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Li X, Li R, Li M, Yao L, Van Spall H, Zhao K, Chen Y, Xiao F, Fu Q, Xie F. A Systematic Review and Quality Assessment of Cardiovascular Disease-Specific Health-Related Quality-of-Life Instruments Part I: Instrument Development and Content Validity. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02331-3. [PMID: 38608875 DOI: 10.1016/j.jval.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 02/12/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVES Health-related quality-of-life (HRQoL) instruments for cardiovascular diseases (CVD) have been commonly used to measure important patient-reported outcomes (PROs) in clinical trials and practices. This study aimed at systematically identifying and assessing the content validity of CVD-specific HRQoL instruments in clinical studies. METHODS The research team searched Cumulative Index to Nursing and Allied Health Literature, Embase, and PubMed from inception to January 20, 2022. The research team included studies that reported the development and content validity for CVD-specific instruments. Two reviewers independently assessed the methodological quality using the Consensus-based Standards for the Selection of Health Measurement Instruments methods on evaluating content validity of PROs. Content analysis was used to categorize the items included in the instruments. RESULTS The research team found 69 studies reporting the content validity of 40 instruments specifically developed for CVD. Fourteen (35.0%) were rated "sufficient" with very low to moderate quality of evidence. For PRO development, all instruments were rated "doubtful" or "inadequate." Twenty-eight (70.0%) instruments cover the core concepts of HRQoL. CONCLUSIONS The quality of development and content validity vary among existing CVD-specific instruments. The evidence on the content validity should be considered when choosing a HRQoL instrument in CVD clinical studies and health economic evaluations.
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Affiliation(s)
- Xue Li
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Health Technology Assessment, China National Health Development Research Center, Beijing, China
| | - Rui Li
- Department of Health Technology Assessment, China National Health Development Research Center, Beijing, China; Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Meixuan Li
- Evidence Based Social Science Research Center/Health Technology Assessment Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Harriette Van Spall
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Research Institute of St Joseph's and Population Health Research Institute, Hamilton, ON, Canada
| | - Kun Zhao
- Department of Health Technology Assessment, China National Health Development Research Center, Beijing, China; Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Yunxiang Chen
- Department of Library, Shengjing Hospital, China Medical University, Shenyang, Liaoning, China
| | - Feiyi Xiao
- Department of Health Technology Assessment, China National Health Development Research Center, Beijing, China
| | - Qiang Fu
- Department of Health Technology Assessment, China National Health Development Research Center, Beijing, China
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; Center for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.
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Hutchings HA, Lanyon KJ, Holland G, Alikhan R, Jenkins R, Laing H, Hughes A, Lobban T, Pollock K, Tod D, Lister S. Can we collect health-related quality of life information from anticoagulated atrial fibrillation participants who have recently experienced a bleed? An observational feasibility study in primary and secondary care in Wales and through a UK online forum. BMJ Open 2023; 13:e075335. [PMID: 37802619 PMCID: PMC10565208 DOI: 10.1136/bmjopen-2023-075335] [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: 05/05/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVE To evaluate the feasibility of recruiting participants diagnosed with atrial fibrillation (AF) taking oral anticoagulation therapies (OATs) and recently experiencing a bleed to collect health-related quality of life (HRQoL) information. DESIGN Observational feasibility study. The study aimed to determine the feasibility of recruiting participants with minor and major bleeds, the most appropriate route for recruitment and the appropriateness of the patient-reported outcome measures (PROMs) selected for collecting HRQoL information in AF patients, and the preferred format of the surveys. SETTING Primary care, secondary care and via an online patient forum. PARTICIPANTS The study population was adult patients (≥18) with AF taking OATs who had experienced a recent major or minor bleed within the last 4 weeks. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes - PROMs: EuroQol 5 Dimensions-5 Levels, Perception of Anticoagulant Treatment Questionnaire, part 2 only (part 2), atrial fibrillation effect on quality of life. Secondary outcomes - Location of bleed, bleed severity, current treatment, patient perceptions of HRQoL in relation to bleeding events. RESULTS We received initial expressions of interest from 103 participants. We subsequently recruited 32 participants to the study-14 from primary care and 18 through the AF forum. No participants were recruited through secondary care. Despite 32 participants consenting, only 26 initial surveys were completed. We received follow-up surveys from 11 participants (8 primary care and 3 AF forum). COVID-19 had a major impact on the study. CONCLUSIONS Primary care was the most successful route for recruitment. Most participants recruited to the study experienced a minor bleed. Further ways to recruit in secondary care should be explored, especially to capture more serious bleeds. TRIAL REGISTRATION NUMBER The study is registered in the Clinicaltrials.gov database, NCT04921176.
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Affiliation(s)
| | - Kirsty J Lanyon
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Gail Holland
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Raza Alikhan
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | | | - Hamish Laing
- VBHC Academy, School of Management, Swansea University, Swansea, UK
| | | | | | - Kevin Pollock
- Bristol-Myers Squibb Pharmaceuticals Ltd, Uxbridge, UK
| | - Daniel Tod
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Steven Lister
- Bristol-Myers Squibb Pharmaceuticals Ltd, Uxbridge, UK
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Moons P, Norekvål TM, Arbelo E, Borregaard B, Casadei B, Cosyns B, Cowie MR, Fitzsimons D, Fraser AG, Jaarsma T, Kirchhof P, Mauri J, Mindham R, Sanders J, Schiele F, Torbica A, Zwisler AD. Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management. Eur Heart J 2023; 44:3405-3422. [PMID: 37606064 DOI: 10.1093/eurheartj/ehad514] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 05/01/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023] Open
Abstract
Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.
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Affiliation(s)
- Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven - University of Leuven, Kapucijnenvoer 35 PB7001, 3000 Leuven, Belgium
- Institute of Health and Care Sciences, University of Gothenburg, Arvid Wallgrens backe 1, 413 46 Gothenburg, Sweden
- Department of Paediatrics and Child Health, University of Cape Town, Klipfontein Rd, Rondebosch, 7700 Cape Town, South Africa
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Haukelandsveien 22, 5009 Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Jonas Lies veg, 875021 Bergen, Norway
| | - Elena Arbelo
- Cardiology Department, Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain
- Institut d'Investigació August Pi i Sunyer (IDIBAPS). Rosselló 149-153, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0, 28029 Madrid, Spain
| | - Britt Borregaard
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense, Denmark
| | - Barbara Casadei
- Division of Cardiovascular Medicine, RDM, University of Oxford; Headley Way, Headington Oxford OX3 9DU, UK
- NIHR Biomedical Research Centre, Headley Way, Headington Oxford OX3 9DU, UK
| | - Bernard Cosyns
- Department of Cardiology, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Martin R Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine, Faculty of Medicine & Lifesciences, King's College London, Sydney St, London SW3 6NP, UK
| | - Donna Fitzsimons
- School of Nursing & Midwifery, Queens University Belfast, 97 Lisburn Road, Belfast | BT9 7BL, Northern Ireland
| | - Alan G Fraser
- School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XW, UK
| | - Tiny Jaarsma
- Department of Medicine, Health and Caring Sciences, Linköping University, Campus Norrköping, 601 74 Norrköping, Sweden
- Nursing Science, Julius Center, University Medical Centre Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, D-20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistrasse 52, D-20246 Hamburg, Germany
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston Birmingham B15 2TT, UK
| | - Josepa Mauri
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain
| | - Richard Mindham
- European Society of Cardiology (ESC) Patient Forum, 2035 route des colles, CS 80179 Biot, 06903 Sophia Antipolis Cedex, France
| | - Julie Sanders
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- William Harvey Research Institute, Charterhouse Square, Queen Mary University of London, London EC1M 6BQ, UK
| | - Francois Schiele
- Department of Cardiology, University Hospital Besancon, 3 Bd Alexandre Fleming, 25030 Besançon, France
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Via Sarfatti, 10 20136 Milan, Italy
| | - Ann Dorthe Zwisler
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Vestergade 17, 5800 Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark
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Li X, Zhao K, Li K, Wang W, Feng S, Wu J, He X, Xie S, Hu H, Fan J, Fu Q, Xie F. China Health Related Outcomes Measures (CHROME): development of a descriptive system to support cardiovascular disease specific preference-based measure for the Chinese population. Qual Life Res 2023:10.1007/s11136-023-03416-y. [PMID: 37119354 DOI: 10.1007/s11136-023-03416-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 05/01/2023]
Abstract
PURPOSE Preference-based measures have been increasingly recommended to measure health outcomes for economic evaluation. However, none of existing cardiovascular disease (CVD)-specific health-related quality of life (HRQoL) instruments are preference-based. This study aimed to develop the descriptive system of preference-based HRQoL instrument for Chinese patients with CVDs under the Initiative of China Health Related Outcomes Measures (CHROME). METHODS Qualitative face-to-face interviews were conducted with Chinese patients with CVDs. Content analysis was employed to generate candidate items for the instrument. Then expert consultation and cognitive debriefing interviews were conducted to guide further selection and revision of the items. RESULTS We interviewed 127 CVD patients with 67.7% being male and 63.8% living in the urban area. A hierarchical code book comprised of four themes, 20 categories, 62 sub-categories, and 207 codes, was developed. Candidate items were selected based on the criteria set by the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology and ISPOR PRO guidance. An online survey and meeting with an expert advisory panel (n = 15) followed by cognitive debriefing interviews with 20 patients and 13 physicians were conducted to further select and revise the candidate items. The descriptive system of CHROME-CVD consists of 14 items, namely frequency and severity of chest pain, chest tightness, palpitation, shortness of breath, dizziness, fatigue, appetite, sleeping, mobility, daily activities, depression, worry, and social relationship. Four or five level responses were selected based on cognitive debriefing results to each item. CONCLUSION The current study developed the descriptive system (items and response options) of CHROME-CVD, the future CVD-specific preference-based HRQoL instrument for Chinese CVD patients.
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Affiliation(s)
- Xue Li
- Department of Health Technology Assessment, China National Health Development Research Center, Beijing, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Kun Zhao
- Department of Health Technology Assessment, China National Health Development Research Center, Beijing, China
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Kexin Li
- China Alliance for Rare Disease, Beijing, China
| | - Wenjun Wang
- Department of Health Technology Assessment, China National Health Development Research Center, Beijing, China
| | - Siting Feng
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jing Wu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
- Center for Social Science Survey and Data, Tianjin University, Tianjin, China
| | - Xiaoning He
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
- Center for Social Science Survey and Data, Tianjin University, Tianjin, China
| | - Shitong Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Hao Hu
- Liaoning Institute of Basic Medicine, Liaoning, China
| | - Jing Fan
- National Center for Cardiovascular Diseases, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qiang Fu
- China National Health Development Research Center, 9 Chegongzhuang Street, Xicheng District, Beijing, 100444, China.
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.
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Blomström-Lundqvist C, Svedung Wettervik V. Reflections on the usefulness of today's atrial fibrillation ablation procedure endpoints and patient-reported outcomes. Europace 2022; 24:ii29-ii43. [PMID: 35661867 DOI: 10.1093/europace/euab318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022] Open
Abstract
The improvement of Patient-reported outcomes, such as health-related quality of life, is the main indication for atrial fibrillation ablation. Despite this guideline derived indication for an AF ablation procedure the current standardized primary endpoint in AF ablation trials is still rhythm-related, and primarily a 30-second long AF episode. The review presents reflections on the non-rational arguments of using rhythm related endpoints rather than Patient-reported outcomes in AF ablation procedure trials despite the mismatch between many of the rhythm related variables and symptoms. Arguments for health-related quality of life as the most optimal primary endpoint in clinical trials are presented while atrial fibrillation burden is presented as the most optimal electrical complementary endpoint, apart from being the major variable in mechanistic trials.
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Cannavan PMS, Cannavan FPDS, Oliveira HC, Walfridsson U, Lopes MHBDM. A Brazilian Portuguese translation, cultural adaptation and validation of the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA) health-related quality of life (HRQOL) scale. PLoS One 2021; 16:e0256851. [PMID: 34449831 PMCID: PMC8396783 DOI: 10.1371/journal.pone.0256851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 08/17/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The health-related quality of life (HRQOL) of patients with tachyarrhythmia can be negatively influenced by the clinical manifestations. The evaluation of HRQOL with validated instruments can provide valuable information that will contribute to clinical decision-making and treatment. In Brazil, however, there is no available scale that evaluates HRQOL in different types of arrhythmia. The purpose of this study was to adapt the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia-HRQOL scale (ASTA-HRQOL scale) to the Brazilian culture, and to assess the psychometric properties of the adapted questionnaire. METHODS The study used a methodological process of cultural adaptation based on international literature guidelines. The analyses were performed with 172 participants, 32 for cultural adaptation and 140 for psychometric validation. Calculation included analysis of reliability by Cronbach's α coefficient, construct validity with convergent validity using the WHOQOL-BREF questionnaire and by the Spearman correlation coefficient, Average Variance Extracted, and assessment of confirmatory factor analysis. RESULTS The translation and adaptation processes showed a satisfactory degree of comprehension and applicability (93% reported them to be easy to understand). Confirmatory factor analysis indicated exclusion of one item from the mental scale, but after qualitative analysis the item was retained. The items presented adequate internal consistency (Cronbach's alpha coefficient = 0.88), and an inverse correlation of moderate magnitude with the physical domain (rho = -0.63) and with the mental domain (rho = -0.58) of the WHOQOL-BREF. CONCLUSIONS The Brazilian Portuguese version of the ASTA-HRQOL scale, the ASTA-Br-HRQOL scale, can be a valuable tool for use in clinical practice and research.
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Affiliation(s)
| | - Fernando Piza de Souza Cannavan
- Department of Clinical Medicine, Discipline of Cardiology, School of Medical Sciences, University of Campinas, Unicamp, Campinas, São Paulo, Brazil
| | | | - Ulla Walfridsson
- Department of Cardiology, University Hospital, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Stephenson JJ, Cepeda MS, Zhang J, Dinh J, Hall K, Esposito DB, Kern DM. The Association Between Doctor and Pharmacy Shopping and Self-Reported Misuse and Abuse of Prescription Opioids: A Survey Study. J Pain Res 2020; 13:689-701. [PMID: 32308468 PMCID: PMC7140905 DOI: 10.2147/jpr.s232409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/19/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND/RATIONALE Little is known about the reasons for visiting multiple doctors/pharmacies, known as doctor/pharmacy shopping, to obtain opioids. OBJECTIVE To investigate patients' self-reported reasons for doctor/pharmacy shopping and assess whether doctor/pharmacy shopping behavior can be used as a surrogate measure of opioid abuse/misuse. METHODS We conducted a cross-sectional web-based survey among adult patients with ≥2 pharmacy claims for immediate-release or extended-release/long-acting opioids between 7/1/2015 and 12/31/2016, identified from a large United States (US) commercial claims database. Patients were classified into no, mild, moderate, or severe shopping categories based on their claims. Reasons for doctor/pharmacy shopping and opioid abuse/misuse were determined from patient responses to the Prescription Opioid Misuse and Abuse Questionnaire. RESULTS A random sample of 10,081 patients was invited to participate in the survey and 1085 (11%) completed surveys. The most frequently reported reasons for doctor/pharmacy shopping were convenience, availability, price, and multiple morbidities requiring pain management. Among patients in the no, minimal, moderate, and severe shopping categories, only 7.8%, 8.5%, 11.8% and 12.6% reported opioid abuse/misuse, respectively. CONCLUSION In this commercially-insured population, patient-reported reasons for doctor/pharmacy shopping do not suggest opioid abuse/misuse. Less than 15% of patients with shopping behavior in the past 3 months reported any reasons attributable to opioid abuse/misuse, indicating that shopping behavior in this population may not be a good surrogate for abuse/misuse.
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Affiliation(s)
| | - M Soledad Cepeda
- Epidemiology, Janssen Research and Development, Titusville, NJ, USA
| | - Jie Zhang
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
- Safety and Epidemiology, HealthCore, Inc., Wilmington, DE, USA
| | - Jade Dinh
- Safety and Epidemiology, HealthCore, Inc., Wilmington, DE, USA
| | - Kelsey Hall
- Safety and Epidemiology, HealthCore, Inc., Wilmington, DE, USA
| | - Daina B Esposito
- Safety and Epidemiology, HealthCore, Inc., Wilmington, DE, USA
- Ciconia, Inc, Westford, MA, USA
- Epidemiology, Boston University, Boston, MA, USA
| | - David M Kern
- Epidemiology, Janssen Research and Development, Titusville, NJ, USA
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