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Xu S, Narwaney KJ, Nguyen AP, Binswanger IA, McClure DL, Glanz JM. An individual segmented trajectory approach for identifying opioid use patterns using longitudinal dispensing data. Pharmacoepidemiol Drug Saf 2024; 33:e5708. [PMID: 37814576 PMCID: PMC10841826 DOI: 10.1002/pds.5708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE The aim of this study is to use electronic opioid dispensing data to develop an individual segmented trajectory approach for identifying opioid use patterns. The resulting opioid use patterns can be used for examining the association between opioid use and drug overdose. METHODS We retrospectively assembled a cohort of members on long-term opioid therapy (LTOT) between January 1, 2006 and June 30, 2019 who were 18 years and older and enrolled in one of three health care systems in the US. We have developed an individual segmented trajectory analysis for identifying various opioid use patterns by scanning over the follow-up and finding distinct opioid use patterns based on variability measured with coefficient of variation and trends of milligram morphine equivalents levels. RESULTS Among 31, 865 members who were on LTOT between January 1, 2006 and June 30, 2019, 58.3% were female, and the average age was 55.4 years (STD = 15.4). The study population had 152 557 person-years of follow-up, with an average follow-up of 4.4 years per enrollment per person (STD = 3.4). This novel approach identified up to 13 distinct patterns including 88 756 episodes of "stable" pattern (42.1%) with an average follow-up of 11.2 months, 29 140 episodes of "increasing" pattern (13.8%) with an average follow-up of 6.0 months, 13 201 episodes of ≤10% dose reduction (6.3%) with an average follow-up of 10.4 months, 7286 episodes of 11%-20% dose reduction (3.5%) with an average follow-up of 5.3 months, 4457 episodes of 21%-30% dose reduction (2.1%) with an average follow-up of 4.0 months, and 9903 episodes of >30% dose reduction (4.7%) with an average follow-up of 2.6 months. CONCLUSIONS A novel approach was developed to identify 13 distinct opioid use patterns using each individual's longitudinal dispensing data and these patterns can be used in examining overdose risk during the time that these patterns are ongoing.
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Affiliation(s)
- Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Ingrid A Binswanger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora, Colorado, USA
| | - David L McClure
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
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Glanz JM, Xu S, Narwaney KJ, McClure DL, Rinehart DJ, Ford MA, Nguyen AP, Binswanger IA. Association Between Opioid Dose Reduction Rates and Overdose Among Patients Prescribed Long-Term Opioid Therapy. Subst Abus 2023; 44:209-219. [PMID: 37702046 DOI: 10.1177/08897077231186216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Tapering long-term opioid therapy is an increasingly common practice, yet rapid opioid dose reductions may increase the risk of overdose. The objective of this study was to compare overdose risk following opioid dose reduction rates of ≤10%, 11% to 20%, 21% to 30%, and >30% per month to stable dosing. METHODS We conducted a retrospective cohort study in three health systems in Colorado and Wisconsin. Participants were patients ≥18 years of age prescribed long-term opioid therapy between January 1, 2006, and June 30, 2019. Five opioid dosing patterns and drug overdoses (fatal and nonfatal) were identified using electronic health records, pharmacy records, and the National Death Index. Cox proportional hazard regression was conducted on a propensity score-weighted cohort to estimate adjusted hazard ratios (aHRs) for follow-up periods of 1, 3, 6, 9, and 12 months after a dose reduction. RESULTS In a cohort of 17 540 patients receiving long-term opioid therapy, 42.7% of patients experienced a dose reduction. Relative to stable dosing, a dose reduction rate of >30% was associated with an increased risk of overdose and the aHR estimates decreased as the follow-up increased; the aHRs for the 1-, 6- and 12-month follow-ups were 5.33 (95% CI, 1.98-14.34), 1.81 (95% CI,1.08-3.03), and 1.49 (95% CI, 0.97-2.27), respectively. The slower tapering rates were not associated with overdose risk. CONCLUSIONS Patients receiving long-term opioid therapy exposed to dose reduction rates of >30% per month had increased overdose risk relative to patients exposed to stable dosing. Results support the use of slow dose reductions to minimize the risk of overdose.
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Affiliation(s)
- Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - David L McClure
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Deborah J Rinehart
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Morgan A Ford
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora, CO, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Xu S, Clarke CL, Newcomer SR, Daley MF, Glanz JM. Analyzing self-controlled case series data when case confirmation rates are estimated from an internal validation sample. Biom J 2018; 60:748-760. [PMID: 29768667 DOI: 10.1002/bimj.201700088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 01/10/2023]
Abstract
Vaccine safety studies are often electronic health record (EHR)-based observational studies. These studies often face significant methodological challenges, including confounding and misclassification of adverse event. Vaccine safety researchers use self-controlled case series (SCCS) study design to handle confounding effect and employ medical chart review to ascertain cases that are identified using EHR data. However, for common adverse events, limited resources often make it impossible to adjudicate all adverse events observed in electronic data. In this paper, we considered four approaches for analyzing SCCS data with confirmation rates estimated from an internal validation sample: (1) observed cases, (2) confirmed cases only, (3) known confirmation rate, and (4) multiple imputation (MI). We conducted a simulation study to evaluate these four approaches using type I error rates, percent bias, and empirical power. Our simulation results suggest that when misclassification of adverse events is present, approaches such as observed cases, confirmed case only, and known confirmation rate may inflate the type I error, yield biased point estimates, and affect statistical power. The multiple imputation approach considers the uncertainty of estimated confirmation rates from an internal validation sample, yields a proper type I error rate, largely unbiased point estimate, proper variance estimate, and statistical power.
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Affiliation(s)
- Stanley Xu
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA.,School of Public Health, University of Colorado, Aurora, CO, 80045, USA
| | - Christina L Clarke
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA
| | - Sophia R Newcomer
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA.,School of Public Health, University of Colorado, Aurora, CO, 80045, USA
| | - Matthew F Daley
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Jason M Glanz
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA.,School of Public Health, University of Colorado, Aurora, CO, 80045, USA
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Campos LF, Şentürk D, Chen Y, Nguyen DV. Bias and estimation under misspecification of the risk period in self-controlled case series studies. Stat (Int Stat Inst) 2017; 6:373-389. [PMID: 30473787 DOI: 10.1002/sta4.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The self-controlled case series (SCCS) method is useful for estimating the relative incidence (RI) of acute events, such as adverse events (AEs) during a specified risk period following an exposure (e.g., 6-week period after vaccinations or 30-day period after infection-related hospitalizations). In practice, the "optimal" risk period is unknown and must be specified. To date, two approaches are available to guide the specification of the risk period. Both methods do not fully utilize the nature of the bias due to misspecification, which to date has not been characterized. Thus, we elucidate the bias of SCCS estimate of the RI when the risk period is misspecified. We then propose a novel method that more effectively estimates the optimal risk period and the associated RI of AEs. The new method incorporates information on the functional form of the bias. Efficacy of the proposed approach is illustrated with substantial reduction in bias and variance in simulation studies. The proposed method is illustrated with two SCCS studies to determine the (1) risk of idiopathic thrombocytopenic purpura after measles-mumps-rubella vaccination in children and (2) risk of cardiovascular events after infection-related hospitalizations in older patients on dialysis.
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Affiliation(s)
| | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, CA 90095, USA
| | - Yanjun Chen
- Institute for Clinical and Translational Science, Irvine, CA 92617, USA
| | - Danh V Nguyen
- Department of Medicine, University of California Irvine, Orange, CA 92868, USA
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Nelson JC, Shortreed SM, Yu O, Peterson D, Baxter R, Fireman B, Lewis N, McClure D, Weintraub E, Xu S, Jackson LA. Integrating database knowledge and epidemiological design to improve the implementation of data mining methods that evaluate vaccine safety in large healthcare databases. Stat Anal Data Min 2014. [DOI: 10.1002/sam.11232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jennifer C. Nelson
- Biostatistics Unit, Group Health Research Institute; Seattle WA 98101 USA
- Department of Biostatistics; University of Washington; Seattle WA 98195 USA
| | - Susan M. Shortreed
- Biostatistics Unit, Group Health Research Institute; Seattle WA 98101 USA
- Department of Biostatistics; University of Washington; Seattle WA 98195 USA
| | - Onchee Yu
- Biostatistics Unit, Group Health Research Institute; Seattle WA 98101 USA
| | - Do Peterson
- Biostatistics Unit, Group Health Research Institute; Seattle WA 98101 USA
| | - Roger Baxter
- Vaccine Study Center and Division of Research, Northern California Kaiser Permanente; Oakland CA 94612 USA
| | - Bruce Fireman
- Vaccine Study Center and Division of Research, Northern California Kaiser Permanente; Oakland CA 94612 USA
| | - Ned Lewis
- Vaccine Study Center and Division of Research, Northern California Kaiser Permanente; Oakland CA 94612 USA
| | - Dave McClure
- Epidemiology Research Center, Marshfield Clinic Research Foundation; Marshfield WI 54449 USA
| | - Eric Weintraub
- Centers for Disease Control and Prevention; Atlanta GA 30333 USA
| | - Stan Xu
- Kaiser Permanente Institute for Health Research; Denver CO 80231 USA
| | - Lisa A. Jackson
- Biostatistics Unit, Group Health Research Institute; Seattle WA 98101 USA
- Department of Epidemiology; University of Washington; Seattle WA 98195 USA
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Daley MF, Yih WK, Glanz JM, Hambidge SJ, Narwaney KJ, Yin R, Li L, Nelson JC, Nordin JD, Klein NP, Jacobsen SJ, Weintraub E. Safety of diphtheria, tetanus, acellular pertussis and inactivated poliovirus (DTaP-IPV) vaccine. Vaccine 2014; 32:3019-24. [PMID: 24699471 DOI: 10.1016/j.vaccine.2014.03.063] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/14/2014] [Accepted: 03/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND In 2008, a diphtheria, tetanus, acellular pertussis, and inactivated poliovirus combined vaccine (DTaP-IPV) was licensed for use in children 4 through 6 years of age. While pre-licensure studies did not demonstrate significant safety concerns, the number vaccinated in these studies was not sufficient to examine the risk of uncommon but serious adverse events. OBJECTIVE To assess the risk of serious adverse events following DTaP-IPV vaccination. METHODS The study was conducted from January 2009 through September 2012 in the Vaccine Safety Datalink (VSD) project. In the VSD, electronic vaccination and encounter data are updated and aggregated weekly as part of ongoing surveillance activities. Based on previous reports and biologic plausibility, eight potential adverse events were monitored: meningitis/encephalitis; seizures; stroke; Guillain-Barré syndrome; Stevens-Johnson syndrome; anaphylaxis; serious allergic reactions other than anaphylaxis; and serious local reactions. Adverse event rates in DTaP-IPV recipients were compared to historical incidence rates in the VSD population prior to 2009. Sequential probability ratio testing was used to analyze the data on a weekly basis. RESULTS During the study period, 201,116 children received DTaP-IPV vaccine. Ninety-seven percent of DTaP-IPV recipients also received other vaccines on the same day, typically measles-mumps-rubella and varicella vaccines. There was no statistically significant increased risk of any of the eight pre-specified adverse events among DTaP-IPV recipients when compared to historical incidence rates. CONCLUSIONS In this safety surveillance study of more than 200,000 DTaP-IPV vaccine recipients, there was no evidence of increased risk for any of the pre-specified adverse events monitored. Continued surveillance of DTaP-IPV vaccine safety may be warranted to monitor for rare adverse events, such as Guillain-Barré syndrome.
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Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Avenue, Denver, CO 80231, United States; Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 065, Aurora, CO 80045, United States.
| | - W Katherine Yih
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215, United States.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Avenue, Denver, CO 80231, United States.
| | - Simon J Hambidge
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Avenue, Denver, CO 80231, United States; Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 065, Aurora, CO 80045, United States; Community Health Services, Denver Health, 777 Bannock Street, Denver, CO 80204, United States.
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Avenue, Denver, CO 80231, United States.
| | - Ruihua Yin
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215, United States.
| | - Lingling Li
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA 02215, United States.
| | - Jennifer C Nelson
- Biostatistics Unit, Group Health Research Institute, 1730 Minor Ave #1600, Seattle, WA 98101, United States; Department of Biostatistics, University of Washington, 5th Floor, 1107 NE 45th St., Seattle, 98105, United States.
| | - James D Nordin
- HealthPartners Institute for Education and Research, Mail stop 21111R, PO Box 1524, Minneapolis, MN 55440-1524, United States.
| | - Nicola P Klein
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, United States.
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, 2nd Floor, Pasadena, CA 91101, United States.
| | - Eric Weintraub
- Immunization Safety Office, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333, United States.
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