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Iki M, Fujimori K, Nakatoh S, Tamaki J, Ishii S, Okimoto N, Imano H, Ogawa S. Average daily glucocorticoid dose, number of prescription days, and cumulative dose in the initial 90 days of glucocorticoid therapy are associated with subsequent hip and clinical vertebral fracture risk: a retrospective cohort study using a nationwide health insurance claims database in Japan. Osteoporos Int 2024; 35:805-818. [PMID: 38267664 DOI: 10.1007/s00198-024-07023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE Fracture risk assessment is recommended at three months after glucocorticoid (GC) therapy initiation. This study aimed to assess whether GC exposure in the initial 90 days of GC therapy is associated with subsequent hip and clinical vertebral fracture risk using the nationwide health insurance claims database of Japan (NDBJ). METHODS Patients aged ≥ 50 years who were prescribed GC (≥ 70 mg prednisolone or equivalent; PSL) in the initial 90 days of GC therapy and were followed for hip and clinical vertebral fracture incidences for the subsequent 1080 days were selected from NDBJ. Associations of GC exposure with hip or clinical vertebral fracture risk were evaluated by Cox regression analysis adjusted for potential confounders. RESULTS We selected 316,396 women and 299,871 men for the GC-exposed group and 43,164 women and 33,702 men for the reference group. Higher GC doses and longer prescription days in the initial 90 days of GC therapy were significantly and dose-dependently associated with increased fracture risk relative to the reference group. Patients receiving GC ≥ 5 mg PSL/day had a significantly increased fracture risk in the stratum of 30-59 days of GC prescription. In addition, female patients who received GC (≥ 1 and < 2.5 mg PSL/day) for 90 days in the initial 90 days of GC therapy had a significantly increased fracture risk. CONCLUSIONS GC exposure in the initial 90 days of GC therapy was dose-dependently associated with hip and clinical vertebral fracture risk. GC may increase fracture risk with lower doses for shorter durations than previously reported. Fracture risk assessment three months after glucocorticoid (GC) therapy initiation is recommended. We found that GC exposure in the initial 90 days of GC therapy at lower daily doses for shorter durations than previously reported were significantly and dose-dependently associated with fracture risk using a nationwide health insurance claims database.
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Affiliation(s)
- Masayuki Iki
- Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
| | - Kenji Fujimori
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
- Department of Health Administration and Policy, Tohoku University School of Medicine, 2-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8575, Japan
| | - Shinichi Nakatoh
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
- Department of Orthopedic Surgery, Asahi General Hospital, 477 Tomari, Asahimachi, Shimo-Nikawa-Gun, Toyama, 939-0798, Japan
| | - Junko Tamaki
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - Shigeyuki Ishii
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
- Department of Regulatory Science, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachiouji, Tokyo, 193-0392, Japan
| | - Nobukazu Okimoto
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
- Okimoto Clinic, 185-4 Kubi, Yutaka-Machi, Kure, Hiroshima, 734-0304, Japan
| | - Hironori Imano
- Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Sumito Ogawa
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
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Dave CV, Li Y, Steinman MA, Lee SJ, Liu X, Jing B, Graham LA, Marcum ZA, Fung KZ, Odden MC. Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents. JAMA Intern Med 2024:2818019. [PMID: 38648065 PMCID: PMC11036308 DOI: 10.1001/jamainternmed.2024.0507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/28/2023] [Indexed: 04/25/2024]
Abstract
Importance Limited evidence exists on the association between initiation of antihypertensive medication and risk of fractures in older long-term nursing home residents. Objective To assess the association between antihypertensive medication initiation and risk of fracture. Design, Setting, and Participants This was a retrospective cohort study using target trial emulation for data derived from 29 648 older long-term care nursing home residents in the Veterans Health Administration (VA) from January 1, 2006, to October 31, 2019. Data were analyzed from December 1, 2021, to November 11, 2023. Exposure Episodes of antihypertensive medication initiation were identified, and eligible initiation episodes were matched with comparable controls who did not initiate therapy. Main Outcome and Measures The primary outcome was nontraumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation. Results were computed among subgroups of residents with dementia, across systolic and diastolic blood pressure thresholds of 140 and 80 mm Hg, respectively, and with use of prior antihypertensive therapies. Analyses were adjusted for more than 50 baseline covariates using 1:4 propensity score matching. Results Data from 29 648 individuals were included in this study (mean [SD] age, 78.0 [8.4] years; 28 952 [97.7%] male). In the propensity score-matched cohort of 64 710 residents (mean [SD] age, 77.9 [8.5] years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensive medication was 5.4 compared with 2.2 in the control arm. This finding corresponded to an adjusted hazard ratio (HR) of 2.42 (95% CI, 1.43-4.08) and an adjusted excess risk per 100 person-years of 3.12 (95% CI, 0.95-6.78). Antihypertensive medication initiation was also associated with higher risk of severe falls requiring hospitalizations or emergency department visits (HR, 1.80 [95% CI, 1.53-2.13]) and syncope (HR, 1.69 [95% CI, 1.30-2.19]). The magnitude of fracture risk was numerically higher among subgroups of residents with dementia (HR, 3.28 [95% CI, 1.76-6.10]), systolic blood pressure of 140 mm Hg or higher (HR, 3.12 [95% CI, 1.71-5.69]), diastolic blood pressure of 80 mm Hg or higher (HR, 4.41 [95% CI, 1.67-11.68]), and no recent antihypertensive medication use (HR, 4.77 [95% CI, 1.49-15.32]). Conclusions and Relevance Findings indicated that initiation of antihypertensive medication was associated with elevated risks of fractures and falls. These risks were numerically higher among residents with dementia, higher baseline blood pressures values, and no recent antihypertensive medication use. Caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.
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Affiliation(s)
- Chintan V. Dave
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey
- Department of Veterans Affairs-New Jersey Health Care System, East Orange
| | - Yongmei Li
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California
| | - Sei J. Lee
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California
| | - Xiaojuan Liu
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California
| | - Bocheng Jing
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California
| | - Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California
| | | | - Kathy Z. Fung
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California
| | - Michelle C. Odden
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California
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Wang W, Liu M, He Q, Wang M, Xu J, Li L, Li G, He L, Zou K, Sun X. Validation and impact of algorithms for identifying variables in observational studies of routinely collected data. J Clin Epidemiol 2024; 166:111232. [PMID: 38043830 DOI: 10.1016/j.jclinepi.2023.111232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Among observational studies of routinely collected health data (RCD) for exploring treatment effects, algorithms are used to identify study variables. However, the extent to which algorithms are reliable and impact the credibility of effect estimates is far from clear. This study aimed to investigate the validation of algorithms for identifying study variables from RCD, and examine the impact of alternative algorithms on treatment effects. METHODS We searched PubMed for observational studies published in 2018 that used RCD to explore drug treatment effects. Information regarding the reporting, validation, and interpretation of algorithms was extracted. We summarized the reporting and methodological characteristics of algorithms and validation. We also assessed the divergence in effect estimates given alternative algorithms by calculating the ratio of estimates of the primary vs. alternative analyses. RESULTS A total of 222 studies were included, of which 93 (41.9%) provided a complete list of algorithms for identifying participants, 36 (16.2%) for exposure, and 132 (59.5%) for outcomes, and 15 (6.8%) for all study variables including population, exposure, and outcomes. Fifty-nine (26.6%) studies stated that the algorithms were validated, and 54 (24.3%) studies reported methodological characteristics of 66 validations, among which 61 validations in 49 studies were from the cross-referenced validation studies. Of those 66 validations, 22 (33.3%) reported sensitivity and 16 (24.2%) reported specificity. A total of 63.6% of studies reporting sensitivity and 56.3% reporting specificity used test-result-based sampling, an approach that potentially biases effect estimates. Twenty-eight (12.6%) studies used alternative algorithms to identify study variables, and 24 reported the effects estimated by primary analyses and sensitivity analyses. Of these, 20% had differential effect estimates when using alternative algorithms for identifying population, 18.2% for identifying exposure, and 45.5% for classifying outcomes. Only 32 (14.4%) studies discussed how the algorithms may affect treatment estimates. CONCLUSION In observational studies of RCD, the algorithms for variable identification were not regularly validated, and-even if validated-the methodological approach and performance of the validation were often poor. More seriously, different algorithms may yield differential treatment effects, but their impact is often ignored by researchers. Strong efforts, including recommendations, are warranted to improve good practice.
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Affiliation(s)
- Wen Wang
- Institute of Integrated Traditional Chinese and Western Medicine, Chinese Evidence-based Medicine and Cochrane China Center, West China Hospital, Sichuan University, Chengdu 610041, China; NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China; Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China.
| | - Mei Liu
- Institute of Integrated Traditional Chinese and Western Medicine, Chinese Evidence-based Medicine and Cochrane China Center, West China Hospital, Sichuan University, Chengdu 610041, China; NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China; Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Qiao He
- Institute of Integrated Traditional Chinese and Western Medicine, Chinese Evidence-based Medicine and Cochrane China Center, West China Hospital, Sichuan University, Chengdu 610041, China; NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China; Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Mingqi Wang
- Institute of Integrated Traditional Chinese and Western Medicine, Chinese Evidence-based Medicine and Cochrane China Center, West China Hospital, Sichuan University, Chengdu 610041, China; NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China; Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Jiayue Xu
- Institute of Integrated Traditional Chinese and Western Medicine, Chinese Evidence-based Medicine and Cochrane China Center, West China Hospital, Sichuan University, Chengdu 610041, China; NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China; Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Ling Li
- Institute of Integrated Traditional Chinese and Western Medicine, Chinese Evidence-based Medicine and Cochrane China Center, West China Hospital, Sichuan University, Chengdu 610041, China; NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China; Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Guowei Li
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario L8S 4L8, Canada; Center for Clinical Epidemiology and Methodology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong 510317, China; Biostatistics Unit, Research Institute at St. Joseph's Healthcare Hamilton, Hamilton, Ontario L8N 4A6, Canada
| | - Lin He
- Intelligence Library Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Kang Zou
- Institute of Integrated Traditional Chinese and Western Medicine, Chinese Evidence-based Medicine and Cochrane China Center, West China Hospital, Sichuan University, Chengdu 610041, China; NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China; Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Xin Sun
- Institute of Integrated Traditional Chinese and Western Medicine, Chinese Evidence-based Medicine and Cochrane China Center, West China Hospital, Sichuan University, Chengdu 610041, China; NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China; Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China.
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Fu SH, Yu PY, Li CY, Hung CC, Lee CC, Chen HY, Tai TW, Hwang JS, Yang RS, Chiang H, Lin SY, Wu CH, Liao LC, Chuang CJ, Wu CY, Chang CY, Lee MT, Chen CH, Wang CY. Diagnostic accuracy of algorithms to define incident and second hip fractures: A Taiwan validation study. J Formos Med Assoc 2023; 122 Suppl 1:S82-S91. [PMID: 37353444 DOI: 10.1016/j.jfma.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/31/2023] [Accepted: 05/29/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Previous epidemiological researchers have used various algorithms to identify a second hip fracture; however, there has been no validation of these algorithms to date. This study aimed to verify existing algorithms for identifying second hip fracture under the International Classification of Diseases diagnostic coding systems. Furthermore, we examined the validity of two newly proposed algorithms that integrated the concept of periprosthetic fractures and laterality of the ICD-10 coding system. METHODS Claims data of patients hospitalized for hip fracture from National Taiwan University Hospitals between 2007 and 2020 were retrieved. Hip fracture was confirmed by 2 orthopaedic surgeons with medical records and imaging data as gold standards. The validity of 9 existing and 2 newly proposed algorithms for identifying second hip fracture was evaluated. RESULTS The positive predictive value (PPV) range between 84% and 90% in existing algorithms for identifying second hip fractures. Noteworthy, the longer time interval for discrimination resulted in slightly increased PPV (from 87% to 90%), while decreased sensitivity noticeably (from 87% to 72%). When considering the information about periprosthetic fracture, the PPV increased to 91% without diminished sensitivity. The PPV of the newly proposed ICD-10-specific algorithm was 100%. CONCLUSION Algorithms integrated clinical insights of periprosthetic fractures and laterality concept of ICD-10 coding system provided satisfactory validity and help precisely define second hip fracture in future database research.
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Affiliation(s)
- Shau-Huai Fu
- Department of Orthopedics, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ping-Ying Yu
- Department of General Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Chih-Chien Hung
- Department of Orthopedics, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chia-Che Lee
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Hsuan-Yu Chen
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ta-Wei Tai
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Biocompatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jawl-Shan Hwang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Rong-Sen Yang
- Department of Orthopedics, National Taiwan University Hospital, Taipei, Taiwan
| | - Hongsen Chiang
- Department of Orthopedics, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Yen Lin
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chih-Hsing Wu
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ling-Chiao Liao
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chin-Ju Chuang
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Chiu-Yi Wu
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Cheng-Ying Chang
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Ming-Tsung Lee
- National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin County, Taiwan; Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Chung-Hwan Chen
- Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Orthopaedic Research Center and Department of Orthopedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Chen-Yu Wang
- Department of Pharmacy, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan; National Center for Geriatrics and Welfare Research, National Health Research Institutes, Yunlin County, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Fu EL, D'Andrea E, Wexler DJ, Patorno E, Paik JM. Safety of Sodium-Glucose Cotransporter-2 Inhibitors in Patients with CKD and Type 2 Diabetes: Population-Based US Cohort Study. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00094. [PMID: 36827225 PMCID: PMC10278835 DOI: 10.2215/cjn.0000000000000115] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/14/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Limited information exists regarding the safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with CKD treated in routine care. We evaluated the safety of SGLT2i in patients with CKD and type 2 diabetes treated in US routine practice. METHODS Using claims data from Medicare and two large US commercial databases (April 2013-December 2021), we included 96,128 adults with CKD stages 3-4 and type 2 diabetes who newly filled prescriptions for SGLT2i versus glucagon-like peptide-1 receptor agonists (GLP-1RA). Safety outcomes included diabetic ketoacidosis (DKA), lower limb amputations, nonvertebral fractures, genital infections, hypovolemia, AKI, hypoglycemia, and severe urinary tract infections (UTIs). Hazard ratios (HRs) and incidence rate differences per 1000 person-years were estimated after 1:1 propensity score matching, adjusted for >120 baseline characteristics. RESULTS Compared with GLP-1RA, SGLT2i initiators had a higher risk of nonvertebral fractures (HR, 1.30; 95% confidence interval [CI], 1.03 to 1.65]; incidence rate difference, 2.13 [95% CI, 0.28 to 3.97]), lower limb amputations (HR, 1.65 [95% CI, 1.22 to 2.23]; incidence rate difference, 2.46 [95% CI, 1.00 to 3.92]), and genital infections (HR, 3.08 [95% CI, 2.73 to 3.48]; incidence rate difference, 41.26 [95% CI, 37.06 to 45.46]). Similar risks of DKA (HR, 1.07 [95% CI, 0.74 to 1.54]; incidence rate difference, 0.29 [95% CI, -0.89 to 1.46]), hypovolemia (HR, 0.99 [95% CI, 0.86 to 1.14]; incidence rate difference, 0.20 [95% CI, -2.85 to 3.25]), hypoglycemia (HR, 1.08 [95% CI, 0.92 to 1.26]; incidence rate difference, 1.46 [95% CI, -1.31 to 4.23]), and severe UTI (HR, 1.02 [95% CI, 0.87 to 1.19]; incidence rate difference, 0.35 [95% CI, -2.51 to 3.21]) were observed. SGLT2i had lower risk for AKI (HR, 0.93 [95% CI, 0.87 to 0.99]; incidence rate difference, -6.75 [95% CI, -13.69 to 0.20]). CONCLUSIONS In US patients with CKD and type 2 diabetes receiving routine care, SGLT2i use was associated with higher risks of genital infections and potentially lower limb amputations and nonvertebral fractures.
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Affiliation(s)
- Edouard L. Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elvira D'Andrea
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Deborah J. Wexler
- Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Julie M. Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
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Iki M, Fujimori K, Nakatoh S, Tamaki J, Ishii S, Okimoto N, Kamiya K, Ogawa S. Real-world effectiveness of anti-osteoporosis medications for the prevention of incident hip and clinical vertebral fractures in patients on long-term glucocorticoid therapy: A nationwide health insurance claims database study in Japan. Bone 2023; 166:116605. [PMID: 36347433 DOI: 10.1016/j.bone.2022.116605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Early initiation of anti-osteoporosis medications (AOMs) is recommended for patients on long-term glucocorticoid (GC) therapy. This study aimed to clarify the real-world effectiveness of AOMs against incident hip and vertebral fractures in patients undergoing GC therapy using the nationwide health insurance claims database of Japan (NDBJ). METHODS Patients aged ≥50 years who were prescribed GC (≥5 mg/day prednisolone or equivalent) for ≥90 days and who were followed up regarding AOM prescription and hip and clinical vertebral fracture incidences for the subsequent 1080 days between 2012 and 2018 were selected from NDBJ. Associations of AOMs prescribed within 90 days since GC therapy initiation with hip or vertebral fracture risk were evaluated by Cox proportional hazards regression using propensity score inverse probability weighting (IPW) for receiving any AOM or individual AOMs. RESULTS In total, 96,475 women and 98,385 men were included in the analysis; 38.0 % of women and 27.6 % of men received AOMs. Patients who received any AOM and those who received bisphosphonates or denosumab had a significantly lower risk of hip and clinical vertebral fractures than those who received no AOM in both sexes after propensity score IPW. Teriparatide was associated with an increased risk of both fractures in women and an increased risk of clinical vertebral fractures in men. Selection biases such as confounding by indication might have caused an underestimation of AOMs' protective effects. CONCLUSIONS Bisphosphonates and denosumab were associated with a lower fracture incidence in patients on long-term GC therapy in real-world settings.
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Affiliation(s)
- Masayuki Iki
- Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan.
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Shinichi Nakatoh
- Department of Orthopedic Surgery, Asahi General Hospital, 477 Tomari, Asahimachi, Shimo-Nikawa-gun, Toyama 939-0798, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Junko Tamaki
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Shigeyuki Ishii
- Department of Regulatory Science, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachiouji, Tokyo 193-0392, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Nobukazu Okimoto
- Okimoto Clinic, 185-4 Kubi, Yutaka-machi, Kure, Hiroshima 734-0304, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Kuniyasu Kamiya
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Sumito Ogawa
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8511, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
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7
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Validation of Operational Definition to Identify Patients with Osteoporotic Hip Fractures in Administrative Claims Data. Healthcare (Basel) 2022; 10:healthcare10091724. [PMID: 36141336 PMCID: PMC9498336 DOI: 10.3390/healthcare10091724] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 08/31/2022] [Indexed: 11/18/2022] Open
Abstract
As incidences of osteoporotic hip fractures (OHFs) have increased, identifying OHFs has become important to establishing the medical guidelines for their management. This study was conducted to develop an operational definition to identify patients with OHFs using two diagnosis codes and eight procedure codes from health insurance claims data and to assess the operational definition’s validity through a chart review. The study extracted data on OHFs from 522 patients who underwent hip surgeries based on diagnosis codes. Orthopedic surgeons then reviewed these patients’ medical records and radiographs to identify those with true OHFs. The validities of nine different algorithms of operational definitions, developed using a combination of three levels of diagnosis codes and eight procedure codes, were assessed using various statistics. The developed operational definition showed an accuracy above 0.97 and an area under the receiver operating characteristic curve above 0.97, indicating excellent discriminative power. This study demonstrated that the operational definition that combines diagnosis and procedure codes shows a high validity in detecting OHFs and can be used as a valid tool to detect OHFs from big health claims data.
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8
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Meyer AC, Ebeling M, Drefahl S, Hedström M, Ek S, Sandström G, Modig K. The Impact of Hip Fracture on Geriatric Care and Mortality Among Older Swedes: Mapping Care Trajectories and Their Determinants. Am J Epidemiol 2022; 192:41-50. [PMID: 35968686 PMCID: PMC9825727 DOI: 10.1093/aje/kwac149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 06/16/2022] [Accepted: 08/10/2022] [Indexed: 01/12/2023] Open
Abstract
In this study, we examined the impact of hip fractures on trajectories of home care, nursing home residence, and mortality among individuals aged 65 years or more and explored the impacts of living arrangements, cohabitation, frailty, and socioeconomic position on these trajectories. Based on a linkage of nationwide Swedish population registers, our study included 20,573 individuals with first hip fracture in 2014-2015. Care trajectories during the 2 years following the fracture were visualized and compared with those of 2 hip-fracture-free control groups drawn from the general population: age- and sex-matched controls and health-matched controls identified through propensity score matching. Multistate modeling was employed to identify sociodemographic and health-related factors associated with care trajectories among hip fracture patients. We found that hip fracture patients already had worse health than the general population before their fracture. However, when controlling for prefracture health, hip fractures still had a considerable impact on use of elder-care services and mortality. Comparisons with the health-matched controls suggest that hip fractures have an immediate, yet short-term, impact on care trajectories. Long-term care needs are largely attributable to poorer health profiles independent of the fracture itself. This emphasizes the importance of adequate comparison groups when examining the consequences of diseases which are often accompanied by other underlying health problems.
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Affiliation(s)
- Anna C Meyer
- Correspondence to Dr. Anna C. Meyer, Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, P.O. Box 210, SE-171 77 Stockholm, Sweden (e-mail: )
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9
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Iki M, Fujimori K, Nakatoh S, Tamaki J, Ishii S, Okimoto N, Kamiya K, Ogawa S. Delayed initiation of anti-osteoporosis medications increases subsequent hip and vertebral fractures in patients on long-term glucocorticoid therapy: A nationwide health insurance claims database study in Japan. Bone 2022; 160:116396. [PMID: 35351673 DOI: 10.1016/j.bone.2022.116396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE Early initiation of anti-osteoporosis medications (AOMs) is recommended for patients on long-term glucocorticoid (GC) therapy. This study aimed to examine whether physicians prescribe AOMs as soon as GC therapy is initiated, and whether a delay in AOM initiation affects hip and vertebral fracture incidence, using the nationwide health insurance claims database of Japan (NDBJ). METHODS Patients aged ≥50 years who were prescribed GC (≥5 mg/day prednisolone or equivalent) for ≥90 days and who were followed for AOM use and hip and vertebral fracture events for the subsequent 1080 days in 2012-2018 were selected from NDBJ. Delay in AOM initiation was defined as the number of days without AOMs following GC therapy initiation. Associations between delay in AOM initiation and hip and vertebral fracture risk were evaluated by Cox proportional hazards regression. RESULTS In total, 92,143 women and 94,772 men were included in the analysis, of which only 39.3% of women and 28.5% of men received AOMs within 90 days from GC therapy initiation. Approximately, 15% of hip fractures and 30% of vertebral fractures occurred before AOM initiation in patients with delayed AOM initiation. HRs of both fractures were significantly greater in patients with a longer delay in AOM initiation (p value for trend<0.001). After excluding patients who had fractures before AOM initiation, the magnitude of HRs significantly decreased, and HR trends for hip fracture became insignificant. CONCLUSIONS Delayed initiation of AOMs may result in increased fracture events, which may be reduced by early initiation of AOMs.
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Affiliation(s)
- Masayuki Iki
- Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan.
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Shinichi Nakatoh
- Department of Orthopedic Surgery, Asahi General Hospital, 477 Tomari, Asahimachi, Shimo-Nikawa-gun, Toyama 939-0798, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Junko Tamaki
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Shigeyuki Ishii
- Department of Regulatory Science, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachiouji, Tokyo 193-0392, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Nobukazu Okimoto
- Okimoto Clinic, 185-4 Kubi, Yutaka-machi, Kure, Hiroshima 734-0304, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Kuniyasu Kamiya
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Sumito Ogawa
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8511, Japan; National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka-Sayama, Osaka 589-8511, Japan
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10
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Landau AJ, Oladeji AK, Hosseinzadeh P. Assessment of Ethno-racial and Insurance-based Disparities in Pediatric Forearm and Tibial Fracture Care in the United States. J Am Acad Orthop Surg Glob Res Rev 2022; 6:e22.00126. [PMID: 35908228 PMCID: PMC10566840 DOI: 10.5435/jaaosglobal-d-22-00126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Despite growing attention to healthcare disparities and interventions to improve inequalities, additional identification of disparities is needed, particularly in the pediatric population. We used state and nationwide databases to identify factors associated with the surgical treatment of pediatric forearm and tibial fractures. METHODS The Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases from four US states and the Nationwide Emergency Department Sample database were quarried using International Classification of Diseases codes to identify patients from 2006 to 2015. Multivariable regression models were used to determine factors associated with surgical treatment. RESULTS State databases identified 130,006 forearm (1575 open) and 51,979 tibial fractures (1339 open). Surgical treatment was done in 2.6% of closed and 37.5% of open forearm fractures and 7.9% of closed and 60.5% of open tibial fractures. A national estimated total of 3,312,807 closed and 46,569 open forearm fractures were included, 59,024 (1.8%) of which were treated surgically. A total of 719,374 closed and 26,144 open tibial fractures were identified; 52,506 (7.0%) were treated surgically. Multivariable regression revealed that race and/or insurance status were independent predictors for the lower likelihood of surgery in 3 of 4 groups: Black patients were 43% and 35% less likely to have surgery after closed and open forearm fractures, respectively, and patients with Medicaid were less often treated surgically for open tibial fractures in state (17%) and nationwide (20%) databases. CONCLUSIONS Disparities in pediatric forearm and tibial fracture care persist, especially for Black patients and those with Medicaid; identification of influencing factors and interventions to address them are important in improving equality and value of care.
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Affiliation(s)
- Andrew J. Landau
- From the Department of Orthopaedic Surgery; Washington University School of Medicine, St. Louis, MO
| | - Afolayan K. Oladeji
- From the Department of Orthopaedic Surgery; Washington University School of Medicine, St. Louis, MO
| | - Pooya Hosseinzadeh
- From the Department of Orthopaedic Surgery; Washington University School of Medicine, St. Louis, MO
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11
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Shin H, Schneeweiss S, Glynn RJ, Patorno E. Cardiovascular Outcomes in Patients Initiating First-Line Treatment of Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors Versus Metformin : A Cohort Study. Ann Intern Med 2022; 175:927-937. [PMID: 35605236 DOI: 10.7326/m21-4012] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Evidence on the risk for cardiovascular events associated with use of first-line sodium-glucose cotransporter-2 inhibitors (SGLT-2i) compared with metformin is limited. OBJECTIVE To assess cardiovascular outcomes among adults with type 2 diabetes (T2D) who initiated first-line treatment with SGLT-2i versus metformin. DESIGN Population-based cohort study. SETTING Claims data from 2 large U.S. commercial and Medicare databases (April 2013 to March 2020). PARTICIPANTS Patients with T2D aged 18 years and older (>65 years in Medicare) initiating treatment with SGLT-2i or metformin during April 2013 to March 2020, without any use of antidiabetic medications before cohort entry, were identified. After 1:2 propensity score matching in each database, pooled hazard ratios (HRs) and 95% CIs were reported. INTERVENTION First-line SGLT-2i (canagliflozin, empagliflozin, or dapagliflozin) or metformin. MEASUREMENTS Primary outcomes were a composite of hospitalization for myocardial infarction (MI), hospitalization for ischemic or hemorrhagic stroke or all-cause mortality (MI/stroke/mortality), and a composite of hospitalization for heart failure (HHF) or all-cause mortality (HHF/mortality). Safety outcomes including genital infections were assessed. RESULTS Among 8613 first-line SGLT-2i initiators matched to 17 226 metformin initiators, SGLT-2i initiators had a similar risk for MI/stroke/mortality (HR, 0.96; 95% CI, 0.77 to 1.19) and a lower risk for HHF/mortality (HR, 0.80; CI, 0.66 to 0.97) during a mean follow-up of 12 months. Initiators receiving SGLT-2i showed a lower risk for HHF (HR, 0.78; CI, 0.63 to 0.97), a numerically lower risk for MI (HR, 0.70; CI, 0.48 to 1.00), and similar risk for stroke, mortality, and MI/stroke/HHF/mortality compared with metformin. Initiators receiving SGLT-2i had a higher risk for genital infections (HR, 2.19; CI, 1.91 to 2.51) and otherwise similar safety as those receiving metformin. LIMITATION Treatment selection was not randomized. CONCLUSION As first-line T2D treatment, initiators receiving SGLT-2i showed a similar risk for MI/stroke/mortality, lower risk for HHF/mortality and HHF, and a similar safety profile except for an increased risk for genital infections compared with those receiving metformin. PRIMARY FUNDING SOURCE Brigham and Women's Hospital and Harvard Medical School.
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Affiliation(s)
- HoJin Shin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (H.S., R.J.G., E.P.)
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, and Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (S.S.)
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (H.S., R.J.G., E.P.)
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (H.S., R.J.G., E.P.)
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12
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Li L, Marozoff S, Lu N, Xie H, Kopec JA, Cibere J, Esdaile JM, Aviña-Zubieta JA. Association of tramadol with all-cause mortality, cardiovascular diseases, venous thromboembolism, and hip fractures among patients with osteoarthritis: a population-based study. Arthritis Res Ther 2022; 24:85. [PMID: 35410440 PMCID: PMC8996663 DOI: 10.1186/s13075-022-02764-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background The use of tramadol among osteoarthritis (OA) patients has been increasing rapidly around the world, but population-based studies on its safety profile among OA patients are scarce. We sought to determine if tramadol use in OA patients is associated with increased risks of all-cause mortality, cardiovascular diseases (CVD), venous thromboembolism (VTE), and hip fractures compared with commonly prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) or codeine. Methods Using administrative health datasets from British Columbia, Canada, we conducted a sequential propensity score-matched cohort study among all OA patients between 2005 and 2013. The tramadol cohort (i.e., tramadol initiation) was matched with four comparator cohorts (i.e., initiation of naproxen, diclofenac, cyclooxygenase-2 [Cox-2] inhibitors, or codeine). Outcomes are all-cause mortality, first-ever CVD, VTE, and hip fractures within the year after the treatment initiation. Patients were followed until they either experienced an event, left the province, or the 1-year follow-up period ended, whichever occurred first. Cox proportional hazard models were used to estimate hazard ratios after adjusting for competing risk of death. Results Overall, 100,358 OA patients were included (mean age: 68 years, 63% females). All-cause mortality was higher for tramadol compared to NSAIDs with rate differences (RDs/1000 person-years, 95% CI) ranging from 3.3 (0.0–6.7) to 8.1 (4.9–11.4) and hazard ratios (HRs, 95% CI) ranging from 1.2 (1.0–1.4) to 1.5 (1.3–1.8). For CVD, no differences were observed between tramadol and NSAIDs. Tramadol had a higher risk of VTE compared to diclofenac, with RD/1000 person-years (95% CI) of 2.2 (0.7–3.7) and HR (95% CI) of 1.7 (1.3–2.2). Tramadol also had a higher risk of hip fractures compared to diclofenac and Cox-2 inhibitors with RDs/1000 person-years (95% CI) of 1.9 (0.4–3.4) and 1.7 (0.2–3.3), respectively, and HRs (95% CI) of 1.6 (1.2–2.0) and 1.4 (1.1–1.9), respectively. No differences were observed between tramadol and NSAIDs for all events. Conclusions OA patients initiating tramadol have an increased risk of mortality, VTE, and hip fractures within 1 year compared with commonly prescribed NSAIDs, but not with codeine. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02764-3.
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Affiliation(s)
- Lingyi Li
- Arthritis Research Canada, 230-2238 Yukon Street, Vancouver, BC, V5Y 3P2, Canada.,Experimental Medicine Program, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Shelby Marozoff
- Arthritis Research Canada, 230-2238 Yukon Street, Vancouver, BC, V5Y 3P2, Canada
| | - Na Lu
- Arthritis Research Canada, 230-2238 Yukon Street, Vancouver, BC, V5Y 3P2, Canada
| | - Hui Xie
- Arthritis Research Canada, 230-2238 Yukon Street, Vancouver, BC, V5Y 3P2, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Jacek A Kopec
- Arthritis Research Canada, 230-2238 Yukon Street, Vancouver, BC, V5Y 3P2, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jolanda Cibere
- Arthritis Research Canada, 230-2238 Yukon Street, Vancouver, BC, V5Y 3P2, Canada.,Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - John M Esdaile
- Arthritis Research Canada, 230-2238 Yukon Street, Vancouver, BC, V5Y 3P2, Canada.,Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, 230-2238 Yukon Street, Vancouver, BC, V5Y 3P2, Canada. .,Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, Canada.
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13
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Patorno E, Pawar A, Wexler DJ, Glynn RJ, Bessette LG, Paik JM, Najafzadeh M, Brodovicz KG, Déruaz-Luyet A, Schneeweiss S. Effectiveness and safety of empagliflozin in routine care patients: Results from the EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) study. Diabetes Obes Metab 2022; 24:442-454. [PMID: 34729891 PMCID: PMC8939295 DOI: 10.1111/dom.14593] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 01/10/2023]
Abstract
AIM To investigate effectiveness and safety outcomes among patients with type 2 diabetes (T2D) initiating empagliflozin versus dipeptidyl peptidase-4 (DPP-4) inhibitor treatment across the broad spectrum of cardiovascular risk. METHODS In a population-based cohort study we identified 39 072 pairs of 1:1 propensity score-matched adult patients with T2D initiating empagliflozin or DPP-4 inhibitors, using data from 2 US commercial insurance databases and Medicare between August 2014 and September 2017. The primary outcomes were a composite of myocardial infarction (MI)/stroke, and hospitalization for heart failure (HHF). Safety outcomes were bone fractures, lower-limb amputations (LLAs), diabetic ketoacidosis (DKA), and acute kidney injury (AKI). We estimated pooled hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for more than 140 baseline covariates. RESULTS Study participants had a mean age of 60 years and only 28% had established cardiovascular disease. Compared to DPP-4 inhibitors, empagliflozin was associated with similar risk of MI/stroke (HR 0.99 [95% CI 0.81-1.21]), and lower risk of HHF (HR 0.48 [95% CI 0.35-0.67] and 0.63 [95% CI 0.54-0.74], based on a primary and any heart failure discharge diagnosis, respectively). The HR was 0.52 (95% CI 0.38-0.72) for all-cause mortality (ACM) and 0.83 (95% CI 0.70-0.98) for a composite of MI/stroke/ACM. Empagliflozin was associated with a similar risk of LLA and fractures, an increased risk of DKA (HR 1.71 [95% CI 1.08-2.71]) and a decreased risk of AKI (HR 0.60 [95% CI 0.43-0.85]). CONCLUSIONS In clinical practice, the initiation of empagliflozin versus a DPP-4 inhibitor was associated with a lower risk of HHF, ACM and MI/stroke/ACM, a similar risk of MI/stroke, and a safety profile consistent with documented information.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, 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
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly G Brodovicz
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | | | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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14
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Melbye P, Gundtoft P, Lien-Iversen T, Barklin Morgan D, Pörneki JC, Viberg B. Secondary surgeries 20 years after surgical and non-surgical treatment of ACL rupture: A population-based cohort study. Knee 2022; 35:1-7. [PMID: 35144195 DOI: 10.1016/j.knee.2022.01.007] [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] [Received: 04/16/2021] [Revised: 01/17/2022] [Accepted: 01/23/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Studies with less than 10 years of follow-up have demonstrated no difference between surgical and non-surgical treatment after an anterior cruciate ligament (ACL) rupture; however, long-term effects remain unclear. The aim of this study was to compare the risk of long-term secondary surgical procedures after primary surgical and non-surgical treatment for ACL ruptures. METHODS Patients aged 18-35, registered in the Danish National Patient Registry with an ACL rupture between January 1, 1996 and December 31, 2000 with a minimum of 20 years follow-up were included. The surgically treated group was defined as receiving an ACL reconstruction within 1 year after diagnosis. Major secondary surgical procedures were defined as subsequent ACL surgeries (reconstruction/revision), arthroplasty, deep infection, arthrodesis, or amputation. Minor secondary surgical procedures were defined as meniscal surgery, synovectomy, and manipulation under anesthesia (MUA). Multivariate regression analysis was performed to assess relative risk (RR), adjusted for age and sex. The results are reported with 95% confidence intervals. RESULTS 7,539 patients had an ACL rupture; 1,970 patients were surgically treated. In the surgically treated group, 5.9% of patients underwent major secondary surgeries; this was 6.1% in the non-surgically treated group, yielding an adjusted RR of 1.05 (0.85;1.30). There were 43.9% minor secondary surgeries in the surgically treated group and 49.1% in the non-surgically treated group, yielding an adjusted RR of 1.29 (1.20;1.39). CONCLUSIONS No significant differences in the rate of major secondary surgical procedures between the groups, the non-surgical group was associated with a higher risk of minor secondary surgeries.
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Affiliation(s)
- Pernille Melbye
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Sygehusvej 24, 6000 Kolding, Denmark.
| | - Per Gundtoft
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Sygehusvej 24, 6000 Kolding, Denmark
| | - Teodor Lien-Iversen
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Sygehusvej 24, 6000 Kolding, Denmark
| | - Daniel Barklin Morgan
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Sygehusvej 24, 6000 Kolding, Denmark
| | - Jens Christian Pörneki
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Sygehusvej 24, 6000 Kolding, Denmark
| | - Bjarke Viberg
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark, Sygehusvej 24, 6000 Kolding, Denmark
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15
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Fu TS, Huang TS, Sun CC, Shyu YC, Chen FP. Impact of bisphosphonates and comorbidities on initial hip fracture prognosis. Bone 2022; 154:116239. [PMID: 34688941 DOI: 10.1016/j.bone.2021.116239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/28/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
The aim of this study is to investigate the impact of bisphosphonate treatment on the prognosis of patients with initial hip fracture. Patients aged fifty years and older with initial hip fracture were identified from the Taiwan National Health Insurance Research Database between 2002 and 2011. A multi-state model was established to evaluate the transition between "first to second hip fracture", "first hip fracture to death", and "second hip fracture to death". Transition probability and cumulative hazards were used to compare the prognosis of initial hip fracture in a bisphosphonate treated cohort versus non-treated cohort. In addition, Deyo-Charlson comorbidities, both vertebral and non-vertebral fractures, and cataracts were also included for analysis. After 10-year follow-up, there is decreased cumulative transition probability for both second hip fracture and mortality after both first and second hip fracture in the bisphosphonate treated cohort. Multivariable, transition-specific time-dependent Cox model revealed that bisphosphonate treatment significantly reduced risk for second hip fracture in the first 5 years of the treatment (HR 0.88; 95% CI 0.79-0.99; P: 0.034), first hip fracture mortality (HR 0.88; 95% CI 0.83-0.93; P < 0.001), and second hip fracture mortality in the first 2 years of the treatment (HR 0.78; 95% CI 0.65-0.95; P = 0.011). Female sex, both vertebral and non-vertebral fractures, cataracts, dementia in the first 2 years, and DM with complication were all significantly associated with risk of a second hip fracture. Cerebrovascular disease and hemiplegia comorbidities had less risk of a second hip fracture. The risk of mortality after both first and second hip fracture was significantly associated with congestive heart failure, renal disease, myocardial infarction, and moderate to severe liver disease. Our study demonstrated that bisphosphonate treatment and strict management of comorbidities after the initial hip fracture significantly decrease the risk for a second hip fracture and mortality.
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Affiliation(s)
- Tsai-Sheng Fu
- Department of Orthopaedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 259, Taiwan; Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Ting-Shuo Huang
- Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of General Surgery, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of Chinese Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 259, Taiwan; Department of Ophthalmology, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Chi-Chin Sun
- Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of Chinese Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 259, Taiwan; Department of Ophthalmology, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Yu-Chiau Shyu
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Institute of Molecular Biology, Academia Sinica, Nankang, 115 Taipei, Taiwan
| | - Fang-Ping Chen
- Department of Medicine, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 259, Taiwan; Osteoporosis Prevention and Treatment Center, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan; Department of Obstetrics and Gynecology, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan.
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Ervasti J, Pentti J, Nyberg ST, Shipley MJ, Leineweber C, Sørensen JK, Alfredsson L, Bjorner JB, Borritz M, Burr H, Knutsson A, Madsen IE, Magnusson Hanson LL, Oksanen T, Pejtersen JH, Rugulies R, Suominen S, Theorell T, Westerlund H, Vahtera J, Virtanen M, Batty GD, Kivimäki M. Long working hours and risk of 50 health conditions and mortality outcomes: a multicohort study in four European countries. THE LANCET REGIONAL HEALTH. EUROPE 2021; 11:100212. [PMID: 34917998 PMCID: PMC8642716 DOI: 10.1016/j.lanepe.2021.100212] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Studies on the association between long working hours and health have captured only a narrow range of outcomes (mainly cardiometabolic diseases and depression) and no outcome-wide studies on this topic are available. To achieve wider scope of potential harm, we examined long working hours as a risk factor for a wide range of disease and mortality endpoints. METHODS The data of this multicohort study were from two population cohorts from Finland (primary analysis, n=59 599) and nine cohorts (replication analysis, n=44 262) from Sweden, Denmark, and the UK, all part of the Individual-participant Meta-analysis in Working Populations (IPD-Work) consortium. Baseline-assessed long working hours (≥55 hours per week) were compared to standard working hours (35-40 h). Outcome measures with follow-up until age 65 years were 46 diseases that required hospital treatment or continuous pharmacotherapy, all-cause, and three cause-specific mortality endpoints, ascertained via linkage to national health and mortality registers. FINDINGS 2747 (4·6%) participants in the primary cohorts and 3027 (6·8%) in the replication cohorts worked long hours. After adjustment for age, sex, and socioeconomic status, working long hours was associated with increased risk of cardiovascular death (hazard ratio 1·68; 95% confidence interval 1·08-2·61 in primary analysis and 1·52; 0·90-2·58 in replication analysis), infections (1·37; 1·13-1·67 and 1·45; 1·13-1·87), diabetes (1·18; 1·01-1·38 and 1·41; 0·98-2·02), injuries (1·22; 1·00-1·50 and 1·18; 0·98-1·18) and musculoskeletal disorders (1·15; 1·06-1·26 and 1·13; 1·00-1·27). Working long hours was not associated with all-cause mortality. INTERPRETATION Follow-up of 50 health outcomes in four European countries suggests that working long hours is associated with an elevated risk of early cardiovascular death and hospital-treated infections before age 65. Associations, albeit weak, were also observed with diabetes, musculoskeletal disorders and injuries. In these data working long hours was not related to elevated overall mortality. FUNDING NordForsk, the Medical Research Council, the National Institute on Aging, the Wellcome Trust, Academy of Finland, and Finnish Work Environment Fund.
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Affiliation(s)
- Jenni Ervasti
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Jaana Pentti
- Finnish Institute of Occupational Health, Helsinki, Finland
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Public Health, University of Turku, and Population Research Centre, University of Turku and Turku University Hospital, Turku, Finland
| | - Solja T. Nyberg
- Finnish Institute of Occupational Health, Helsinki, Finland
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Martin J. Shipley
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Constanze Leineweber
- Stress Research Institute at the Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Jeppe K. Sørensen
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Lars Alfredsson
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
| | - Jakob B. Bjorner
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | | | - Hermann Burr
- Federal Institute for Occupational Safety and Health, Berlin, Germany
| | - Anders Knutsson
- Department of Health Sciences, Mid Sweden University, Sundsvall, Sweden
| | - Ida E.H. Madsen
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | | | - Tuula Oksanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Jan H. Pejtersen
- VIVE–The Danish Center for Social Science Research, Copenhagen, Denmark
| | - Reiner Rugulies
- National Research Centre for the Working Environment, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Denmark
- Department of Psychology, University of Copenhagen, Denmark
| | - Sakari Suominen
- Department of Public Health, University of Turku, and Population Research Centre, University of Turku and Turku University Hospital, Turku, Finland
- University of Skövde, School of Health and Education, Skövde, Sweden
| | - Töres Theorell
- Stress Research Institute at the Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Hugo Westerlund
- Stress Research Institute at the Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Jussi Vahtera
- Department of Public Health, University of Turku, and Population Research Centre, University of Turku and Turku University Hospital, Turku, Finland
| | - Marianna Virtanen
- School of Educational Sciences and Psychology, University of Eastern Finland, Joensuu, Finland
- Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - G. David Batty
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Mika Kivimäki
- Finnish Institute of Occupational Health, Helsinki, Finland
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Epidemiology and Public Health, University College London, London, UK
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Khalid SI, Thomson KB, Becerra AZ, Omotosho P, Spagnoli A, Torquati A. Rates, Risks, and Time to Fracture in Patients Undergoing Laparoscopic Vertical Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass. ANNALS OF SURGERY OPEN 2021; 2:e099. [PMID: 37637884 PMCID: PMC10455321 DOI: 10.1097/as9.0000000000000099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To assess the rates, risks, and time to fracture in patients undergoing laparoscopic vertical sleeve gastrectomy (VSG) versus those undergoing Roux-en-Y gastric bypass (RYGB). Summary Background Data Metabolic and bariatric surgery has been implicated in significant bone loss and may increase fracture risk. Preoperative patient characteristics that might impact fracture risk and the time to fractures have not been established. Furthermore, the patient characteristics that might impact fracture risk and the time to fractures by surgical approach are unknown. Methods This population-based retrospective cohort analysis used Humana claims data from January 1, 2007 to March 31, 2017, and included 4073 patients undergoing laparoscopic RYGB and VSG as a first surgical intervention for weight loss. The primary outcomes were the incidence of fractures (Humeral, Radial or Ulnar, Pelvic, Hip, and Vertebral) within 48 months after laparoscopic VSG versus RYGB and days to these fractures. Results An analysis of total fractures (odds ratio [OR] 0.53; 95% confidence interval [CI], 0.38-0.73), vertebral fractures (OR 0.61; 95% CI, 0.38-0.99), hip fractures (OR 0.36; 95% CI, 0.15-0.84), and humeral fractures (OR 0.44; 95% CI, 0.22-0.90) demonstrated a reduction in fracture risk in patients undergoing VSG versus RYGB. Furthermore, postmenopausal status was independently associated with increased odds of total fractures and hip fractures (OR 2.18; 95% CI, 1.06-4.50; OR 5.83; 95% CI, 1.16-29.27; respectively). Likewise, osteoporosis at the time of surgery was associated with increased odds of total fractures (OR 1.61; 95% CI, 1.09-2.37), vertebral fractures (OR 2.01; 95% CI, 1.19-3.39), and hip fractures (OR 2.38; 95% CI, 1.19-4.77). Except for a significantly decreased odds of vertebral fractures in osteoporotic patients undergoing VSG versus RYGB (OR 0.41; 95% CI, 0.18-0.95), osteoporotic or postmenopausal status at the time of surgery was not found to increase odds of fracture depending on surgical intervention. However, time to fracture (total) and for all site-specific fractures, except for pelvic fractures, was significantly reduced in postmenopausal women undergoing RYGB versus VSG. Time to fracture (total) and for all site-specific fractures except pelvic and radial or ulnar fractures was significantly reduced in osteoporotic patients undergoing RYGB versus VSG. Conclusions and Relevance Though bariatric surgery is associated with several health-related benefits, increased fracture risk is an important factor to discuss with patients undergoing bariatric surgery. Bariatric surgery strategy, RYGB versus VSG, carries a differential risk of fracture, with RYGB carrying a higher risk of fracture and decreased time to fracture. Furthermore, patients who are postmenopausal or osteoporotic at the time of surgery carry an increased risk of total fractures, independent of bariatric surgery strategy. Being mindful of patient-specific fracture risk after bariatric surgery may help anticipate, identify, and prevent fractures.
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Affiliation(s)
- Syed I. Khalid
- From the Department of Surgery, Rush University Medical Center, Chicago, IL
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL
| | | | - Adan Z. Becerra
- From the Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Philip Omotosho
- From the Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Anna Spagnoli
- From the Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Alfonso Torquati
- From the Department of Surgery, Rush University Medical Center, Chicago, IL
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18
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Yamaguchi S, Kimura S, Akagi R, Yoshimura K, Kawasaki Y, Shiko Y, Sasho T, Ohtori S. Increase in Achilles Tendon Rupture Surgery in Japan: Results From a Nationwide Health Care Database. Orthop J Sports Med 2021; 9:23259671211034128. [PMID: 34708136 PMCID: PMC8543583 DOI: 10.1177/23259671211034128] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/30/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Nationwide epidemiologic studies in Scandinavian countries have shown that the incidence of Achilles tendon ruptures (ATRs) has increased, and the rate of surgical treatment has declined markedly in the past decade. However, there is a lack of national-level data on the trend of ATRs and surgical procedures in other regions. Purpose: To clarify the trend in the incidence of ATRs and the proportion of surgery using the nationwide health care database in Japan. Study Design: Descriptive epidemiology study. Methods: Age- and sex-stratified data on the annual number of ATRs and surgical procedures between 2010 and 2017 were obtained from the Japanese national health care database, which includes almost all inpatient and outpatient medical claims nationwide. The Japanese population data were also obtained from the population census. The change in the annual incidence of ATRs per 100,000 people was assessed using a Poisson regression analysis. The trend in the annual proportion of surgeries relative to the occurrence of tendon ruptures was determined using a linear regression analysis. Results: A total of 112,601 ATRs, with men accounting for 67%, were identified over 8 years. Patients aged ≥60 years accounted for 27,106 (24%), while those aged 20 to 39 years and 40 to 59 years accounted for 36,164 (32%) and 49,331 (44%), respectively. The annual incidence of ATR ranged from 12.8/100,000 to 13.9/100,000 (women, 8.2-8.9/100,000; men, 17.2-19.5/100,000), which did not change over the study period (P = .82). Moreover, the annual incidences did not change across sexes and age categories. The annual proportion of surgery increased significantly, from 67% in 2010 to 72% in 2017 (P = .003). The annual proportions increased across sexes and age categories except for women aged 40 to 59 years. Conclusion: The incidence of ATR did not change between 2010 and 2017, according to the Japanese nationwide health care database. Furthermore, the proportion of surgical treatment increased during the study period. Overall, 70% of patients underwent surgical treatment. This study suggested that the trend in ATR and surgery differed across regions.
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Affiliation(s)
- Satoshi Yamaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan.,Graduate School of Global and Transdisciplinary Studies, Chiba University, Chiba, Japan
| | - Seiji Kimura
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Ryuichiro Akagi
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Kensuke Yoshimura
- Center for Next Generation of Community Health, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan.,Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba, Japan
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Risk of Non-Vertebral Fracture in Gout Compared to Rheumatoid Arthritis. J Clin Med 2021; 10:jcm10204655. [PMID: 34682784 PMCID: PMC8539966 DOI: 10.3390/jcm10204655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the risk of non-vertebral fractures in patients with gout compared with those with rheumatoid arthritis (RA). Methods: Using claims data from Medicare (2008–2015), we conducted a cohort study of patients with gout versus RA matched on age, sex, and index date with a 1:1 ratio. The primary outcome was a composite endpoint of non-vertebral fractures including hip, pelvis, humerus, and wrist identified with the validated algorithms. We also assessed hip fractures separately. Multivariable Cox proportional hazards regression estimated the hazard ratio (HR) for the outcomes in gout versus RA adjusted for 45 covariates. Results: We included a total of 134,157 matched pairs of gout and RA patients (mean age: 73.7 years). Risk factors for fracture were more prevalent in RA, while other comorbidities including obesity, coronary heart disease, hypertension, and diabetes were more common in gout. Over the mean 2.8 years follow-up, the incidence rate (IR)/1000 person-year (PY) of non-vertebral fractures was 10.42 in gout and 15.01 in RA. For hip fractures, the IR/1000 PY was 4.86 in gout and 7.73 in RA. The multivariable HR associated with gout versus RA was 0.84 (95% confidence interval (CI) 0.80–0.88) for non-vertebral fractures and 0.76 (95% CI 0.71–0.82) for hip fractures. Stratified analyses by age, sex, prior fractures, steroid use, and TNF inhibitor use showed similar results. Conclusions: In this large cohort of older patients, gout was associated with a modestly decreased risk of non-vertebral or hip fractures versus RA. However, non-vertebral fractures occurred frequently in both gout and RA.
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Zhuo M, Hawley CE, Paik JM, Bessette LG, Wexler DJ, Kim DH, Tong AY, Kim SC, Patorno E. Association of Sodium-Glucose Cotransporter-2 Inhibitors With Fracture Risk in Older Adults With Type 2 Diabetes. JAMA Netw Open 2021; 4:e2130762. [PMID: 34705014 PMCID: PMC8552056 DOI: 10.1001/jamanetworkopen.2021.30762] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Whether sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are associated with an increased risk of fractures in older adults with type 2 diabetes (T2D) outside of clinical trials remains unknown. OBJECTIVE To examine the association of incident fracture among older adults with T2D with initiating an SGLT-2i compared with initiating a dipeptidyl peptidase 4 inhibitor (DPP-4i) or a glucagon-like peptide 1 receptor agonist (GLP-1RA). DESIGN, SETTING, AND PARTICIPANTS This is a population-based, new-user cohort study including older adults (aged ≥65 years) with T2D enrolled in Medicare fee-for-service from April 2013 to December 2017. Data analysis was performed from October 2020 to April 2021. EXPOSURES New users of an SGLT-2i, DPP-4i, or GLP-1RA without a previous fracture were matched in a 1:1:1 ratio using 3-way propensity score matching. MAIN OUTCOMES AND MEASURES The primary outcome was a composite end point of nontraumatic pelvic fracture, hip fracture requiring surgery, or humerus, radius, or ulna fracture requiring intervention within 30 days. After 3-way 1:1:1 propensity score matching, multivariable Cox proportional hazards regression models were used to generate hazard ratios (HRs) for SGLT-2i compared with DPP-4i and GLP-1RA and Kaplan-Meier curves to visualize fracture risk over time across groups. RESULTS Of 466 933 new initiators of study drugs, 62 454 patients were new SGLT-2i users. After 3-way matching, 45 889 (73%) new SGLT-2i users were matched to new users of DPP-4i and GLP-1RA, yielding a cohort of 137 667 patients (mean [SD] age, 72 [5] years; 64 126 men [47%]) matched 1:1:1 for analyses. There was no difference in the risk of fracture in SGLT-2i users compared with DPP-4i users (HR, 0.90; 95% CI, 0.73-1.11) or GLP-1RA users (HR, 1.00; 95% CI, 0.80-1.25). Results were consistent across categories of sex, frailty (nonfrail, prefrail, and frail), age (<75 and ≥75 years), and insulin use (baseline users and nonusers). CONCLUSIONS AND RELEVANCE In this nationwide Medicare cohort, initiating an SGLT-2i was not associated with an increased risk of fracture in older adults with T2D compared with initiating a DPP-4i or GLP-1RA, with consistent results across categories of frailty, age, and insulin use. These findings add to the evidence base evaluating the potential risks associated with SGLT-2i use for older adults outside of randomized clinical trials.
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Affiliation(s)
- Min Zhuo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Chelsea E. Hawley
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- New England Geriatric Research, Education and Clinical Center, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Julie M. Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Lily G. Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deborah J. Wexler
- Diabetes Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Dae H. Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Angela Y. Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C. Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Pawar A, Desai RJ, He M, Bessette L, Kim SC. Comparative Risk of Nonvertebral Fractures Among Patients With Rheumatoid Arthritis Treated With Biologic or Targeted Synthetic Disease-Modifying Antirheumatic Drugs. ACR Open Rheumatol 2021; 3:531-539. [PMID: 34196497 PMCID: PMC8363846 DOI: 10.1002/acr2.11292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to compare the incidence rate of nonvertebral osteoporotic fractures (NVFs) in patients with rheumatoid arthritis (RA) initiating one of the nine biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs). METHODS We analyzed claims data from Optum (2008 to March 2019), Medicare, and MarketScan (2008-2017) to identify adults with RA who newly initiated b/tsDMARDs. Adalimumab was the most frequently used and was thus selected as a reference. The primary outcome was a composite of incident NVFs, including hip, humerus, pelvis, and wrist fractures, based on validated algorithms. We adjusted for greater than 70 potential confounders in each database through propensity score-based inverse probability treatment weighting. Follow-up time started the day after cohort entry until the first occurrence of one of the following: outcome, treatment discontinuation, switching, nursing home admission, death, disenrollment, or end of study period. For each drug comparison, weighted Cox proportional hazards models estimated the hazard ratios (HRs) and 95% confidence intervals (CIs). Secondary analyses were conducted in patients switching from a tumor necrosis factor inhibitor to a different b/tsDMARD. RESULTS A total of 134,693 b/tsDMARD initiators were identified across three databases. The adjusted HRs showed similar risk of composite NVFs in all b/tsDMARD exposures compared with adalimumab: abatacept, HR 1.03 (95% CI 0.82-1.30); certolizumab, HR 1.08 (95% CI 0.79-1.49); etanercept, HR 1.12 (95% CI 0.89-1.40); golimumab, HR 0.91 (95% CI 0.59-1.39); infliximab, HR 1.03 (95% CI 0.84-1.28); rituximab, HR 1.07 (95% CI 0.74-1.55); tocilizumab, HR 1.24 (95% CI 0.71-2.17); and tofacitinib, HR 1.07 (95% CI 0.69-1.64). Secondary analyses showed similar results. CONCLUSION This multidatabase cohort study found no differences in the risk of NVFs across individual b/tsDMARDs for RA, which provides reassurance to physicians prescribing b/tsDMARDs, especially to patients at high risk of developing NVFs.
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Affiliation(s)
- Ajinkya Pawar
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Rishi J. Desai
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Mengdong He
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Lily Bessette
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Seoyoung C. Kim
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMassachusetts
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22
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Gallini A, Jegou D, Lapeyre-Mestre M, Couret A, Bourrel R, Ousset PJ, Fabre D, Andrieu S, Gardette V. Development and Validation of a Model to Identify Alzheimer's Disease and Related Syndromes in Administrative Data. Curr Alzheimer Res 2021; 18:142-156. [PMID: 33882802 DOI: 10.2174/1567205018666210416094639] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/12/2021] [Accepted: 03/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Administrative data are used in the field of Alzheimer's Disease and Related Syndromes (ADRS), however their performance to identify ADRS is unknown. OBJECTIVE i) To develop and validate a model to identify ADRS prevalent cases in French administrative data (SNDS), ii) to identify factors associated with false negatives. METHODS Retrospective cohort of subjects ≥ 65 years, living in South-Western France, who attended a memory clinic between April and December 2013. Gold standard for ADRS diagnosis was the memory clinic specialized diagnosis. Memory clinics' data were matched to administrative data (drug reimbursements, diagnoses during hospitalizations, registration with costly chronic conditions). Prediction models were developed for 1-year and 3-year periods of administrative data using multivariable logistic regression models. Overall model performance, discrimination, and calibration were estimated and corrected for optimism by resampling. Youden index was used to define ADRS positivity and to estimate sensitivity, specificity, positive predictive and negative probabilities. Factors associated with false negatives were identified using multivariable logistic regressions. RESULTS 3360 subjects were studied, 52% diagnosed with ADRS by memory clinics. Prediction model based on age, all-cause hospitalization, registration with ADRS as a chronic condition, number of anti-dementia drugs, mention of ADRS during hospitalizations had good discriminative performance (c-statistic: 0.814, sensitivity: 76.0%, specificity: 74.2% for 2013 data). 419 false negatives (24.0%) were younger, had more often ADRS types other than Alzheimer's disease, moderate forms of ADRS, recent diagnosis, and suffered from other comorbidities than true positives. CONCLUSION Administrative data presented acceptable performance for detecting ADRS. External validation studies should be encouraged.
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Affiliation(s)
- Adeline Gallini
- CERPOP, Universite de Toulouse, Inserm, UPS, Toulouse, France
| | - David Jegou
- CERPOP, Universite de Toulouse, Inserm, UPS, Toulouse, France
| | | | - Anaïs Couret
- CERPOP, Universite de Toulouse, Inserm, UPS, Toulouse, France
| | - Robert Bourrel
- Caisse Nationale d'Assurance Maladie des Travailleurs Salaries (CNAMTS), Echelon Regional du Service Medical Midi-Pyrenees - F31000 Toulouse, France
| | - Pierre-Jean Ousset
- CHU Toulouse, Centre Memoire de Ressources et de Recherches - F31000 Toulouse, France
| | - D Fabre
- CHU Toulouse, Departement D'information Medicale - F31000 Toulouse, France
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Sølling AS, Christensen DH, Darvalics B, Harsløf T, Thomsen RW, Langdahl B. Fracture rates in patients discontinuing alendronate treatment in real life: a population-based cohort study. Osteoporos Int 2021; 32:1103-1115. [PMID: 33411002 DOI: 10.1007/s00198-020-05745-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/13/2020] [Indexed: 12/31/2022]
Abstract
UNLABELLED In this nationwide register-based cohort study, we found no difference in the risk of fractures in patients discontinuing versus continuing alendronate (ALN) treatment after 5 years. INTRODUCTION Information on fracture risk in patients discontinuing ALN in a real-life setting is sparse. We aimed to examine ALN discontinuation patterns, compare fracture rates in patients discontinuing versus continuing ALN after 5 years of treatment, and define determinants of fractures in ALN discontinuers. METHODS A nationwide population-based cohort study using Danish health registry data. Our source population was individuals who had redeemed ≥ 2 ALN prescriptions between January 1, 1995, and September 1, 2017. RESULTS We found that 25% of all ALN initiators used ALN for less than 1 year and 43% continued treatment for at least 5 years. We classified n = 1865 as ALN discontinuers and n = 29,619 as ALN continuers. Using Cox proportional hazards regression analysis and an "as-treated" approach, we observed no increased risk of any fracture (incidence rate ratio (IRR) 1.06, 95% CI 0.92-1.23), vertebral fracture (IRR 0.59, 95% CI 0.33-1.05), hip fracture (IRR 1.04, 95% CI 0.75-1.45), or major osteoporotic fracture (IRR 1.05, 95% CI 0.88-1.25) in the ALN discontinuers compared to continuers during a follow-up time of 1.84 ± 1.56 years (mean ± SD) and 2.51 ± 1.60 years, respectively. ALN re-initiation was a major determinant of follow-up among the discontinuers. Old age (> 80 vs. 50-60 years, unadjusted IRR 2.92, 95% CI 1.18-7.24) was the strongest determinant for fractures following ALN discontinuation. CONCLUSION In a real-world setting, less than 50% continued ALN treatment for 5 years. We found no difference in the risk of fractures in patients discontinuing versus continuing ALN after 5 years.
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Affiliation(s)
- A S Sølling
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - D H Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
| | - B Darvalics
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
| | - T Harsløf
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - R W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
| | - B Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Bergdahl C, Nilsson F, Wennergren D, Ekholm C, Möller M. Completeness in the Swedish Fracture Register and the Swedish National Patient Register: An Assessment of Humeral Fracture Registrations. Clin Epidemiol 2021; 13:325-333. [PMID: 34045902 PMCID: PMC8149280 DOI: 10.2147/clep.s307762] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/06/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Register-based clinical research is important. However, it is essential that the collected data are reliable for the registers to be a valuable source of information. This study evaluated the quality of humeral fracture data in the Swedish Fracture Register (SFR) and in the Swedish National Patient Register (NPR). Furthermore, a model for improved case ascertainment was developed for future validation processes. Materials and Methods Data were obtained from the NPR and SFR for all individuals aged ≥16 years with an acute humeral fracture ICD-code treated at Sahlgrenska University Hospital. The true number of humeral fractures (“gold standard”) was determined by cross-linkage between the two registers and a medical charts review. The completeness of registrations in each register was measured as the proportion of registrations compared with the gold standard, and accuracy was measured as positive predictive values (PPV). Results The NPR demonstrated a high level of completeness (97%) and lower accuracy (PPV 70%) for acute humeral fractures, whereas the SFR had slightly lower completeness (88%) but perfect accuracy (PPV 100%). The most common systematic error was the registration of re-admissions as acute fractures in the NPR (84% of all erroneous registrations). With this knowledge, an adjustment model for NPR data was constructed to increase the accuracy of fracture registrations (PPV 92%) without excluding valid registrations. Conclusion Data from the NPR tend to overestimate the true number of fractures, and proper case selection is needed in order for the data to function as a solid basis for epidemiological research and healthcare planning. In contrast, the SFR constitutes a complete, accurate and efficient source of information. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/eh0mBFzrWBk
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Affiliation(s)
- Carl Bergdahl
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Filip Nilsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - David Wennergren
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Carl Ekholm
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
| | - Michael Möller
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg/Mölndal, Sweden
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25
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Meyer AC, Ek S, Drefahl S, Ahlbom A, Hedström M, Modig K. Trends in Hip Fracture Incidence, Recurrence, and Survival by Education and Comorbidity: A Swedish Register-based Study. Epidemiology 2021; 32:425-433. [PMID: 33512961 PMCID: PMC8011509 DOI: 10.1097/ede.0000000000001321] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 01/13/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hip fractures are common and severe conditions among older individuals, associated with high mortality, and the Nordic countries have the highest incidence rates globally. With this study, we aim to present a comprehensive picture of trends in hip fracture incidence and survival in the older Swedish population stratified by education, birth country, and comorbidity level. METHODS This study is based on a linkage of several population registers and included the entire population over the age of 60 living in Sweden. We calculated age-standardized incidence rates for first and recurrent hip fractures as well as age-standardized proportions of patients surviving 30 and 365 days through the time period 1998 to 2017. We calculated all outcomes for men and women in the total population and in each population stratum. RESULTS Altogether, we observed 289,603 first hip fractures during the study period. Age-standardized incidence rates of first and recurrent fractures declined among men and women in the total population and in each educational-, birth country-, and comorbidity group. Declines in incidence were more pronounced for recurrent than for first fractures. Approximately 20% of women and 30% of men died within 1 year of their first hip fracture. Overall, survival proportions remained constant throughout the study period but improved when taking into account comorbidity level. CONCLUSIONS Hip fracture incidence has declined across the Swedish population, but mortality after hip fracture remained high, especially among men. Hip fracture patients constitute a vulnerable population group with increasing comorbidity burden and high mortality risk.
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Affiliation(s)
- Anna C. Meyer
- From the Institute of Environmental Medicine, Karolinska Institutet, Unit of Epidemiology, Stockholm, Sweden
| | - Stina Ek
- From the Institute of Environmental Medicine, Karolinska Institutet, Unit of Epidemiology, Stockholm, Sweden
| | - Sven Drefahl
- Demography Unit, Stockholm University, Stockholm, Sweden
| | - Anders Ahlbom
- From the Institute of Environmental Medicine, Karolinska Institutet, Unit of Epidemiology, Stockholm, Sweden
| | - Margareta Hedström
- Department of Clinical Sciences, Intervention and Technology (CLINTEC) Karolinska Institutet, Stockholm, Sweden
- Department of Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Modig
- From the Institute of Environmental Medicine, Karolinska Institutet, Unit of Epidemiology, Stockholm, Sweden
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26
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Meyer AC, Modig K. The role of having children for the incidence of and survival after hip fracture - A nationwide cohort study. Bone 2021; 145:115873. [PMID: 33548574 DOI: 10.1016/j.bone.2021.115873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Childless older women have a higher risk of sustaining a hip fracture than mothers. Several biological mechanisms linking parity to bone health among women have been proposed but it remains unclear whether a similar association exists among men. Adult children may also support their ageing parents with hip fracture, thereby potentially increasing survival chances. AIM To investigate how having children is related to the incidence of and survival after hip fracture among Swedish men and women over the age of 70. METHODS This nation-wide cohort study is based on data from several administrative population registers and a clinical hip fracture register. During 2013 to 2017, we estimated multivariable-adjusted incidence rate ratios to examine the association between number of children and incidence of first hip fracture and hazard ratios to examine survival after first hip fracture. RESULTS More than two million individuals were followed for hip fracture incidence and 45,991 patients for survival. Women had a higher risk of sustaining a hip fracture, but men had substantially higher mortality than women. Adjusting for education, comorbidity level, and further covariates, having children was associated with a lower risk of sustaining a hip fracture and a longer survival after hip fracture. CONCLUSIONS Older childless individuals may constitute risk groups for both the incidence of and mortality after hip fracture. Mechanisms linking parity to hip fracture risk are likely complex and not limited to biological mechanisms related to pregnancy, childbirth, or breastfeeding among women.
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Affiliation(s)
- Anna C Meyer
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Karin Modig
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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27
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Viberg B, Frøslev T, Overgaard S, Pedersen AB. Mortality and revision risk after femoral neck fracture: comparison of internal fixation for undisplaced fracture with arthroplasty for displaced fracture: a population-based study from Danish National Registries. Acta Orthop 2021; 92:163-169. [PMID: 33228452 PMCID: PMC8158198 DOI: 10.1080/17453674.2020.1850940] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and purpose - Hemiarthroplasty has lower reoperation frequency and better mobilization compared with internal fixation (IF) in patients with undisplaced femoral neck fractures (FNF), which might translate into lower mortality. In this population-based cohort study we compare the risk of mortality and reoperation in undisplaced FNF treated with IF and displaced FNF treated with arthroplasty in patients older than 70 years old. We assume that, per se, there is no difference in mortality risk between patients with a displaced and an undisplaced FNF.Patients and methods - Hip fracture patients were identified in the Danish Multidisciplinary Hip Fracture Registry during 2005-2015. Data on medication, comorbidities, reoperation, and mortality were retrieved from other Danish medical databases. IF and arthroplasty patients were compared with regards to mortality and reoperation up to 5 years postoperatively. We calculated hazard ratios (HR) with 95% confidence intervals (CI) adjusting for relevant confounders.Results - We included 19,260 FNF treated with arthroplasty and 10,337 FNF with IF. There was an increased risk of mortality for arthroplasty within 30 days, HR 1.3 (95% CI 1.3-1.4), compared with IF but not after 1 and 5 years. Arthroplasty patients had adjusted HRs for reoperation of 0.8 (0.8-0.9) within 1 year, 0.8 (0.7-0.9) within 2 years, and 0.8 (0.8-0.9) within 5 years postoperatively compared with IF.Interpretation - Patients treated for a displaced FNF with arthroplasty had a higher risk of 30-day mortality compared with patients who had an undisplaced FNF treated with IF. It has to be considered that there were baseline differences in the groups but there was no difference in mortality risk up to 5 years post-surgery. Concerning reoperation, patients with a displaced FNF treated with arthroplasty had a lower risk of reoperation compared with IF for undisplaced FNF.
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Affiliation(s)
- Bjarke Viberg
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital – University Hospital of SouthernDenmark, Kolding; ,Department of Regional Health Research, University of Southern Denmark, Odense; ,Orthopaedics Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense; ,Correspondence:
| | - Trine Frøslev
- Department of Clinical Epidemiology, Aarhus University Hospital;
| | - Søren Overgaard
- Orthopaedics Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense; ,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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28
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Patorno E, Pawar A, Bessette LG, Kim DH, Dave C, Glynn RJ, Munshi MN, Schneeweiss S, Wexler DJ, Kim SC. Comparative Effectiveness and Safety of Sodium-Glucose Cotransporter 2 Inhibitors Versus Glucagon-Like Peptide 1 Receptor Agonists in Older Adults. Diabetes Care 2021; 44:826-835. [PMID: 33495295 PMCID: PMC7896266 DOI: 10.2337/dc20-1464] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/20/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Both sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA) demonstrated cardiovascular benefits in randomized controlled trials of patients with type 2 diabetes (T2D) generally <65 years old and mostly with cardiovascular disease. We aimed to evaluate the comparative effectiveness and safety of SGLT2i and GLP-1RA among real-world older adults. RESEARCH DESIGN AND METHODS Using Medicare data (April 2013-December 2016), we identified 90,094 propensity score-matched (1:1) T2D patients ≥66 years old initiating SGLT2i or GLP-1RA. Primary outcomes were major adverse cardiovascular events (MACE) (i.e., myocardial infarction, stroke, or cardiovascular death) and hospitalization for heart failure (HHF). Other outcomes included diabetic ketoacidosis (DKA), genital infections, fractures, lower-limb amputations (LLA), acute kidney injury (AKI), severe urinary tract infections, and overall mortality. We estimated hazard ratios (HRs) and rate differences (RDs) per 1,000 person-years, controlling for 140 baseline covariates. RESULTS Compared with GLP-1RA, SGLT2i initiators had similar MACE risk (HR 0.98 [95% CI 0.87, 1.10]; RD -0.38 [95% CI -2.48, 1.72]) and reduced HHF risk (HR 0.68 [95% CI 0.57, 0.80]; RD -3.23 [95% CI -4.68, -1.77]), over a median follow-up of ∼6 months. They also had 0.7 more DKA events (RD 0.72 [95% CI 0.02, 1.41]), 0.9 more LLA (RD 0.90 [95% CI 0.10, 1.70]), 57.1 more genital infections (RD 57.08 [95% CI 53.45, 60.70]), and 7.1 fewer AKI events (RD -7.05 [95% CI -10.27, -3.83]) per 1,000 person-years. CONCLUSIONS Among older adults, those taking SGLT2i had similar MACE risk, decreased HHF risk, and increased risk of DKA, LLA, and genital infections versus those taking GLP-1RA.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Dae H Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Chintan Dave
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Medha N Munshi
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA.,Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Li L, Xie H, Lu N, Esdaile JM, Aviña-Zubieta JA. Impact of Systemic Lupus Erythematosus on the Risk of Newly Diagnosed Hip Fracture: A General Population-Based Study. Arthritis Care Res (Hoboken) 2021; 73:259-265. [PMID: 31758639 DOI: 10.1002/acr.24112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 11/19/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Hip fractures have serious consequences, including a 1-year mortality rate of 30%. Population-based studies on hip fractures in individuals with systemic lupus erythematosus (SLE) are scarce. Our objective was to assess the independent risk of hip fractures in patients with newly diagnosed SLE compared to the general population, accounting for baseline and time-varying confounders. METHODS A cohort of all patients with incident SLE who received health care between January 1, 1997 and March 31, 2015 was assembled. The primary outcome was the occurrence of the first hip fracture since the study entry date. Individuals without SLE were randomly selected from the general population and matched (5:1) to those with SLE based on age, sex, and index year. Cumulative incidence was calculated after accounting for competing risks of death. Marginal structural Cox models were used to estimate the impact of SLE on hip fractures, adjusting for baseline and time-dependent covariates (i.e., glucocorticoid use and the number of outpatient, inpatient, and rheumatologist visits). RESULTS Among 5,047 individuals with incident SLE and 25,235 individuals without SLE (86% female, mean age 40 years), we found 73 and 272 hip fractures during 78,915 and 395,427 person-years, respectively. The crude incidence rate ratio was 1.34 (95% confidence interval [95% CI] 1.02-1.75). After adjusting for baseline covariates, the hazard ratio (HR) was 1.86 (95% CI 1.37-2.52). After further adjustment for time-dependent covariates, the HR remained significant at 1.62 (95% CI 1.06-2.48). CONCLUSION Patients with newly diagnosed SLE have a 62% increased risk of hip fractures compared to individuals without SLE. For patients with SLE, this result has important implications for prevention of osteoporosis, which may lead to hip fractures.
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Affiliation(s)
- Lingyi Li
- Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Hui Xie
- Arthritis Research Canada, Richmond, and Simon Fraser University, Burnaby, British Columbia, Canada
| | - Na Lu
- Arthritis Research Canada, Richmond, British Columbia, Canada
| | - John M Esdaile
- Arthritis Research Canada, Richmond, and University of British Columbia, Vancouver, British Columbia, Canada
| | - J Antonio Aviña-Zubieta
- Arthritis Research Canada, Richmond, and University of British Columbia, Vancouver, British Columbia, Canada
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30
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Rosenberg EA, Bůžková P, Fink HA, Robbins JA, Shores MM, Matsumoto AM, Mukamal KJ. Testosterone, dihydrotestosterone, bone density, and hip fracture risk among older men: The Cardiovascular Health Study. Metabolism 2021; 114:154399. [PMID: 33058848 PMCID: PMC9060596 DOI: 10.1016/j.metabol.2020.154399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/25/2020] [Accepted: 09/26/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Little is known about the relationships of dihydrotestosterone (DHT), a more potent androgen than testosterone (T), with bone mineral density (BMD) and fracture risk. Our objectives were to evaluate the relationships of T, DHT and sex hormone binding globulin (SHBG) with BMD, fracture risk, and lean body mass (LBM). METHODS We evaluated 1128 older men free of cardiovascular disease in a prospective cohort study using data from the Cardiovascular Health Study. T and DHT were measured by liquid chromatography-tandem mass spectrometry and SHBG by fluoroimmunoassay. Our outcomes included incident hip fracture (n = 106) over a median of 10.2 years and BMD and LBM by dual-energy x-ray absorptiometry (n = 439). RESULTS In Cox regression models mutually adjusted for T, SHBG, and covariates, each standard deviation increment in DHT (0.23 ng/ml) was associated with a 26% lower risk of hip fracture (adjusted hazard ratio [aHR] 0.74, 95% confidence interval (CI) 0.55-1.00, p = 0.049). Similarly, SHBG was associated with fracture in mutually adjusted models (aHR HR 1.26, 95% CI, 1.01-1.58, p = 0.045). In contrast, T (aHR, 1.16, 95% CI, 0.86-1.56, p = 0.324) was not significantly associated with fracture in mutually adjusted models. T, DHT and SHBG were not associated with BMD. T and DHT were both positively associated with LBM in individual models. CONCLUSIONS In older men, DHT was inversely associated with hip fracture risk and SHBG was positively associated with hip fracture risk, while T was not. Future studies should elucidate the mechanisms by which DHT affects bone health.
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Affiliation(s)
- Emily A Rosenberg
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Petra Bůžková
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, MN, United States of America
| | - John A Robbins
- Department of Medicine, University of California Davis, Sacramento, CA, United States of America
| | - Molly M Shores
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States of America; Mental Health Service, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Alvin M Matsumoto
- Department of Medicine, University of Washington, Seattle, WA, United States of America; Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
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D’Silva KM, Cromer SJ, Yu EW, Fischer M, Kim SC. Risk of Incident Atrial Fibrillation With Zoledronic Acid Versus Denosumab: A Propensity Score-Matched Cohort Study. J Bone Miner Res 2021; 36:52-60. [PMID: 33137852 PMCID: PMC7938865 DOI: 10.1002/jbmr.4174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/19/2020] [Accepted: 08/23/2020] [Indexed: 12/13/2022]
Abstract
Zoledronic acid (ZA) is an effective agent in osteoporosis and malignancy-related bone disease but may be associated with increased risk of atrial fibrillation (AF), although current studies disagree on this risk. To examine the risk of incident AF among patients receiving ZA compared with denosumab in the first year of treatment, we performed a new-user, active comparator cohort study including privately insured Americans between January 1, 2010, and June 30, 2019. Individuals aged ≥50 years without known arrhythmia or advanced kidney disease who initiated ZA were 1:1 propensity score (PS)-matched to individuals initiating denosumab in separate osteoporosis and malignancy cohorts. The primary outcome was incident diagnosis of AF (≥1 inpatient or ≥2 outpatient diagnostic codes) over 1 year. Secondary outcomes included stroke/transient ischemic attack (TIA) and nonvertebral fracture. In the osteoporosis cohort (n = 16,235 pairs), mean age was 71 years, and 93% were female. There was higher risk of AF with ZA compared with denosumab over 1 year (incidence rate [IR] = 18.6 versus 14.9 per 1000 person-years; hazard ratio [HR] = 1.25; 95% confidence interval [CI] 1.04 to 1.50). In the malignancy cohort (n = 7732 pairs), mean age was 70 years, and 66% were female. There was a numerically higher, albeit not statistically significant, risk of AF with ZA compared with denosumab over 1 year (IR = 46.9 versus 39.0 per 1000 person-years; HR = 1.19; 95% CI 1.00 to 1.43; p = 0.06). No difference in stroke/TIA rates occurred. In the malignancy cohort, ZA was less effective than denosumab at preventing nonvertebral fractures (HR = 1.32; 95% CI 1.01 to 1.74). Compared with denosumab, ZA treatment for osteoporosis and possibly for malignancy-related bone disease is associated with modestly increased risk of incident AF in the first year of treatment. © 2020 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Kristin M D’Silva
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sara Jane Cromer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, USA
| | - Elaine W Yu
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
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Shin A, Park EH, Dong YH, Ha YJ, Lee YJ, Lee EB, Song YW, Kang EH. Comparative risk of osteoporotic fracture among patients with rheumatoid arthritis receiving TNF inhibitors versus other biologics: a cohort study. Osteoporos Int 2020; 31:2131-2139. [PMID: 32514765 DOI: 10.1007/s00198-020-05488-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/01/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED In this population-based cohort study on comparative osteoporotic fracture risks between different biologic disease-modifying drugs among patients with rheumatoid arthritis (RA), we did not find a significant difference in the risk of osteoporotic fractures between RA patients receiving TNF inhibitors versus abatacept or tocilizumab. INTRODUCTION We aimed to investigate the comparative risk of osteoporotic fractures between rheumatoid arthritis (RA) patients who initiated TNF inhibitors (TNFis) versus abatacept or tocilizumab. METHODS Using the Korea National Health Insurance Service datasets from 2002 to 2016, RA patients who initiated TNFis, abatacept, or tocilizumab were identified. The primary outcome was a composite end point of non-vertebral fractures and hospitalized vertebral fractures; secondary outcomes were two components of the primary outcome and fractures occurring at the humerus/forearm. Propensity score (PS) matching with a variable ratio up to 10 TNFi initiators per 1 comparator drug initiator was used to adjust for > 50 baseline confounders. We estimated hazard ratios (HRs) and 95% confidence interval (CI) of fractures comparing TNFi initiators to abatacept and to tocilizumab by Cox proportional hazard models stratified by a matching ratio. RESULTS After PS-matching, 2307 TNFi initiators PS-matched on 588 abatacept initiators, and 2462 TNFi initiators on 640 tocilizumab initiators were included. A total of 77 fractures occurred during a mean follow-up of 454 days among TNFi and abatacept initiators and 83 fractures during 461 days among TNFi and tocilizumab initiators. The PS-matched HR (95% CI) was 0.91 (0.48-1.71) comparing TNFi versus abatacept initiators, and 1.00 (0.55-1.83) comparing TNFi versus tocilizumab initiators. Analysis on vertebral and non-vertebral fractures showed similar results. CONCLUSIONS In this nationally representative cohort, we did not find a significant difference in the risk of fractures between TNFi initiators versus abatacept or tocilizumab among RA patients.
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Affiliation(s)
- A Shin
- Division of Rheumatology Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - E H Park
- Division of Rheumatology Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Y-H Dong
- Faculty of Pharmacy School of Pharmaceutical Science, National Yang-Ming University, Taipei, Taiwan
- Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Y-J Ha
- Division of Rheumatology Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Y J Lee
- Division of Rheumatology Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - E B Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Y W Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology and College of Medicine, Seoul National University, Seoul, South Korea
| | - E H Kang
- Division of Rheumatology Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
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Simoni AH, Nikolajsen L, Olesen AE, Christiansen CF, Johnsen SP, Pedersen AB. The association between initial opioid type and long-term opioid use after hip fracture surgery in elderly opioid-naïve patients. Scand J Pain 2020; 20:755-764. [PMID: 32853173 DOI: 10.1515/sjpain-2019-0170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/10/2020] [Indexed: 11/15/2022]
Abstract
Objectives Long-term opioid use after hip fracture surgery has been demonstrated in previously opioid-naïve elderly patients. It is unknown if the opioid type redeemed after hip surgery is associated with long-term opioid use. The aim of this study was to examine the association between the opioid type redeemed within the first three months after hip fracture surgery and opioid use 3-12 months after the surgery. Methods A nationwide population-based cohort study was conducted using data from Danish health registries (2005-2015). Previously opioid-naïve patients registered in the Danish Multidisciplinary Hip Fracture Registry, aged ≥65 years, who redeemed ≥1 opioid prescription within three months after the surgery, were included. Long-term opioid use was defined as ≥1 redeemed prescription within each of three three-month periods within the year after hip fracture surgery. The proportion with long-term opioid use after surgery, conditioned on nine-month survival, was calculated according to opioid types within three months after surgery. Adjusted odds ratios (aOR) for different opioid types were computed by logistic regression analyses with 95% confidence intervals (CI) using morphine as reference. Subgroup analyses were performed according to age, comorbidity and calendar time before and after 2010. Results The study included 26,790 elderly, opioid-naïve patients with opioid use within three months after hip fracture surgery. Of these patients, 21% died within nine months after the surgery. Among the 21,255 patients alive nine months after surgery, 15% became long-term opioid users. Certain opioid types used within the first three months after surgery were associated with long-term opioid use compared to morphine (9%), including oxycodone (14%, aOR; 1.76, 95% CI 1.52-2.03), fentanyl (29%, aOR; 4.37, 95% CI 3.12-6.12), codeine (13%, aOR; 1.55, 95% CI 1.14-2.09), tramadol (13%, aOR; 1.56, 95% CI 1.35-1.80), buprenorphine (33%, aOR; 5.37, 95% CI 4.14-6.94), and >1 opioid type (27%, aOR; 3.83, 95% CI 3.31-4.44). The proportion of long-term opioid users decreased from 18% before 2010 to 13% after 2010. Conclusions The findings suggest that use of certain opioid types after hip fracture surgery is more associated with long-term opioid use than morphine and the proportion initiating long-term opioid use decreased after 2010. The findings suggest that some elderly, opioid-naïve patients appear to be presented with untreated pain conditions when seen in the hospital for a hip fracture surgery. Decisions regarding the opioid type prescribed after hospitalization for hip fracture surgery may be linked to different indication for pain treatment, emphasizing the likelihood of careful and conscientious opioid prescribing behavior.
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Affiliation(s)
- Amalie H Simoni
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lone Nikolajsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne E Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Søren P Johnsen
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Meyer AC, Hedström M, Modig K. The Swedish Hip Fracture Register and National Patient Register were valuable for research on hip fractures: comparison of two registers. J Clin Epidemiol 2020; 125:91-99. [DOI: 10.1016/j.jclinepi.2020.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 05/13/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
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Yu EW, Kim SC, Sturgeon DJ, Lindeman KG, Weissman JS. Fracture Risk After Roux-en-Y Gastric Bypass vs Adjustable Gastric Banding Among Medicare Beneficiaries. JAMA Surg 2020; 154:746-753. [PMID: 31090893 DOI: 10.1001/jamasurg.2019.1157] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Importance Roux-en-Y gastric bypass (RYGB) is associated with significant bone loss and may increase fracture risk, whereas substantial bone loss and increased fracture risk have not been reported after adjustable gastric banding (AGB). Previous studies have had little representation of patients aged 65 years or older, and it is currently unknown how age modifies fracture risk. Objective To compare fracture risk after RYGB and AGB procedures in a large, nationally representative cohort enriched for older adults. Design, Setting, and Participants This population-based retrospective cohort analysis used Medicare claims data from January 1, 2006, to December 31, 2014, from 42 345 severely obese adults, of whom 29 624 received RYGB and 12 721 received AGB. Data analysis was performed from April 2017 to November 2018. Main Outcomes and Measures The primary outcome was incident nonvertebral (ie, wrist, humerus, pelvis, and hip) fractures after RYGB and AGB surgery defined using a combination of International Classification of Diseases, Ninth Edition and Current Procedural Terminology 4 codes. Results Of 42 345 participants, 33 254 (78.5%) were women. With a mean (SD) age of 51 (12) years, recipients of RYGB were younger than AGB recipients (55 [12] years). Both groups had similar comorbidities, medication use, and health care utilization in the 365 days before surgery. Over a mean (SD) follow-up of 3.5 (2.1) years, 658 nonvertebral fractures were documented. The fracture incidence rate was 6.6 (95% CI, 6.0-7.2) after RYGB and 4.6 (95% CI, 3.9-5.3) after AGB, which translated to a hazard ratio (HR) of 1.73 (95% CI, 1.45-2.08) after multivariable adjustment. Site-specific analyses demonstrated an increased fracture risk at the hip (HR, 2.81; 95% CI, 1.82-4.49), wrist (HR, 1.70; 95% CI, 1.33-2.14), and pelvis (HR, 1.48; 95% CI, 1.08-2.07) among RYGB recipients. No significant interactions of fracture risk with age, sex, diabetes status, or race were found. In particular, adults 65 years and older showed similar patterns of fracture risk to younger adults. Sensitivity analyses using propensity score matching showed similar results (nonvertebral fracture: HR 1.75; 95% CI, 1.22-2.52). Conclusions and Relevance This study of a large, US population-based cohort including a substantial population of older adults found a 73% increased risk of nonvertebral fracture after RYGB compared with AGB, including increased risk of hip, wrist, and pelvis fractures. Fracture risk was consistently increased among RYGB patients vs AGB across different subgroups, and to a similar degree among older and younger adults. Increased fracture risk appears to be an important unintended consequence of RYGB.
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Affiliation(s)
- Elaine W Yu
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Immunology and Allergy; Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel J Sturgeon
- Center for Surgery and Public Health; Brigham and Women's Hospital,Harvard Medical School, Boston, Massachusetts
| | - Katherine G Lindeman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joel S Weissman
- Center for Surgery and Public Health; Brigham and Women's Hospital,Harvard Medical School, Boston, Massachusetts
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Bushnell GA, Gerhard T, Crystal S, Olfson M. Benzodiazepine Treatment and Fracture Risk in Young Persons With Anxiety Disorders. Pediatrics 2020; 146:peds.2019-3478. [PMID: 32499386 PMCID: PMC7329250 DOI: 10.1542/peds.2019-3478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Benzodiazepines are commonly prescribed to treat anxiety disorders and have been associated with falls and fractures in older adults. It is unknown whether benzodiazepines increase fracture risk in youth. We examined whether youth with anxiety disorders initiating benzodiazepine treatment have an increased risk of fractures compared with youth initiating selective serotonin reuptake inhibitors (SSRIs). METHODS We used claims from commercially insured children (6-17 years) and young adults (18-24) with a recent anxiety disorder diagnosis, initiating benzodiazepines or SSRIs (2008-2016). Youth were followed until fracture, treatment discontinuation or switching, disenrollment, 3 months, or December 31, 2016. The primary end point was diagnostic codes for upper and lower limb fractures. Incident fracture rates, incident rate ratios (IRRs), and incident rate differences (IRDs) were estimated with propensity score inverse probability of treatment weighting. RESULTS The cohort included 120 715 children and 179 768 young adults. In children, crude fracture rates during treatment were 33.1 per 1000 person-years (PYs) for benzodiazepine initiators and 25.1 per 1000 PYs for SSRI initiators. Adjusted IRR and IRD were 1.53 (95% confidence interval [CI]: 0.94-2.50) and 13.4 per 1000 PYs. Risk was heightened in children initiating long-acting benzodiazepines versus SSRIs (adjusted IRR = 2.30 [95% CI: 1.08-4.91]). Fracture rates were lower in young adults, with minimal differences between treatments (adjusted IRR = 0.85 [95% CI: 0.57-1.27]; adjusted IRD = -1.3 per 1000 PYs). CONCLUSIONS An increased rate of fractures in children, but not young adults, with anxiety disorders initiating benzodiazepine treatment compared to SSRI treatment suggests a need for increased caution in the weeks after benzodiazepine initiation in children.
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Affiliation(s)
| | - Tobias Gerhard
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey,Center for Pharmacoepidemiology and Treatment Science, Rutgers, The State University of New Jersey, New Brunswick, New Jersey,Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health and,Department of Psychiatry, Columbia University Irving Medical Center, Columbia University, New York, New York; and
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Khalid SI, Omotosho PA, Spagnoli A, Torquati A. Association of Bariatric Surgery With Risk of Fracture in Patients With Severe Obesity. JAMA Netw Open 2020; 3:e207419. [PMID: 32520360 PMCID: PMC7287567 DOI: 10.1001/jamanetworkopen.2020.7419] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Given the complex relationship between body mass index, body composition, and bone density and the correlative nature of the studies that have established the prevailing notion that higher body mass indices may be protective against osteopenia and osteoporosis and, therefore, fracture, the absolute risk of fracture in patients with severe obesity who undergo either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) compared with those who do not undergo bariatric surgery is unknown. OBJECTIVE To assess the rates of fractures associated with obesity and compare rates between those who do not undergo bariatric surgery, those who undergo RYGB, and those who undergo SG. DESIGN, SETTING, AND PARTICIPANTS In this retrospective multicenter cohort study of Medicare Standard Analytic Files derived from Medicare parts A and B records from January 2004 to December 2014, patients classified as eligible for bariatric surgery using the US Centers of Medicare & Medicaid criteria who either did not undergo bariatric surgery or underwent RYGB or SG were exactly matched in a 1:1 fashion based on their age, sex, Elixhauser Comorbidity Index, hypertension, smoking status, nonalcoholic fatty liver disease, hyperlipidemia, type 2 diabetes, osteoporosis, osteoarthritis, and obstructive sleep apnea status. Data were analyzed from November to December 2019. EXPOSURES RYGB or SG. MAIN OUTCOMES AND MEASURES The primary outcome measured in this study was the odds of fracture overall based on exposure to bariatric surgery. Secondary outcomes included the odds of type of fracture (humerus, radius or ulna, pelvis, hip, vertebrae, and total fractures) based on exposure to bariatric surgery. RESULTS A total of 49 113 patients were included and were equally made up of 16 371 bariatric surgery-eligible patients who did not undergo weight loss surgery, 16 371 patients who had undergone RYGB, and 16 371 patients who had undergone SG. Each group consisted of an equal number of 4109 men (25.1%) and 12 262 women (74.9%) and had an equal distribution of ages, with 11 780 patients (72.0%) 64 years or younger, 4230 (25.8%) aged 65 to 69 years, 346 (2.1%) aged 70 to 74 years, and 15 (0.1%) aged 75 to 79 years. Patients undergoing RYGB were found to have no significant difference in odds of fractures compared with bariatric surgery-eligible patients who did not undergo surgery. Patients undergoing undergone SG were found to have decreased odds of fractures of the humerus (odds ratio [OR], 0.57; 95% CI, 0.45-0.73), radius or ulna (OR, 0.38; 95% CI, 0.25-0.58), hip (OR, 0.49; 95% CI, 0.33-0.74), pelvis (OR, 0.34; 95% CI, 0.18-0.64), vertebrae (OR, 0.60; 95% CI, 0.48-0.74), or fractures in general (OR, 0.53; 95% CI, 0.46-0.62). Compared with patients undergoing SG, patients undergoing RYGB had a significantly greater risk of total fractures (OR, 1.79; 95% CI, 1.55-2.06) and humeral fractures (OR, 1.60; 95% CI, 1.24-2.07). CONCLUSIONS AND RELEVANCE In this cohort study, bariatric surgery was associated with a reduced risk of fracture in bariatric surgery-eligible patients. Sleeve gastrectomy might be the best option for weight loss in patients in which fractures could be a concern, as RYGB may be associated with an increased fracture risk compared with SG.
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Affiliation(s)
- Syed I. Khalid
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Philip A. Omotosho
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Anna Spagnoli
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Alfonso Torquati
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
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Hjelholt TJ, Edwards NM, Vesterager JD, Kristensen PK, Pedersen AB. The Positive Predictive Value of Hip Fracture Diagnoses and Surgical Procedure Codes in the Danish Multidisciplinary Hip Fracture Registry and the Danish National Patient Registry. Clin Epidemiol 2020; 12:123-131. [PMID: 32099478 PMCID: PMC7007794 DOI: 10.2147/clep.s238722] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 01/13/2020] [Indexed: 01/10/2023] Open
Abstract
Aim The health-care databases may be a valuable source for epidemiological research in hip fracture surgery, if the diagnoses are valid. We examined the validity of hip fracture diagnoses and surgical procedure codes in the Danish Multidisciplinary Hip Fracture Registry (DMHFR) and the Danish National Patient Registry (DNPR) by calculating the positive predictive value (PPV). Methods We identified a random sample of 750 hip fracture patients registered in the DMHFR between 2014 and 2017. Diagnoses have been coded by the 10th revision of the International Classification of Diseases, while procedures have been coded by the Nordic Medico-Statistical Committee classification in the DNPR and directly transferred to the DMHFR. Using the surgical procedure description from the medical record as gold standard, we estimated the PPV of the hip fracture diagnoses and surgical procedure codes in the DMHFR and the DNPR with 95% confidence interval (CIs). Results The PPV was 90% (95% CI: 86%-93%) for fracture of the neck of femur, 92% (95% CI: 87%-95%) for trochanteric fracture, and 83% (95% CI: 78%-88%) for subtrochanteric fracture. Joining trochanteric and subtrochanteric fracture resulted in a PPV of 97% (95% CI: 95%-98%). Procedure codes had a PPV of 100% for primary prosthetic replacement and internal fixation with intramedullary nail, 96% (95% CI: 85%-99%) for internal fixation using screws alone, 91% (95% CI: 84%-96%) for internal fixation using plates and screws, and 89% (95% CI: 83%-94%) for internal fixation with other or combined methods. Stratifying by age group, gender, hospital type and calendar year of surgery showed similar results as the overall PPV estimates. Conclusion Our findings indicate a high quality of the hip fracture diagnoses and corresponding procedure codes in the DMHFR and the DNPR, with a majority of PPVs above 90%. Thus, the DMHFR and the DNPR are a valuable data source on hip fracture for epidemiological research.
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Affiliation(s)
- Thomas J Hjelholt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Nina M Edwards
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Jeppe D Vesterager
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Pia K Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark.,Department of Orthopedic Surgery, Horsens Regional Hospital, Horsens 8700, Denmark
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
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Kjørholt KE, Kristensen NR, Prieto-Alhambra D, Johnsen SP, Pedersen AB. Increased risk of mortality after postoperative infection in hip fracture patients. Bone 2019; 127:563-570. [PMID: 31340186 DOI: 10.1016/j.bone.2019.07.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/16/2019] [Accepted: 07/19/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative infection is a common complication in hip fracture patients and the risk appears to have increased during the last decade. However, the impact of infection on mortality after hip fracture surgery remains unclear. PURPOSE We aimed to examine the association between infection (any, as well as specific infections), with all-cause mortality following hip fracture surgery. METHODS Using Danish nationwide registries, we conducted a population-based cohort study on 74,771 hip fracture patients ≥65 years old operated from 2005 to 2016. We included hospital-treated infection as a time-varying exposure, and calculated 30-days mortality rate per 1000 person-years (PY). We used time-varying Cox Proportional Hazard Regression to compute 30-days adjusted hazards ratios (aHRs) with 95% confidence interval (CI) comparing the mortality of hip fracture patients with and without infections. We adjusted for sex, age, comorbidities, medication use, and marital status. RESULTS Within 30 days of surgery, 9592 (12.8%) patients developed a hospital-treated infection. Among these, 30-days mortality was 8.43 per 1000 PY compared with 3.34 among patients without infection (aHR = 2.72, 95% CI: 2.56-2.88). For patients who developed pneumonia, aHR was 4.18 (95% CI: 3.91-4.48), whereas the aHR was 8.86 (95% CI: 7.88-9.95) for patients who developed systemic sepsis. For patients who sustained reoperation due to infection, aHR was 2.95 (95%CI: 1.88-4.64). The mortality was higher in infected vs. non-infected patients irrespective of patients' age, sex and comorbidity. CONCLUSION Infection within 30 days of hip fracture surgery is associated with substantially increased mortality risk. Further research should improve our knowledge about patients at increased risk and prevention measures for specific infections.
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Affiliation(s)
- Kaja Eriksrud Kjørholt
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark.
| | - Nickolaj Risbo Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Daniel Prieto-Alhambra
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Old Rd, Oxford OX3 7LD, United Kingdom
| | - Søren Paaske Johnsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Mølleparkvej 10, 9000 Aalborg, Denmark
| | - Alma Bečić Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
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Pedersen AB, Heide-Jørgensen U, Sørensen HT, Prieto-Alhambra D, Ehrenstein V. Comparison of Risk of Osteoporotic Fracture in Denosumab vs Alendronate Treatment Within 3 Years of Initiation. JAMA Netw Open 2019; 2:e192416. [PMID: 31002319 PMCID: PMC6481596 DOI: 10.1001/jamanetworkopen.2019.2416] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE Head-to-head randomized clinical trials showed greater efficacy of denosumab vs alendronate in improving bone mineral density. Although there is an association of changes in bone mineral density with reductions in fracture risk, the magnitude of the association is not well established. OBJECTIVE To compare the risk of hip and any fracture in patients treated with denosumab and alendronate in routine practice settings. DESIGN, SETTING, AND PARTICIPANTS This Danish nationwide, population-based, historical cohort study of a population with universal access to health care used prospectively collected, individually linked data from Danish health registries with complete follow-up. Cohorts consisted of 92 355 individuals 50 years or older who were new users of denosumab (n = 4624) or alendronate (n = 87 731) from May 2010 to December 2017 after at least 1 year without an antiosteoporosis medication dispensing. EXPOSURES Initiation of denosumab or alendronate. MAIN OUTCOMES AND MEASURES The primary outcome was hospitalization for hip fracture, and the secondary outcome was hospitalization for any fracture. Inverse probability of treatment weights and the intention-to-treat approach were used to calculate cumulative incidences and adjusted hazard ratios (aHRs) with 95% CIs. RESULTS Of the 92 355 included patients, 75 046 (81.3%) were women, and the mean (SD) age was 71 (10) years. The denosumab cohort had a lower proportion of men than the alendronate cohort (12.7% [589] vs 19.0% [16 700]), while age distributions were similar in the 2 cohorts. Within 3 years of follow-up, initiation of denosumab or alendronate was associated with cumulative incidences of 3.7% and 3.1%, respectively, for hip fracture and 9.0% and 9.0%, respectively, for any fracture. Overall, the aHRs for denosumab vs alendronate were 1.08 (95% CI, 0.92-1.28) for hip fracture and 0.92 (95% CI, 0.83-1.02) for any fracture. The aHR of denosumab vs alendronate for hip fracture was 1.07 (95% CI, 0.85-1.34) among patients with a history of any fracture and 1.05 (95% CI, 0.83-1.32) among patients without history of fracture. The aHR for any fracture for denosumab vs alendronate was 0.84 (95% CI, 0.71-0.98) among patients with a history of any fracture and 0.77 (95% CI, 0.64-0.93) among patients with no history of fracture. CONCLUSIONS AND RELEVANCE Treatment with denosumab and alendronate was associated with similar risks of hip or any fracture over a 3-year period, regardless of fracture history.
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Affiliation(s)
- Alma B. Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik T. Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Daniel Prieto-Alhambra
- Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine, Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Grup de Recerca en Epidemiologia de las Malalties Prevalents de l’Aparell Locomotor Research Group, Centro de Investigación Biomédica en Red Fragilidad y Envejcimiento Saludable (CIBERFes), Instituto de Salud Carlos III and Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Simoni AH, Nikolajsen L, Olesen AE, Christiansen CF, Pedersen AB. Opioid use after hip fracture surgery: A Danish nationwide cohort study from 2005 to 2015. Eur J Pain 2019; 23:1309-1317. [PMID: 30848038 DOI: 10.1002/ejp.1392] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is currently a knowledge gap regarding persistent opioid use after hip fracture surgery. Thus, opioid use within a year after hip fracture surgery in patients with/without opioid use before surgery was examined. METHODS This population-based cohort study included all patients (aged ≥ 65) undergoing primary hip fracture surgery in Denmark (2005-2015) identified from the Danish Multidisciplinary Hip Fracture Database. Opioid use was assessed from The Danish National Health Service Prescription Database as redeemed prescriptions. The proportion of patients with ≥1 opioid prescription was computed within 6 months before surgery and each of four 3-month periods (quarters) after surgery, among patients alive first day in each period. Proportion differences (95% CI) were calculated for each quarter compared to before surgery. Proportions were calculated for users and nonusers before surgery, including initiators after first quarter. RESULTS This study included 69,456 patients. Proportion differences of opioid users were 35.0 (95% CI 34.5-35.5), 7.0 (95% CI 6.5-7.5), 2.9 (95% CI 2.4-3.4) and 1.4 percentage-points (95% CI 0.9-1.9) the four quarters after surgery compared to before. Among opioid nonusers before surgery, 54.7% (95% CI 54.3-55.1), 21.8% (95% CI 21.4-22.2), 17.8% (95% CI 17.4-18.2) and 16.8% (95% CI 16.4-17.2) were opioid users in 1st-4th quarter after surgery. However, 8.5% (95% CI 8.2-8.7) of the nonusers before surgery in 4th quarter initiated opioid use more than a quarter after surgery. CONCLUSIONS The proportion of opioid users increased after hip fracture surgery and was 1.4 percentage-points increased in fourth quarter compared to before. Of opioid nonusers before surgery, 16.8% were opioid users fourth quarter after surgery. SIGNIFICANCE Opioid use 1 year after hip fracture surgery is common, both in patients who were opioid users and nonusers before the surgery. These significant findings point out the need for indication of benefits and risks of opioid use in the acute and long-term management of patients undergoing hip fracture surgery.
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Affiliation(s)
- Amalie H Simoni
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Danish Center for Clinical Health Services Research (DACS), Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Lone Nikolajsen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne E Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Fralick M, Kim SC, Schneeweiss S, Kim D, Redelmeier DA, Patorno E. Fracture Risk After Initiation of Use of Canagliflozin: A Cohort Study. Ann Intern Med 2019; 170:155-163. [PMID: 30597484 PMCID: PMC6602870 DOI: 10.7326/m18-0567] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors promote glycosuria, resulting in possible effects on calcium, phosphate, and vitamin D homeostasis. Canagliflozin is associated with decreased bone mineral density and a potential increased risk for fracture. OBJECTIVE To estimate risk for nonvertebral fracture among new users of canagliflozin compared with a glucagon-like peptide-1 (GLP-1) agonist. DESIGN Population-based new-user cohort study. SETTING Two U.S. commercial health care databases providing data on more than 70 million patients from March 2013 to October 2015. PATIENTS Persons with type 2 diabetes who initiated use of canagliflozin were propensity score-matched in a 1:1 ratio to those initiating use of a GLP-1 agonist. MEASUREMENTS The primary outcome was a composite end point of humerus, forearm, pelvis, or hip fracture requiring intervention. Secondary outcomes included fractures at other sites. A fixed-effects meta-analysis that pooled results from the 2 databases provided an overall hazard ratio (HR). RESULTS 79 964 patients initiating use of canagliflozin were identified and matched to 79 964 patients initiating use of a GLP-1 agonist. Mean age was 55 years, 48% were female, average baseline hemoglobin A1c level was 8.7%, and 27% were prescribed insulin. The rate of the primary outcome was similar for canagliflozin (2.2 events per 1000 person-years) and GLP-1 agonists (2.3 events per 1000 person-years), with an overall HR of 0.98 (95% CI, 0.75 to 1.26). Risk for pelvic, hip, humerus, radius, ulna, carpal, metacarpal, metatarsal, or ankle fracture was also similar for canagliflozin (14.5 events per 1000 person-years) and GLP-1 agonists (16.1 events per 1000 person-years) (overall HR, 0.92 [CI, 0.83 to 1.02]). LIMITATION Unmeasured confounding, measurement error, and low fracture rate. CONCLUSION In this study of middle-aged patients with type 2 diabetes and relatively low fracture risk, canagliflozin was not associated with increased risk for fracture compared with GLP-1 agonists. PRIMARY FUNDING SOURCE Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics.
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Affiliation(s)
- Michael Fralick
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, and Clinician Scientist Training Program, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (M.F.)
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.C.K., S.S., D.K., E.P.)
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.C.K., S.S., D.K., E.P.)
| | - Dae Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.C.K., S.S., D.K., E.P.)
| | - Donald A Redelmeier
- Sunnybrook Hospital and University of Toronto, Toronto, Ontario, Canada (D.A.R.)
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.C.K., S.S., D.K., E.P.)
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Commonly Initiated Opioids and Risk of Fracture Hospitalizations in United States Nursing Homes. Drugs Aging 2018; 35:925-936. [PMID: 30187291 DOI: 10.1007/s40266-018-0583-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The aim of this study was to estimate the comparative safety of initiating commonly used opioids among older, long-stay United States nursing home residents with fracture hospitalizations. METHODS We conducted a new-user retrospective cohort study of nursing home residents initiating short-acting oxycodone, hydrocodone, or tramadol by merging the 2011-2013 Minimum Data Set 3.0 to Medicare hospitalization and pharmacy claims. Residents (≥ 65 years, no cancer or hospice use) contributed treatment episodes (> 120 days with no prior opioid claims) and were followed for 180 days until incident fracture hospitalization (hip, femur, humerus, pelvis, radius/ulna), death (competing risk), treatment changes (e.g., discontinuation), or administrative censoring. Competing risks models with inverse probability of treatment weighting were used to estimate subdistribution hazard ratios (HRSD) and 95% confidence intervals (CI). RESULTS Overall, 110,862 residents contributed 134,432 treatment episodes: 14,373 oxycodone; 69,182 hydrocodone; and 50,877 tramadol initiators. The incidences of fracture hospitalizations per 100 person-years were 9.4 (95% CI 7.5-11.7) for oxycodone, 7.9 (95% CI 7.1-8.8) for hydrocodone, and 5.0 (95% CI 4.3-5.7) for tramadol initiators. In weighted models, oxycodone initiators had a similar rate of fractures to hydrocodone initiators (HRSD 1.08, 95% CI 0.79-1.48). Tramadol initiators had lower fracture rates than hydrocodone initiators (HRSD 0.67, 95% CI 0.56-0.80). CONCLUSIONS The lower rate of fractures that we documented among tramadol initiators compared with hydrocodone initiators is consistent, albeit attenuated compared with prior studies among community-dwelling older adults. However, overall fracture rates were lower than in community settings, potentially due to the limited risk of falling in this population with limited mobility.
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Colón-Emeric CS, Pieper CF, Van Houtven CH, Grubber JM, Lyles KW, Lafleur J, Adler RA. Limited Osteoporosis Screening Effectiveness Due to Low Treatment Rates in a National Sample of Older Men. Mayo Clin Proc 2018; 93:1749-1759. [PMID: 30497697 PMCID: PMC6338211 DOI: 10.1016/j.mayocp.2018.06.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/25/2018] [Accepted: 06/04/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the association between dual-energy x-ray absorptiometry (DXA) testing for osteoporosis and subsequent fractures in US male veterans without a previous fracture. PATIENTS AND METHODS This is a propensity score-matched observational study using Centers for Medicare and Medicaid Services and Veterans Affairs (VA) data from January 1, 2000, through December 31, 2010, with a mean follow-up time of 4.7 years (range, 0-10 years). Men receiving VA primary care aged 65 to 99 years without a previous fracture (N=2,539,812) were included. Men undergoing DXA testing were propensity score matched with untested controls in a 1:3 ratio, indicating the probability of DXA testing within the next year. Time to first clinical fracture was the primary outcome. Comorbidities, demographic characteristics, medications, DXA results, and osteoporosis treatment were defined using administrative data and natural language processing. A landmark analysis contingent on surviving to 12 months after screening was completed, accounting for competing risk of mortality. RESULTS During follow-up of 153,311 men tested by DXA and 390,158 controls, 56,083 (10.3%) had sustained a fracture and 111,774 (20.6%) died. Overall, DXA testing was not associated with a decrease in fractures; conclusions are limited by unmeasured confounders and low medication initiation and adherence in those meeting treatment thresholds (12% of follow-up time). In contrast, DXA testing in prespecified subgroups was associated with a lower risk of fracture in comparison to the overall population who underwent DXA testing: androgen deprivation therapy (hazard ratio [HR], 0.77; 95% CI, 0.66-0.89), glucocorticoids (HR, 0.77; 95% CI, 0.72-0.84), age 80 years and older (HR, 0.85; 0.81-0.90), 1 or more VA guideline risk factors (HR, 0.91; 95% CI, 0.87-0.95), and high Fracture Risk Assessment Tool using body mass index score (HR, 0.90; 95% CI, 0.86-0.95). CONCLUSION Current VA DXA testing practices are ineffective overall; interventions to improve treatment adherence are needed. Targeted DXA testing in higher-risk men was associated with a lower fracture risk.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC; Durham VA Geriatric Research, Education and Clinical Center, Durham, NC.
| | - Carl F Pieper
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC
| | - Courtney H Van Houtven
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC; Durham VA Health Services Research and Development Center of Innovation, Durham, NC
| | - Janet M Grubber
- Durham VA Health Services Research and Development Center of Innovation, Durham, NC
| | - Kenneth W Lyles
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC; Durham VA Geriatric Research, Education and Clinical Center, Durham, NC
| | | | - Robert A Adler
- Hunter Holmes McGuire VA Medical Center, Richmond, VA; Department of Medicine, Virginia Commonwealth University, Richmond, VA
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Airy M, Chang TI, Ding VY, Goldstein BA, Bansal N, Niu J, Navaneethan SD, Turakhia MP, Winkelmayer WC. Risk profiles for acute health events after incident atrial fibrillation in patients with end-stage renal disease on hemodialysis. Nephrol Dial Transplant 2018; 33:1590-1597. [PMID: 29145634 DOI: 10.1093/ndt/gfx301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022] Open
Abstract
Background Little is known about the cardiovascular risks of incident atrial fibrillation/flutter (AF) in patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD). Methods We studied older US patients who newly initiated HD for ESRD (2006-11) and who had not previously been diagnosed with AF, stroke, myocardial infarction (MI) or hip fracture. We used Cox regression with AF as a time-varying covariate, adjusted for socio-demographic characteristics and comorbidities to estimate hazard ratios [HRs (95% confidence intervals)] for the events of ischemic stroke, MI and death. Hip fracture served as a negative control outcome. Results We identified 85 377 older patients (mean age: 76.5 years) who initiated HD; of these, 14.3% were subsequently diagnosed with AF (14.9% thereof as primary diagnosis) and 49.8% died during follow-up. Incident AF was associated with nine times higher adjusted mortality during the first 30 days [9.2 (8.8-9.6)], 5-fold higher mortality between 31 and 90 days [4.6 (4.3-4.8)] and double the mortality beyond 90 days from first AF diagnosis [2.2 (2.1-2.3)]. Incident AF was similarly associated with higher adjusted risk of ischemic stroke: 2.1 (1.6-2.7) during the first 30 days, 2.5 (2.0-3.0) between 31 and 90 days and 1.5 (1.3-1.7) beyond 90 days. Similar findings were obtained for MI. However, the risk of hip fracture was only marginally increased following AF diagnosis [≤30 days: 1.1 (0.7-1.6); 31-90 days: 1.4 (1.0-1.8); >90 days: 1.2 (1.1-1.4)]. All associations were attenuated and the association with hip fracture was null when incident AF was defined by a primary diagnosis code. Conclusions AF was strongly associated with increased risks of ischemic stroke, MI and death, with risks highest soon after AF diagnosis but extending beyond 90 days.
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Affiliation(s)
- Medha Airy
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Victoria Y Ding
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Nephrology, Seattle, WA, USA
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mintu P Turakhia
- Cardiovascular Division, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Bruun SB, Petersen I, Kristensen NR, Cronin-Fenton D, Pedersen AB. Selective serotonin reuptake inhibitor use and mortality, postoperative complications, and quality of care in hip fracture patients: a Danish nationwide cohort study. Clin Epidemiol 2018; 10:1053-1071. [PMID: 30214311 PMCID: PMC6118260 DOI: 10.2147/clep.s166309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose To examine the association between selective serotonin reuptake inhibitor (SSRI) use and mortality, postoperative complications, and quality of in-hospital care in hip fracture patients. Patients and methods The study was a nationwide cohort study based on individual-level linked, prospectively collected data from Danish population-based national registries covering all hospitals in Denmark. The health care system in Denmark is tax-funded, and all citizens have equal access to health care services. We included patients with first-time hospitalization due to hip fracture undergoing surgery from 2006–2016. We estimated the risk of 30-day mortality, any unplanned readmission, any reoperation, specific postoperative complications including cardiovascular events and major bleeding, and quality of in-hospital care using Cox and Poisson regression analyses comparing current and former SSRI users with non-users. Results In 68,487 hip fracture patients, 13,272 (19%) were current SSRI users, 2,777 (4%) were former SSRI users, and 52,438 (77%) were SSRI non-users. The 30-day mortality risk was 13% in current SSRI users (HR 1.16, 1.10–1.21) and 12% in former (HR 1.15, 1.04–1.27) compared with 10% in non-users. The HR for any unplanned readmission was 1.11 (1.02–1.20) in current and 1.13 (1.01–1.27) in former SSRI users and for any reoperation 1.21 (1.11–1.31) in current and 1.04 (0.84–1.28) in former SSRI users compared with non-users. The risk of venous thromboembolism, myocardial infarction, stroke, and bleeding were similar irrespective of SSRI use. No association between current and former SSRI use and quality of in-hospital care was found. Conclusion In patients undergoing hip fracture surgery, 30-day mortality and overall readmission risk were elevated in both current and former SSRI users compared with non-users. Those currently using SSRI had a 26% increased reoperation risk compared with non-users. However, SSRI use was not associated with increased risk of other postoperative complications and lower quality of in-hospital care. A limitation of this study was the inability to control for potential confounding of social deprivation.
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Affiliation(s)
| | - Irene Petersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark, .,Department of Primary Care and Population Health, University College London, London, UK
| | | | | | - Alma Becic Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
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Montomoli J, Erichsen R, Gammelager H, Pedersen AB. Liver disease and mortality among patients with hip fracture: a population-based cohort study. Clin Epidemiol 2018; 10:991-1000. [PMID: 30174458 PMCID: PMC6110281 DOI: 10.2147/clep.s168237] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose The aim of this study was to examine the prognostic impact of liver disease on mortality following hip fracture (HF). Patients and methods This nationwide cohort study, based on prospectively collected data retrieved from Danish registries, included all patients diagnosed with incident HF in Denmark during 1996-2013. Patients were classified based on the coexisting liver disease at the time of HF, ie, no liver disease, noncirrhotic liver disease, and liver cirrhosis. We computed 30-day and 31-365-day mortality risks. To compare patients with and without liver disease, we computed mortality adjusted hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) using Cox regression controlled for potential confounders. Results Among 152,180 HF patients, 2,552 (1.7%) patients had noncirrhotic liver disease and 1,866 (1.2%) patients had liver cirrhosis. Thirty-day mortality was 9.4% among patients with noncirrhotic liver disease, 12.6% among patients with liver cirrhosis patients, and 9.7% among patients without liver disease. Compared to patients without liver disease, crude and adjusted HRs within 30 days following HF were, respectively, 0.96 (95% CI: 0.85-1.10) and 1.24 (95% CI: 1.09-1.41) for patients with noncirrhotic liver disease and 1.30 (95% CI: 1.14-1.48) and 2.25 (95% CI: 1.96-2.59) for those with liver cirrhosis. Among patients who survived 30 days post-HF, the 31-365-day mortality was 18.5% among patients with noncirrhotic liver disease, 26.4% among patients with liver cirrhosis, and 19.4% among patients without liver disease. Corresponding crude and adjusted HRs were, respectively, 0.95 (95% CI: 0.86-1.04) and 1.08 (95% CI: 0.99-1.20) for patients with noncirrhotic liver disease and 1.40 (95% CI: 1.27-1.54) and 1.91 (95% CI: 1.72-2.12) for those with liver cirrhosis. Conclusion Liver disease patients, especially those with liver cirrhosis, had increased 30-day mortality and 31-365-day mortality following HF, compared to patients without liver disease.
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Affiliation(s)
- Jonathan Montomoli
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark,
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark,
| | - Henrik Gammelager
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark,
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark,
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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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Pedersen AB, Ehrenstein V, Szépligeti SK, Sørensen HT. Hip Fracture, Comorbidity, and the Risk of Myocardial Infarction and Stroke: A Danish Nationwide Cohort Study, 1995-2015. J Bone Miner Res 2017; 32:2339-2346. [PMID: 28833527 DOI: 10.1002/jbmr.3242] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 11/06/2022]
Abstract
We evaluated risks of MI and stroke in elderly patients with hip fracture compared with the general population. We also examined the interaction between hip fracture and comorbidity with respect to risks of MI or stroke, defined as excess of risk explained by combining risks of hip fracture and comorbidity. We conducted a population-based cohort study using Danish health registries, in 1995 to 2015 including 110,563 hip fracture patients and 552,774 members of the comparison cohort from the general population. Thirty-day cumulative incidences of MI were 1.15% among patients with hip fracture and 0.09% in the general population (adjusted hazard ratio [aHR] = 12.97; 95% confidence interval [CI], 11.56 to 14.55). Thirty-day cumulative incidences of stroke were 2.16% for hip fracture patients and 0.21% in the general population (aHR = 9.42; 95% CI, 8.71 to 10.19). During the 31 to 365 days following hip fracture, the aHR for MI was 1.05 (95% CI, 0.97 to 1.14) and remained at this level during the remainder of follow-up (maximum of 20 years). The aHR for stroke was 1.29 (95% CI, 1.22 to 1.35) during the 31 to 365 days following hip fracture, remained elevated for up to 10 years, and then decreased to the general population level. The aHRs for MI and stroke were increased for both men and women, and in all age and comorbidity groups. During the first 30 days, up to 76% of MI and stroke risk was attributable to interaction between hip fracture and comorbidity. Patients with hip fracture are at increased risk of both MI and stroke up to 1 year following the fracture. Risk of stroke, but not of MI, was elevated during up to 10 years postfracture. Although the absolute risks were low, our finding underscores the importance of targeting multimorbidity, including prevention and adequate treatment, to improve the prognosis of hip fracture patients. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, CA, USA
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Pedersen AB, Ehrenstein V, Szépligeti SK, Sørensen HT. Excess risk of venous thromboembolism in hip fracture patients and the prognostic impact of comorbidity. Osteoporos Int 2017; 28:3421-3430. [PMID: 28871320 DOI: 10.1007/s00198-017-4213-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 08/25/2017] [Indexed: 12/21/2022]
Abstract
UNLABELLED Hip fracture patients were at increased excess risk of venous thromboembolism (VTE) up to 1 year following hip fracture. During the first year, interaction between hip fracture and comorbidity was observed among patients with severe and very severe comorbidity. INTRODUCTION We compared the risk of VTE in hip fracture patients with that in the general population. We also examined whether and to what extent the association between hip fracture and VTE varied by comorbidity level. METHODS Nationwide cohort study based on Danish health registries, 1995-2015. We identified hip fracture patients (n = 110,563) and sampled a comparison cohort without hip fracture from the general population (n = 552,774). Comorbidity was assessed using the Charlson comorbidity index. We calculated attributable fraction, as the proportion of the VTE rate, among persons exposed to both hip fracture and comorbidity, attributed to exposure interaction. RESULTS The cumulative incidences of VTE were 0.73% within 30 days and 0.83% within 31-365 days among hip fracture patients, and 0.05 and 0.43% in the general population. Adjusted hazard ratios (HRs) of VTE among hip fracture patients were 17.29 [95% confidence interval (CI) 14.74-20.28] during the first 30 days and 2.13 (95% CI 1.95-2.32) during 31-365 days following hip fracture. The relative risks of VTE were 1.03 (95% CI 0.96-1.11) and 1.11 (95% CI 1.00-1.23) after 1-5 years and 6-10 years. During the first 30 days and 31-365 days, 14%/28% of VTE rates and 5%/4% of VTE rates were attributable to the interaction between hip fracture and severe/very severe comorbidity, respectively. Mortality risks within 30 days of VTE were 29.4% in hip fracture and 11.0% in general population cohorts. CONCLUSIONS Hip fracture patients were at increased excess risk of VTE up to 1 year following their fracture. During the first year, interaction between hip fracture and comorbidity was observed among patients with severe and very severe comorbidity.
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Affiliation(s)
- A B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark.
| | - V Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
| | - S K Szépligeti
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
| | - H T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
- Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, CA, USA
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