause health care visits by 13.5%, but these changes were not statistically significant. Triptan prescriptions decreased by 30.4% (p = 0.012) and other prophylactic treatments by 31.5% (p = 0.004). No significant changes were observed in the corresponding outcomes in the migraine control group during the same period.

Conclusions

The results of this registry study suggest that in addition to the effect on the monthly number of migraine days documented in clinical trials, erenumab can significantly reduce the number of headache-related sick leave days and health care visits in employed patients with migraine managed in routine clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-021-00303-x.

Evaluation of the Pharmacokinetic Interaction and Safety of Ubrogepant Coadministered With Esomeprazole Magnesium

Ubrogepant is a calcitonin gene-related peptide receptor antagonist for the acute treatment of migraine. Esomeprazole magnesium increases intragastric pH, which may affect oral ubrogepant absorption. This open-label, nonrandomized, crossover trial evaluated esomeprazole magnesium's impact on the pharmacokinetics and safety of coadministered ubrogepant in healthy adults. Participants received ubrogepant 100 mg on day 1, esomeprazole magnesium 40 mg on days 9 to 13, and ubrogepant 100 mg with esomeprazole magnesium 40 mg on day 14. No effect on ubrogepant pharmacokinetics was concluded if 90% confidence intervals of geometric mean ratios were within 80% to 125% for comparison of pharmacokinetic parameters between ubrogepant + esomeprazole magnesium versus ubrogepant alone. Thirty participants enrolled (mean age, 31.7 years; 53.3% males). Ubrogepant peak plasma concentration (C_max ) decreased 23%, time to C_max increased by 1.5 hours, and area under the plasma concentration-time curve was reduced by ≈10% when coadministered with esomeprazole magnesium versus ubrogepant alone. The 90% confidence interval of the geometric mean ratio for C_max did not fall within the 80% to 125% equivalence range, but the decrease was not considered clinically meaningful. Esomeprazole magnesium coadministered with ubrogepant did not increase the incidence rate of treatment-emergent adverse events, and interactions between the medications are likely to have limited clinical relevance.

Medication Overuse and Headache Burden: Results From the CaMEO Study

Objective

To estimate the relative frequency of acute medication overuse (AMO) among people with episodic migraine and chronic migraine, to characterize the types of acute medications overused for migraine, and to identify factors associated with AMO.

Methods

We analyzed data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study (ClinicalTrials.gov, NCT01648530), a cross-sectional and longitudinal internet study that included a systematic sampling of the US population. From September 2012 to November 2013, the CaMEO Study respondents participated in different modules to collect data on the clinical course of migraine, family burden, barriers to care, endophenotypes, and comorbidities. Among people who met the criteria for migraine consistent with the International Classification of Headache Disorders, third edition (ICHD-3), we evaluated types and frequency of medications used for headache/migraine, selected comorbidities, and emergency department (ED) and urgent care (UC) use. AMO was defined by days per month of medication use as specified by ICHD-3 criteria for medication overuse headache (MOH) without the requirement for ≥15 monthly headache days (MHDs). Nested, multivariable binary logistic regression modeling was used to identify factors associated with an increased risk of AMO.

Results

Of 16,789 CaMEO respondents with migraine, 2,975 (17.7%) met the AMO criteria. Approximately 67.9% (2,021/2,975) of AMO respondents reported <15 MHDs. Simple analgesics, combination analgesics, and opioids were the medication classes most commonly overused. Factors associated with AMO in the final multivariable logistic regression model included ≥15 MHDs, moderate to severe disability, severe migraine interictal burden, use of preventive medication, and an ED/UC visit for headache within 6 months.

Conclusions

Approximately two-thirds of respondents with AMO reported <15 MHDs and therefore did not meet the criteria for MOH. Those with AMO had greater disease burden and increased ED/UC utilization relative to people with migraine but not AMO.

Healthcare Expenditures Associated With Comorbid Anxiety and Depression Among Adults With Migraine

Introduction: Depression and anxiety are common among patients with migraine and usually associated with a humanistic and financial burden. This study aims to examine the direct healthcare expenditures among adults with migraine alone or with comorbid anxiety and/or depression. Methods: This was a retrospective cross-sectional study using 2012, 2014, and 2016 Medical Expenditure Panel Survey data. Adult patients aged ≥22 years with migraine headache were included in the study. The direct healthcare expenditures of four migraine groups (migraine alone, migraine and anxiety, migraine and depression, and migraine and both conditions) were compared. Results: There were 1,556 patients who met the inclusion criteria and eventually enrolled in the study. Approximately 42% of the study sample had migraine with comorbid depression and/or anxiety (16.1% have depression, 12.3% have anxiety disorder, and 13.9% have both). The mean total healthcare expenditures of adults with migraine alone ($6,461) were significantly lower than those with comorbid depression and anxiety ($11,102), comorbid anxiety ($10,817), and comorbid depression ($14,577). Migraine with comorbid anxiety and depression was significantly associated with incremental costs of $1,027 in outpatient and $662 emergency room healthcare expenditures and prescription drug compared to the migraine alone group. Conclusions: The healthcare expenditures associated with migraine with comorbid depression and/or anxiety are significantly higher than those without mental health comorbidities. Therefore, regular depression and anxiety screening for patients with migraine may help reduce the healthcare expenditures associated with depression and/or anxiety comorbidities and improve the quality of care.

My Migraine Voice survey: disease impact on healthcare resource utilization, personal and working life in Finland

BACKGROUND

A global My Migraine Voice survey was conducted in 31 countries among 11,266 adults who suffered from ≥4 monthly migraine days (MMD). The aim of this retrospective observational survey-based study was to analyse the country specific results in Finland in order to understand the impact of migraine based on disease severity.

METHODS

The included participants (3%, n = 338/11,266) were stratified by mean MMDs into 4 ≤ MMD < 8 (n = 133), 8 ≤ MMD < 15 (n = 139) and MMD ≥ 15 (n = 66) subgroups. Comorbidities, migraine-related emotional burden and impact on daily living and work productivity and activity impairment (WPAI) were assessed. Subgroup analysis on healthcare resource utilization (HCRU) due to migraine was assessed by visits to healthcare practitioners (HCPs) during the past 6 months and by hospitalizations and emergency room (ER) visits during the past 12 months. The group difference was tested using the one-way ANOVA and for categorical variables using the Chi-squared test. The association between HCRU and MMD and number of comorbidities was assessed using negative binomial regression analysis.

RESULTS

Mean age was 44 years, 93% were women and 67% (n = 227) were employed. Chronic migraine (CM, MMD ≥ 15) was reported in 19.5% of the respondents. The negative impact on daily functioning and emotional burden increased significantly by migraine frequency. Mean number of comorbidities was 2.4, and mean number of HCP visits during the previous 6 months was 5.9. Increase in migraine frequency and comorbidities was associated with higher HCRU. Eighty-eight percent of the respondents reported negative impact on working life and 52% experienced overall work productivity impairment. Over previous month, the mean number of missed working days for all respondents was 2.8 days of which 54% were paid sick leave days, and in CM up to 6.0 days and 30%, respectively. Both absenteeism and presenteeism were higher in the CM group.

CONCLUSIONS

The emotional and functional burden was high, and the societal burden increased by frequency and severity of migraine, as shown by higher HCRU and reduced work productivity. There is a need to improve quality of care in migraine and improve migraine management related issues in both healthcare and society in Finland.