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Nanditha NGA, Dong X, McLinden T, Sereda P, Kopec J, Hogg RS, Montaner JSG, Lima VD. The impact of lookback windows on the prevalence and incidence of chronic diseases among people living with HIV: an exploration in administrative health data in Canada. BMC Med Res Methodol 2022; 22:1. [PMID: 34991473 PMCID: PMC8734246 DOI: 10.1186/s12874-021-01448-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/21/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND We described the impact of different lengths of lookback window (LW), a retrospective time period to observe diagnoses in administrative data, on the prevalence and incidence of eight chronic diseases. METHODS Our study populations included people living with HIV (N = 5151) and 1:5 age-sex-matched HIV-negative individuals (N = 25,755) in British Columbia, Canada, with complete follow-up between 1996 and 2012. We measured period prevalence and incidence of diseases in 2012 using LWs ranging from 1 to 16 years. Cases were deemed prevalent if identified in 2012 or within a defined LW, and incident if newly identified in 2012 with no previous cases detected within a defined LW. Chronic disease cases were ascertained using published case-finding algorithms applied to population-based provincial administrative health datasets. RESULTS Overall, using cases identified by the full 16-year LW as the reference, LWs ≥8 years and ≥ 4 years reduced the proportion of misclassified prevalent and incidence cases of most diseases to < 20%, respectively. The impact of LWs varied across diseases and populations. CONCLUSIONS This study underscored the importance of carefully choosing LWs and demonstrated data-driven approaches that may inform these choices. To improve comparability of prevalence and incidence estimates across different settings, we recommend transparent reporting of the rationale and limitations of chosen LWs.
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Affiliation(s)
- Ni Gusti Ayu Nanditha
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Xinzhe Dong
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Taylor McLinden
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Paul Sereda
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Jacek Kopec
- Arthritis Research Canada, Richmond, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Viviane D Lima
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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Wartko PD, Weiss NS, Enquobahrie DA, Chan KCG, Stephenson-Famy A, Mueller BA, Dublin S. Maternal Gestational Weight Gain in Relation to Antidepressant Continuation in Pregnancy. Am J Perinatol 2021; 38:1442-1452. [PMID: 32604448 PMCID: PMC8487259 DOI: 10.1055/s-0040-1713652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Both excessive and inadequate gestational weight gain (GWG) are associated with adverse health outcomes for the woman and her child. Antidepressant use in pregnancy could affect GWG, based on evidence in nonpregnant women that some antidepressants may cause weight gain and others weight loss. Previous studies of antidepressant use and GWG were small with limited ability to account for confounding, including by maternal mental health status and severity. We assessed the association of antidepressant continuation in pregnancy with GWG among women using antidepressants before pregnancy. STUDY DESIGN Our retrospective cohort study included singleton livebirths from 2001 to 2014 within Kaiser Permanente Washington, an integrated health care system. Data were obtained from electronic health records and linked Washington State birth records. Among women with ≥1 antidepressant fill within 6 months before pregnancy, women who filled an antidepressant during pregnancy were considered "continuers;" women without a fill were "discontinuers." We calculated mean differences in GWG and relative risks (RR) of inadequate and excessive weight gain based on Institute of Medicine guidelines. Using inverse probability of treatment weighting with generalized estimating equations, we addressed differences in maternal characteristics, including mental health conditions. RESULTS Among the 2,887 births, 1,689 (59%) were to women who continued antidepressants in pregnancy and 1,198 (42%) were to discontinuers. After accounting for confounding, continuers had similar weight gain to those who discontinued (mean difference: 1.3 lbs, 95% confidence interval [CI]: -0.1 to 2.8 lbs) and similar risks of inadequate and excessive GWG (RR: 0.95, 95% CI: 0.80-1.14 and RR: 1.06, 95% CI: 0.98-1.14, respectively). Findings were comparable for specific antidepressants and trimesters of exposure. CONCLUSION We did not find evidence that continuation of antidepressants in pregnancy led to differences in GWG. KEY POINTS · Antidepressant use is associated with weight change in nonpregnant populations.. · Prior evidence on whether antidepressant use in pregnancy affects gestational weight gain is sparse.. · We accounted for confounding by characteristics such as mental health conditions and their severity.. · We found no association between pregnancy antidepressant continuation and gestational weight gain..
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Affiliation(s)
- Paige D Wartko
- Department of Epidemiology, University of Washington,
Seattle, Washington.,Kaiser Permanente Washington Health Research Institute,
Seattle, Washington
| | - Noel S Weiss
- Department of Epidemiology, University of Washington,
Seattle, Washington.,Public Health Sciences Division, Fred Hutchinson Cancer
Research Center, Seattle, WA, USA
| | | | - KC Gary Chan
- Department of Biostatistics, University of Washington,
Seattle, Washington
| | | | - Beth A Mueller
- Department of Epidemiology, University of Washington,
Seattle, Washington.,Public Health Sciences Division, Fred Hutchinson Cancer
Research Center, Seattle, WA, USA
| | - Sascha Dublin
- Department of Epidemiology, University of Washington,
Seattle, Washington.,Kaiser Permanente Washington Health Research Institute,
Seattle, Washington
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DuMontier C, Fillmore NR, Yildirim C, Cheng D, La J, Orkaby AR, Charest B, Cirstea D, Yellapragada S, Gaziano JM, Do N, Brophy MT, Kim DH, Munshi NC, Driver JA. Contemporary Analysis of Electronic Frailty Measurement in Older Adults with Multiple Myeloma Treated in the National US Veterans Affairs Healthcare System. Cancers (Basel) 2021; 13:cancers13123053. [PMID: 34207459 PMCID: PMC8233717 DOI: 10.3390/cancers13123053] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 12/31/2022] Open
Abstract
Simple Summary Geriatric and frailty assessment are recommended for all older adults with cancer undergoing systemic therapy, but assessments remain difficult to scale. The aim of this study was to use an electronic frailty index based on data from administrative claims and electronic health records—the Veterans Affairs Frailty Index (VA-FI-10)—to estimate frailty and its impact on older United States (US) military veterans treated for multiple myeloma (MM) throughout the national VA Healthcare System. We found frailty to be prevalent and strongly associated with mortality and hospitalizations—independently of age, race, and MM stage. We also showed that changing the way in which the VA-FI-10 is measured affects its classification of frailty for individual veterans but not its association with mortality. These findings support the VA-FI-10’s use in research investigating outcomes in frail veterans treated with contemporary MM therapies. We provide further insights into the VA-FI-10’s potential use in clinical practice. Abstract Electronic frailty indices based on data from administrative claims and electronic health records can be used to estimate frailty in large populations of older adults with cancer where direct frailty measures are lacking. The objective of this study was to use the electronic Veterans Affairs Frailty Index (VA-FI-10)—developed and validated to measure frailty in the national United States (US) VA Healthcare System—to estimate the prevalence and impact of frailty in older US veterans newly treated for multiple myeloma (MM) with contemporary therapies. We designed a retrospective cohort study of 4924 transplant-ineligible veterans aged ≥ 65 years initiating MM therapy within VA from 2004 to 2017. Initial MM therapy was measured using inpatient and outpatient treatment codes from pharmacy data in the VA Corporate Data Warehouse. In total, 3477 veterans (70.6%) were classified as frail (VA-FI-10 > 0.2), with 1510 (30.7%) mildly frail (VA-FI-10 > 0.2–0.3), 1105 (22.4%) moderately frail (VA-FI-10 > 0.3–0.4), and 862 (17.5%) severely frail (VA-FI-10 > 0.4). Survival and time to hospitalization decreased with increasing VA-FI-10 severity (log-rank p-value < 0.001); the VA-FI-10 predicted mortality and hospitalizations independently of age, sociodemographic variables, and measures of disease risk. Varying data sources and assessment periods reclassified frailty severity for a substantial portion of veterans but did not substantially affect VA-FI-10’s association with mortality. Our study supports use of the VA-FI-10 in future research involving older veterans with MM and provides insights into its potential use in identifying frailty in clinical practice.
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Affiliation(s)
- Clark DuMontier
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA 02130, USA; (C.D.); (A.R.O.)
- Division of Aging, Brigham and Women’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
| | - Nathanael R. Fillmore
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
- VA Boston CSP Center, Boston, MA 02130, USA; (N.D.); (M.T.B.)
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Cenk Yildirim
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
| | - David Cheng
- Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Jennifer La
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
| | - Ariela R. Orkaby
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA 02130, USA; (C.D.); (A.R.O.)
- Division of Aging, Brigham and Women’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
| | - Brian Charest
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
| | - Diana Cirstea
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Sarvari Yellapragada
- Michael E. Debakey VA Medical Center and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA;
| | - John Michael Gaziano
- Division of Aging, Brigham and Women’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA 02130, USA; (C.Y.); (J.L.); (B.C.)
- VA Boston Healthcare System, Boston, MA 02130, USA
| | - Nhan Do
- VA Boston CSP Center, Boston, MA 02130, USA; (N.D.); (M.T.B.)
- Boston University School of Medicine, Boston, MA 02118, USA
| | - Mary T. Brophy
- VA Boston CSP Center, Boston, MA 02130, USA; (N.D.); (M.T.B.)
- Boston University School of Medicine, Boston, MA 02118, USA
| | - Dae H. Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA 02131, USA;
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Nikhil C. Munshi
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
- VA Boston Healthcare System, Boston, MA 02130, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Jane A. Driver
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA 02130, USA; (C.D.); (A.R.O.)
- Division of Aging, Brigham and Women’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (N.R.F.); (N.C.M.)
- Correspondence: ; Tel.: +1-857-364-2560
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Cheng D, DuMontier C, Yildirim C, Charest B, Hawley CE, Zhuo M, Paik JM, Yaksic E, Gaziano JM, Do N, Brophy M, Cho K, Kim DH, Driver JA, Fillmore NR, Orkaby AR. Updating and Validating the U.S. Veterans Affairs Frailty Index: Transitioning From ICD-9 to ICD-10. J Gerontol A Biol Sci Med Sci 2021; 76:1318-1325. [PMID: 33693638 PMCID: PMC8202143 DOI: 10.1093/gerona/glab071] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The Veterans Affairs Frailty Index (VA-FI) is an electronic frailty index developed to measure frailty using administrative claims and electronic health records data in Veterans. An update to ICD-10 coding is needed to enable contemporary measurement of frailty. METHOD International Classification of Diseases, ninth revision (ICD-9) codes from the original VA-FI were mapped to ICD-10 first using the Centers for Medicaid and Medicare Services (CMS) General Equivalence Mappings. The resulting ICD-10 codes were reviewed by 2 geriatricians. Using a national cohort of Veterans aged 65 years and older, the prevalence of deficits contributing to the VA-FI and associations between the VA-FI and mortality over years 2012-2018 were examined. RESULTS The updated VA-FI-10 includes 6422 codes representing 31 health deficits. Annual cohorts defined on October 1 of each year included 2 266 191 to 2 428 115 Veterans, for which the mean age was 76 years, 97%-98% were male, 78%-79% were White, and the mean VA-FI was 0.20-0.22. The VA-FI-10 deficits showed stability before and after the transition to ICD-10 in 2015, and maintained strong associations with mortality. Patients classified as frail (VA-FI > 0.2) consistently had a hazard of death more than 2 times higher than nonfrail patients (VA-FI ≤ 0.1). Distributions of frailty and associations with mortality varied with and without linkage to CMS data and with different assessment periods for capturing deficits. CONCLUSIONS The updated VA-FI-10 maintains content validity, stability, and predictive validity for mortality in a contemporary cohort of Veterans aged 65 years and older, and may be applied to ICD-9 and ICD-10 claims data to measure frailty.
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Affiliation(s)
- David Cheng
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Clark DuMontier
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Cenk Yildirim
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Brian Charest
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Chelsea E Hawley
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
| | - Min Zhuo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Julie M Paik
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
| | - Enzo Yaksic
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - J Michael Gaziano
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Nhan Do
- Boston VA Cooperative Studies Program, Massachusetts, USA
- Boston University School of Medicine, Massachusetts, USA
| | - Mary Brophy
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Jane A Driver
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathanael R Fillmore
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ariela R Orkaby
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
PURPOSE The aim of the study was to evaluate the association of antidepressant continuation in pregnancy with infant birth weight among women using antidepressants before pregnancy. METHODS This retrospective cohort study used electronic health data linked with state birth records. We identified singleton live births (2001-2014) to enrolled women with 1 or more antidepressant prescriptions filled 6 months or less before pregnancy, including "continuers" (≥1 antidepressant fills during pregnancy, n = 1775) and "discontinuers" (no fill during pregnancy, n = 1249). We compared birth weight, small or large for gestational age (SGA or LGA), low birth weight (LBW; <2500 g), and macrosomia (>4500 g) between the 2 groups, using inverse probability of treatment weighting to account for pre-pregnancy characteristics, including mental health conditions. RESULTS After weighting, infants born to antidepressant continuers weighed 71.9 g less than discontinuers' infants (95% confidence interval [CI], -115.5 to -28.3 g), with a larger difference for female infants (-106.4 g; 95% CI, -164.6 to -48.1) than male infants (-48.5 g; 95% CI, -107.2 to 10.3). For female infants, SGA risk was greater in continuers than discontinuers (relative risk [RR],1.54; 95% CI, 1.02 to 2.32). Low birth weight risk was greater in continuers with 50% or more of days covered (RR, 1.69; 95% CI, 1.11 to 2.58) and exposure in the second trimester (RR, 1.53; 95% CI, 1.02 to 2.29), as compared with discontinuers. CONCLUSIONS Depending on infant sex, as well as duration and timing of use, continuation of antidepressant use during pregnancy may be associated with lower infant birth weight, with corresponding increases in LBW and SGA.
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Marinier K, Macouillard P, de Champvallins M, Deltour N, Poulter N, Mancia G. Effectiveness of two-drug therapy versus monotherapy as initial regimen in hypertension: A propensity score-matched cohort study in the UK Clinical Practice Research Datalink. Pharmacoepidemiol Drug Saf 2019; 28:1572-1582. [PMID: 31482621 PMCID: PMC6916605 DOI: 10.1002/pds.4884] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 12/19/2022]
Abstract
Purpose To compare the effectiveness on blood pressure (BP) of initial two‐drug therapy versus monotherapy in hypertensive patients. Methods Using the Clinical Practice Research Datalink, linked with Hospital Episode Statistics and Office for National Statistics, we identified a cohort of adults with uncontrolled hypertension, initiating one or two antihypertensive drug classes between 2006 and 2014. New users of two drugs and monotherapy were matched 1:2 by propensity score. Main exposure was “as‐treated,” ie, until first regimen change. Primary and secondary endpoints were systolic and diastolic BP control and major adverse cardiovascular event (MACE), respectively. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazard models. Results Of 54 523 eligible patients, 3256 (6.0%) were initiated to a two‐drug combination. Of these, 2807 were matched to 5614 monotherapy users. Mean exposure duration was 12.7 months, with 76.5% patients changing their initial regimen. Two‐drug therapy was associated with a clinically significant BP control increase in all hypertensive patients (HR = 1.17 [95%CI: 1.09‐1.26]), more so in patients with grade 2‐3 hypertension (HR = 1.28 [1.17‐1.41]). An increase of 27% in BP control (HR = 1.27 [1.08‐1.49]) was observed in patients initiating an ACEi+CCB combination compared with initiators of either single class. No significant association was found between two‐drug therapy and MACE. Several sensitivity analyses confirmed the main findings. Conclusions Few patients initiated therapy with two drugs, reflecting UK guidelines' recommendation to start with monotherapy. This study supports the greater effectiveness of two‐drug therapy as the initial regimen for BP control.
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Affiliation(s)
- Karine Marinier
- Department of Pharmacoepidemiology and Real World Evidence, Servier, Suresnes, France
| | | | | | - Nicolas Deltour
- Department of Pharmacoepidemiology and Real World Evidence, Servier, Suresnes, France
| | - Neil Poulter
- School of Public Health, Imperial College London, London, UK
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Wartko PD, Weiss NS, Enquobahrie DA, Chan KCG, Stephenson-Famy A, Mueller BA, Dublin S. Antidepressant continuation in pregnancy and risk of gestational diabetes. Pharmacoepidemiol Drug Saf 2019; 28:1194-1203. [PMID: 31298445 DOI: 10.1002/pds.4799] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/30/2019] [Accepted: 04/15/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Previous studies observed modestly higher risk of gestational diabetes (GDM) associated with antidepressant use in pregnancy, potentially due to confounding by indication. We assessed the association of antidepressant continuation in pregnancy with GDM, as well as blood glucose levels, after accounting for confounding. METHODS We conducted a retrospective cohort study of singleton live births from 2001 to 2014 to women enrolled in Kaiser Permanente Washington, an integrated health care delivery system, utilizing electronic health data and linked Washington State birth records. We required that women have ≥1 antidepressant prescription fills ≤6 months before pregnancy. Women with an antidepressant fill during pregnancy were categorized as "continuers" (n = 1634); those without a fill were "discontinuers" (n = 1211). We calculated relative risks (RRs) for GDM and mean differences in screening blood glucose levels using generalized estimating equations with inverse probability of treatment weighting to account for baseline characteristics, including mental health conditions and indicators of mental health severity. RESULTS Compared with discontinuers, antidepressant continuers had comparable risk of GDM (RR: 1.10; 95% confidence interval [CI], 0.84-1.44) and blood glucose levels (mean difference: 2.3 mg/dL; 95% CI, -1.5 to 6.1 mg/dL). We observed generally similar results for specific antidepressants, with the potential exceptions of risk of GDM associated with sertraline (RR: 1.30; 95% CI, 0.90-1.88) and venlafaxine (RR: 1.52; 95% CI, 0.87-2.68), but neither association was statistically significant. CONCLUSIONS Our study suggests that overall, women who continue antidepressants in pregnancy are not at increased risk for GDM or higher blood glucose, although further study may be warranted for sertraline and venlafaxine.
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Affiliation(s)
- Paige D Wartko
- Department of Epidemiology, University of Washington, Seattle, Washington.,Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, Washington
| | | | - K C Gary Chan
- Department of Biostatistics, University of Washington, Seattle, Washington
| | | | - Beth A Mueller
- Department of Epidemiology, University of Washington, Seattle, Washington.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sascha Dublin
- Department of Epidemiology, University of Washington, Seattle, Washington.,Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Shortreed SM, Cook AJ, Coley RY, Bobb JF, Nelson JC. Challenges and Opportunities for Using Big Health Care Data to Advance Medical Science and Public Health. Am J Epidemiol 2019; 188:851-861. [PMID: 30877288 DOI: 10.1093/aje/kwy292] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
Methodological advancements in epidemiology, biostatistics, and data science have strengthened the research world's ability to use data captured from electronic health records (EHRs) to address pressing medical questions, but gaps remain. We describe methods investments that are needed to curate EHR data toward research quality and to integrate complementary data sources when EHR data alone are insufficient for research goals. We highlight new methods and directions for improving the integrity of medical evidence generated from pragmatic trials, observational studies, and predictive modeling. We also discuss needed methods contributions to further ease data sharing across multisite EHR data networks. Throughout, we identify opportunities for training and for bolstering collaboration among subject matter experts, methodologists, practicing clinicians, and health system leaders to help ensure that methods problems are identified and resulting advances are translated into mainstream research practice more quickly.
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Affiliation(s)
- Susan M Shortreed
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Andrea J Cook
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - R Yates Coley
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Jennifer F Bobb
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
| | - Jennifer C Nelson
- Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, Washington
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Assimon MM, Brookhart MA, Flythe JE. Comparative Cardiac Safety of Selective Serotonin Reuptake Inhibitors among Individuals Receiving Maintenance Hemodialysis. J Am Soc Nephrol 2019; 30:611-623. [PMID: 30885935 DOI: 10.1681/asn.2018101032] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/19/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Individuals receiving maintenance hemodialysis may be particularly susceptible to the lethal cardiac consequences of drug-induced QT prolongation because they have a substantial cardiovascular disease burden and high level of polypharmacy, as well as recurrent exposure to electrolyte shifts during dialysis. Electrophysiologic data indicate that among the selective serotonin reuptake inhibitors (SSRIs), citalopram and escitalopram prolong the QT interval to the greatest extent. However, the relative cardiac safety of SSRIs in the hemodialysis population is unknown. METHODS In this retrospective cohort study, we used data from a cohort of Medicare beneficiaries receiving hemodialysis included in the US Renal Data System registry (2007-2014). We used a new-user design to compare the 1-year risk of sudden cardiac death among hemodialysis patients initiating SSRIs with a higher potential for prolonging the QT interval (citalopram, escitalopram) versus the risk among those initiating SSRIs with lower QT-prolonging potential (fluoxetine, fluvoxamine, paroxetine, sertraline). We estimated adjusted hazard ratios using inverse probability of treatment weighted survival models. Nonsudden cardiac death was treated as a competing event. RESULTS The study included 30,932 (47.1%) hemodialysis patients who initiated SSRIs with higher QT-prolonging potential and 34,722 (52.9%) who initiated SSRIs with lower QT-prolonging potential. Initiation of an SSRI with higher versus lower QT-prolonging potential was associated with higher risk of sudden cardiac death (adjusted hazard ratio, 1.18; 95% confidence interval, 1.05 to 1.31). This association was more pronounced among elderly individuals, females, patients with conduction disorders, and those treated with other non-SSRI QT-prolonging medications. CONCLUSIONS The heterogeneous QT-prolonging potential of SSRIs may differentially affect cardiac outcomes in the hemodialysis population.
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Affiliation(s)
- Magdalene M Assimon
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina;
| | - M Alan Brookhart
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Heath, Chapel Hill, North Carolina; and
| | - Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
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Connolly JG, Schneeweiss S, Glynn RJ, Gagne JJ. Quantifying bias reduction with fixed-duration versus all-available covariate assessment periods. Pharmacoepidemiol Drug Saf 2019; 28:665-670. [PMID: 30786103 DOI: 10.1002/pds.4729] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 11/20/2018] [Accepted: 12/10/2018] [Indexed: 11/08/2022]
Abstract
PURPOSE Implementing a cohort study in longitudinal healthcare databases requires looking back over some covariate assessment period (CAP) preceding cohort entry to measure confounders. We used simulations to compare fixed-duration versus all-available CAPs for confounder adjustment in the presence of differences in available baseline time between exposure groups. METHODS We simulated cohorts of 10 000 patients with binary variables for a single confounder, exposure, and outcome. Baseline time was simulated based on the observed distribution in a claims-based comparison of statin users versus nonusers. We compared bias after measuring confounders using fixed-duration and all-available CAPs, both when exposure groups had similar and discrepant amounts of available baseline time. RESULTS When the comparison groups had similar amounts of baseline time, an all-available CAP was less biased than a fixed-duration CAP. When baseline time differed between comparison groups, the preferable CAP approach depended on the direction of confounding and which exposure group had higher covariate sensitivity. These findings were consistent in direction across sensitivity analyses. CONCLUSION In certain settings of differential available baseline time between exposure groups, the all-available CAP was more biased than the fixed-duration CAP. The relative directions and strengths of confounding and misclassification biases are an important consideration when choosing between a fixed-duration or all-available CAP, but they are often unknown. Therefore, we recommend comparing the amount of available baseline time between exposure groups. When there is a large discrepancy, despite appropriate design choices, we recommend a fixed-duration approach to avoid potential increases in bias because of differential data availability.
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Affiliation(s)
- John G Connolly
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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11
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Assimon MM, Brookhart MA, Fine JP, Heiss G, Layton JB, Flythe JE. A Comparative Study of Carvedilol Versus Metoprolol Initiation and 1-Year Mortality Among Individuals Receiving Maintenance Hemodialysis. Am J Kidney Dis 2018; 72:337-348. [PMID: 29653770 PMCID: PMC6477681 DOI: 10.1053/j.ajkd.2018.02.350] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/04/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Carvedilol and metoprolol are the β-blockers most commonly prescribed to US hemodialysis patients, accounting for ∼80% of β-blocker prescriptions. Despite well-established pharmacologic and pharmacokinetic differences between the 2 medications, little is known about their relative safety and efficacy in the hemodialysis population. STUDY DESIGN A retrospective cohort study using a new-user design. SETTING & PARTICIPANTS Medicare-enrolled hemodialysis patients treated at a large US dialysis organization who initiated carvedilol or metoprolol therapy from January 1, 2007, through December 30, 2012. PREDICTOR Carvedilol versus metoprolol initiation. OUTCOMES All-cause mortality, cardiovascular mortality, and intradialytic hypotension (systolic blood pressure decrease ≥ 20mmHg during hemodialysis plus intradialytic saline solution administration) during a 1-year follow-up period. MEASUREMENTS Survival models were used to estimate HRs and 95% CIs in mortality analyses. Poisson regression was used to estimate incidence rate ratios (IRRs) and 95% CIs in intradialytic hypotension analyses. Inverse probability of treatment weighting was used to adjust for several demographic, clinical, laboratory, and dialysis treatment covariates in all analyses. RESULTS 27,064 individuals receiving maintenance hemodialysis were included: 9,558 (35.3%) carvedilol initiators and 17,506 (64.7%) metoprolol initiators. Carvedilol (vs metoprolol) initiation was associated with greater all-cause (adjusted HR, 1.08; 95% CI, 1.02-1.16) and cardiovascular mortality (adjusted HR, 1.18; 95% CI, 1.08-1.29). In subgroup analyses, similar associations were observed among patients with hypertension, atrial fibrillation, heart failure, and a recent myocardial infarction, the main cardiovascular indications for β-blocker therapy. During follow-up, carvedilol (vs metoprolol) initiators had a higher rate of intradialytic hypotension (adjusted IRR, 1.10; 95% CI, 1.09-1.11). LIMITATIONS Residual confounding may exist. CONCLUSIONS Relative to metoprolol initiation, carvedilol initiation was associated with higher 1-year all-cause and cardiovascular mortality. One potential mechanism for these findings may be the increased occurrence of intradialytic hypotension after carvedilol (vs metoprolol) initiation.
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Affiliation(s)
- Magdalene M Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC; Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC.
| | - M Alan Brookhart
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Jason P Fine
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Gerardo Heiss
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - J Bradley Layton
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC; RTI Health Solutions, Research Triangle Park, Chapel Hill, NC
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
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12
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Pedersen AB, Ehrenstein V, Szépligeti SK, Lunde A, Lagerros YT, Westerlund A, Tell GS, Sørensen HT. Thirty-five-year Trends in First-time Hospitalization for Hip Fracture, 1-year Mortality, and the Prognostic Impact of Comorbidity: A Danish Nationwide Cohort Study, 1980-2014. Epidemiology 2018; 28:898-905. [PMID: 28767515 DOI: 10.1097/ede.0000000000000729] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We examined trends in hip fracture incidence in Denmark from 1980 to 2014, trends in subsequent 1-year mortality, and the prognostic impact of sex, age, and comorbidity. METHODS This nationwide cohort study prospectively collected data from population-based Danish registries. We included 262,437 patients with incident hip fracture and assessed comorbidity using the Charlson Comorbidity Index (CCI). RESULTS Despite slight increases in incidence rates (IRs) of hip fracture up to the mid-1990s, the annual IR decreased by 29% from 1980 to 2014 in women but remained stable in men. Decrease affected all age groups. IR decreased in patients without comorbidity but increased with increasing comorbidity (13% in patients with moderate and 510% in patients with very severe comorbidity). Adjusted mortality rate ratios (MRRs) following hip fracture in 2010-2014 compared with 1980-1984 were 0.68 (95% confidence interval [CI] = 0.65, 0.71) within 30 days and 0.63 (95% CI = 0.61, 0.66) within 31-365 days. The mortality decreased up to 40% irrespective of comorbidity. Compared with patients with no comorbidity, those with very severe comorbidity had adjusted MRRs of 2.48 (95% CI = 2.39, 2.56) and 2.81 (95% CI = 2.74, 2.88) within 30 days and 31-365 days post-hip fracture, respectively. CONCLUSIONS Although the incidence rate of hip fracture increased substantially with increasing comorbidity, the following 1-year mortality decreased by 40% from 1980 through 2014 irrespective of sex, age, and comorbidity level, suggesting improvement in both treatment and rehabilitation of patients with hip fracture. Comorbidity burden was, however, a strong prognostic factor for 1-year mortality after hip fracture.
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Affiliation(s)
- Alma B Pedersen
- aDepartment of Clinical Epidemiology, Aarhus University hospital, Aarhus N, Denmark; bDepartment of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; cClinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Solna, Sweden; and dCentre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
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13
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Corraini P, Szépligeti SK, Henderson VW, Ording AG, Horváth-Puhó E, Sørensen HT. Comorbidity and the increased mortality after hospitalization for stroke: a population-based cohort study. J Thromb Haemost 2018; 16:242-252. [PMID: 29171148 DOI: 10.1111/jth.13908] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Indexed: 12/11/2022]
Abstract
Essentials Comorbidity is prevalent in the stroke population and affects post-stroke survival. A stroke patient cohort (n = 201 691) and a general population cohort were followed for survival. Cancer and advanced renal/liver disease substantially increased one-year stroke mortality. Tailoring stroke interventions according to comorbidity may reduce excess mortality. SUMMARY Background Comorbidity is prevalent among stroke patients, affecting post-stroke survival. It remains unknown whether comorbidity impacts post-stroke mortality beyond the combined individual effects of stroke and comorbidity. Methods Using nationwide Danish databases, we performed a cohort study of 201 691 patients ≥ 18 years old with incident ischemic stroke, intracerebral or subarachnoid hemorrhage, or unspecified stroke during 1995-2012, and 992 942 adults from the general population, matched to stroke patients by birth year, sex and individual comorbidities in the Charlson Comorbidity Index. During up to 5 years of follow-up, we computed standardized mortality rates (SMRs) to assess interaction contrasts as a measure of excess mortality not explained by the additive effects of stroke and comorbidity acting alone. Results Five-year post-stroke mortality was 48%, corresponding to an SMR of 187 deaths per 1000 person-years. During the 30-day peak post-stroke mortality (SMR, 180 per 1000 person-months), interaction with comorbidity represented 23%, 34% and 51% of post-stroke mortality rates among patients with low (score = 1), moderate (score = 2-3) and high (score = 4+) comorbidity based on Charlson Comorbidity Index scores. The interaction accounted for 5% to 32% of subsequent 31-365-day post-stroke mortality rates, depending on comorbidity level. The interaction contrasts were most notable among comorbid patients with cancer, particularly with hematological or metastatic disease, followed by patients with moderate-to-severe liver or renal disease. Conclusion Comorbidity, notably cancer and advanced renal or liver disease, increased 1-year mortality after stroke beyond the combined effects expected from either disease acting alone.
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Affiliation(s)
- P Corraini
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - S K Szépligeti
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - V W Henderson
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Departments of Health Research and Policy (Epidemiology) and of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - A G Ording
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - E Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - H T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Departments of Health Research and Policy (Epidemiology) and of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
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14
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Methodological Issues in Nutritional Epidemiology Research—Sorting Through the Confusion. CURRENT CARDIOVASCULAR RISK REPORTS 2018. [DOI: 10.1007/s12170-018-0567-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Jackson JW, Schmid I, Stuart EA. Propensity Scores in Pharmacoepidemiology: Beyond the Horizon. CURR EPIDEMIOL REP 2017; 4:271-280. [PMID: 29456922 DOI: 10.1007/s40471-017-0131-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose of review Propensity score methods have become commonplace in pharmacoepidemiology over the past decade. Their adoption has confronted formidable obstacles that arise from pharmacoepidemiology's reliance on large healthcare databases of considerable heterogeneity and complexity. These include identifying clinically meaningful samples, defining treatment comparisons, and measuring covariates in ways that respect sound epidemiologic study design. Additional complexities involve correctly modeling treatment decisions in the face of variation in healthcare practice, and dealing with missing information and unmeasured confounding. In this review, we examine the application of propensity score methods in pharmacoepidemiology with particular attention to these and other issues, with an eye towards standards of practice, recent methodological advances, and opportunities for future progress. Recent findings Propensity score methods have matured in ways that can advance comparative effectiveness and safety research in pharmacoepidemiology. These include natural extensions for categorical treatments, matching algorithms that can optimize sample size given design constraints, weighting estimators that asymptotically target matched and overlap samples, and the incorporation of machine learning to aid in covariate selection and model building. Summary These recent and encouraging advances should be further evaluated through simulation and empirical studies, but nonetheless represent a bright path ahead for the observational study of treatment benefits and harms.
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Affiliation(s)
- John W Jackson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205.,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Ian Schmid
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
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16
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Czwikla J, Jobski K, Schink T. The impact of the lookback period and definition of confirmatory events on the identification of incident cancer cases in administrative data. BMC Med Res Methodol 2017; 17:122. [PMID: 28806932 PMCID: PMC5556662 DOI: 10.1186/s12874-017-0407-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/06/2017] [Indexed: 11/22/2022] Open
Abstract
Background This cohort study examined the impact of the lengths of lookback and confirmation periods as well as the definition of confirmatory events on the number of incident cancer cases identified and age-standardized cumulative incidences (ACI) estimated in administrative data using German cancer registry data as a benchmark. Methods ACI per 100,000 insured persons for breast, prostate and colorectal cancer were estimated using BARMER Statutory Health Insurance claims data. Incident cancer cases were defined as having an in- or outpatient diagnosis in 2013, no diagnosis in a lookback period of 1 year and a second diagnosis (or death) in a confirmation period of 1 quarter. We varied lookback periods from 1 to 7 years, confirmation periods from 1 to 4 quarters as well as the definition of confirmatory events and compared ACI estimates to cancer registry data. Results ACI were higher for breast (138.7) and prostate (103.6) but lower for colorectal cancer (42.1) when compared to cancer registries (119.3, 98.0 and 45.5, respectively). Extending the lookback period to 7 years reduced ACI to 129.0, 95.1 and 38.3. An extended confirmation period of 4 quarters increased ACI to 151.3, 114.9 and 46.8. Including breast and colorectal surgeries as a confirmatory event reduced ACI to 114.9 and 37.1, respectively. Conclusions The choice of lookback and confirmation periods and the definition of confirmatory events have considerable impact on the number of incident cancer cases identified and ACI estimated. Researchers need to be aware of potential misclassification when identifying incident cancer cases in administrative data. Further validation studies as well as studies using administrative data to estimate cancer incidences should consider several choices of the lookback and confirmation periods and the definition of confirmatory events to show how these parameters impact the validity and robustness of their results. Electronic supplementary material The online version of this article (doi:10.1186/s12874-017-0407-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonas Czwikla
- Department of Health, Long-term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, P.O. Box 33 04 40, 28334, Bremen, Germany. .,High-Profile Area Health Sciences, University of Bremen, P.O. Box 33 04 40, 28334, Bremen, Germany.
| | - Kathrin Jobski
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, P.O. Box 2503, 26111, Oldenburg, Germany
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Drug Safety Unit, Achterstrasse 30, 28359, Bremen, Germany
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17
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Nakasian SS, Rassen JA, Franklin JM. Effects of expanding the look-back period to all available data in the assessment of covariates. Pharmacoepidemiol Drug Saf 2017; 26:890-899. [PMID: 28397352 DOI: 10.1002/pds.4210] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/02/2017] [Accepted: 03/17/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND A fixed baseline period has been a common covariate assessment approach in pharmacoepidemiological studies from claims but may lead to high levels of covariate misclassification. Simulation studies have recommended expanding the look-back approach to all available data (AAD) for binary indicators of diagnoses, procedures, and medications, but there have been few real data analyses using this approach. OBJECTIVE The objective of the study is to explore the impact on treatment effect estimates and covariate prevalence of expanding the look-back period within five validated studies in the Aetion system, a rapid cycle analytics platform. METHODS We reran the five studies and assessed covariates using (i) a fixed window approach (usually 180 days before treatment initiation), (ii) AAD prior to treatment initiation, and (iii) AAD with a categorized by recency approach, where the most recent occurrence of a covariate was labeled as recent (occurring within the fixed window) or past (before the start of the fixed window). For each covariate assessment approach, we adjusted for covariates via propensity score matching. RESULTS All studies had at least one covariate that had an increase in prevalence of 15% or higher from the fixed window to the AAD approach. However, there was little change in treatment effect estimates resulting from differing covariate assessment approaches. For example, in a study of acute coronary syndrome in high-intensity versus low-intensity statin users, the estimated hazard ratio from the fixed window approach was 1.11 (95% confidence interval 0.98, 1.25) versus 1.21 (1.07, 1.37) when using AAD and 1.19 (1.05, 1.35) using categorized by recency. CONCLUSION Expanding the baseline period to AAD improved covariate sensitivity by capturing data that would otherwise be missed yet did not meaningfully change the overall treatment effect estimates compared with the fixed window approach. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Sonja S Nakasian
- Division of Pharmacoepidemiology & Pharmacoeconomics, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA.,Aetion, Inc., New York, NY, USA.,Ludwig-Maximilians University of Munich, Munich, Germany
| | | | - Jessica M Franklin
- Division of Pharmacoepidemiology & Pharmacoeconomics, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
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Chertow GM, Liu J, Monda KL, Gilbertson DT, Brookhart MA, Beaubrun AC, Winkelmayer WC, Pollock A, Herzog CA, Ashfaq A, Sturmer T, Rothman KJ, Bradbury BD, Collins AJ. Epoetin Alfa and Outcomes in Dialysis amid Regulatory and Payment Reform. J Am Soc Nephrol 2016; 27:3129-3138. [PMID: 26917691 PMCID: PMC5042674 DOI: 10.1681/asn.2015111232] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 01/10/2016] [Indexed: 12/13/2022] Open
Abstract
Erythropoiesis-stimulating agents (ESAs) are commonly used to treat anemia in patients with CKD, including those receiving dialysis, although clinical trials have identified risks associated with ESA use. We evaluated the effects of changes in dialysis payment policies and product labeling instituted in 2011 on mortality and major cardiovascular events across the United States dialysis population in an open cohort study of patients on dialysis from January 1, 2005, through December 31, 2012, with Medicare as primary payer. We compared observed rates of death and major cardiovascular events in 2011 and 2012 with expected rates calculated on the basis of rates in 2005-2010, accounting for differences in patient characteristics and influenza virulence. An abrupt decline in erythropoietin dosing and hemoglobin concentration began in late 2010. Observed rates of all-cause mortality, cardiovascular mortality, and myocardial infarction in 2011 and 2012 were consistent with expected rates. During 2012, observed rates of stroke, venous thromboembolic disease (VTE), and heart failure were lower than expected (absolute deviation from trend per 100 patient-years [95% confidence interval]: -0.24 [-0.08 to -0.37] for stroke, -2.43 [-1.35 to -3.70] for VTE, and -0.77 [-0.28 to -1.27] for heart failure), although non-ESA-related changes in practice and Medicare payment penalties for rehospitalization may have confounded the results. This initial evidence suggests that action taken to mitigate risks associated with ESA use and changes in payment policy did not result in a relative increase in death or major cardiovascular events and may reflect improvements in stroke, VTE, and heart failure.
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Affiliation(s)
- Glenn M Chertow
- Stanford University School of Medicine, Palo Alto, California;
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | | | - David T Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - M Alan Brookhart
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | | | - Wolfgang C Winkelmayer
- Stanford University School of Medicine, Palo Alto, California; Baylor College of Medicine, Houston, Texas
| | - Allan Pollock
- Clinical Development, Amgen, Inc., Thousand Oak, California
| | - Charles A Herzog
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; University of Minnesota School of Medicine, Minneapolis, Minnesota; and
| | - Akhtar Ashfaq
- Clinical Development, Amgen, Inc., Thousand Oak, California
| | - Til Sturmer
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | | | | | - Allan J Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; University of Minnesota School of Medicine, Minneapolis, Minnesota; and
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