Identifying patients with gastroesophageal reflux disease in a managed care organization

Validity of Algorithms for Identification of Individuals Suffering from Chronic Noncancer Pain in Administrative Databases: A Systematic Review

BACKGROUND

Secondary analysis of health administrative databases is indispensable to enriching our understanding of health trajectories, health care utilization, and real-world risks and benefits of drugs among large populations.

OBJECTIVES

This systematic review aimed at assessing evidence about the validity of algorithms for the identification of individuals suffering from nonarthritic chronic noncancer pain (CNCP) in administrative databases.

METHODS

Studies reporting measures of diagnostic accuracy of such algorithms and published in English or French were searched in the Medline, Embase, CINAHL, AgeLine, PsycINFO, and Abstracts in Social Gerontology electronic databases without any dates of coverage restrictions up to March 1, 2018. Reference lists of included studies were also screened for additional publications.

RESULTS

Only six studies focused on commonly studied CNCP conditions and were included in the review. Some algorithms showed a ≥60% combination of sensitivity and specificity values (back pain disorders in general, fibromyalgia, low back pain, migraine, neck/back problems studied together). Only algorithms designed to identify fibromyalgia cases reached a ≥80% combination (without replication of findings in other studies/databases).

CONCLUSIONS

In summary, the present investigation informs us about the limited amount of literature available to guide and support the use of administrative databases as valid sources of data for research on CNCP. Considering the added value of such data sources, the important research gaps identified in this innovative review provide important directions for future research. The review protocol was registered with PROSPERO (CRD42018086402).

Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults

BACKGROUND

Bisphosphonates are seldom used in frail, older adults, in part due to lack of direct evidence of efficacy in this population and increasing concerns about safety.

OBJECTIVE

We estimated the effects of bisphosphonates on hip fractures, nonvertebral fractures, and severe esophagitis among frail, older adults.

DESIGN

Population-based retrospective cohort using 2008 to 2013 linked national Minimum Data Set assessments; Online Survey Certification and Reporting System records; and Medicare claims.

SETTING

US nursing homes (NHs).

PARTICIPANTS

Long-stay NH residents 65 years and older without recent osteoporosis medication use (N = 24,571). Bisphosphonate initiators were 1:1 propensity score matched to calcitonin initiators (active comparator).

MEASUREMENTS

Hospitalized hip fracture, nonvertebral fracture, and esophagitis outcomes were measured using part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated, controlling for over 100 baseline characteristics.

RESULTS

The matched cohort included 5209 new bisphosphonate users and an equal number of calcitonin users (mean age [SD] = 85 [8] years; 87% female; 52% moderate-severe cognitive impairment). Over a mean follow-up of 2.5 (SD = 1.7) years, 568 residents (5.5%) had a hip fracture, 874 (8.4%) had a nonvertebral fracture, and 199 (1.9%) had a hospitalized esophagitis event. Users of bisphosphonates were less likely than calcitonin users to experience hip fracture (HR = 0.83; 95% CI = 0.71-0.98), with an average gain in time without fracture of 28.4 days (95% CI = 6.0-50.8 days). Bisphosphonate and calcitonin users had similar rates of nonvertebral fracture (HR = 0.91; 95% CI = 0.80-1.03) and esophagitis events (HR = 1.11; 95% CI = 0.84-1.47). The effects of bisphosphonates on fractures and esophagitis were generally homogeneous across subgroups, including those defined by age, sex, history of prior fracture, and baseline fracture risk.

CONCLUSIONS

Use of bisphosphonates is associated with a meaningful reduction in hip fracture among frail, older adults, but little difference in nonvertebral fracture or severe esophagitis. J Am Geriatr Soc 67:768-776, 2019.

Migraineurs were reliably identified using administrative data

BACKGROUND

Migraine is a common and important source of pain and disability in society. Accurately identifying such people using routinely collected health data would be beneficial for health services research.

OBJECTIVE

Externally validate a previously published method to identify migraineurs using health administrative data; and determine if a better model can be derived using data-mining techniques.

METHODS

Migraine status was determined for Ontarians participating in a population-based, cross-sectional survey. Consenting participants were linked to population-based health administrative data to identify age, sex, and coded diagnoses. Discrimination and calibration measures were used to appraise the models. A de novo technique we term "double threshold analysis" was used to determine optimal lower and upper expected probabilities to identify migraine status in the newly derived model.

RESULTS

A total of 1,01,114 people (mean age 46 years, 46% male) were included in the study, of which 11,314 (11.2%) had migraines. Using data-driven parameter estimates, the previous model to identify migraineurs had adequate discrimination (c-statistic 0.707 [95% CI 0.701-0.712]) and calibration (Hosmer-Lemeshow [H-L] statistic 20.8). A new model that included diagnostic code scores for physician visits, emergency visits, and hospitalizations with nonlinear terms for age and interactions significantly improved the model (c-statistic 0.724 [0.716-0.733], 16.4). Categorizing all people with a predicted migraine probability less than 10% or greater than 90% as without and having the disease, respectively, resulted in a sensitivity of 3.1%, a specificity of 99.96%, and a positive predictive value of 81.0% while capturing 57.0% of the cohort and 29.3% of migraineurs.

CONCLUSION

A previously derived model to identify migraineurs was improved using data-mining techniques permitting accurate cohort identification using routinely collected health administrative data.

Dietary guideline adherence for gastroesophageal reflux disease

Background

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disease, and the cost of health care and lost productivity due to GERD is extremely high. Recently described side effects of long-term acid suppression have increased the interest in nonpharmacologic methods for alleviating GERD symptoms. We aimed to examine whether GERD patients follow recommended dietary guidelines, and if adherence is associated with the severity and frequency of reflux symptoms.

Methods

We conducted a population-based cross-sectional study within the Kaiser Permanente Northern California population, comparing 317 GERD patients to 182 asymptomatic population controls. All analyses adjusted for smoking and education.

Results

GERD patients, even those with moderate to severe symptoms or frequent symptoms, were as likely to consume tomato products and large portion meals as GERD-free controls and were even more likely to consume soft drinks and tea [odds ratio (OR) = 2.01 95% confidence interval (CI) 1.12-3.61; OR = 2.63 95% CI 1.24-5.59, respectively] and eat fried foods and high fat diet. The only reflux-triggering foods GERD patients were less likely to consume were citrus and alcohol [OR = 0.59; 95% CI: 0.35-0.97 for citrus; OR = 0.41 95% CI 0.19-0.87 for 1 + drink/day of alcohol]. The associations were similar when we excluded users of proton pump inhibitors.

Conclusions

GERD patients consume many putative GERD causing foods as frequently or even more frequently than asymptomatic patients despite reporting symptoms. These findings suggest that, if dietary modification is effective in reducing GERD, substantial opportunities for nonpharmacologic interventions exist for many GERD patients.

Effects of dietary fiber, fats, and meat intakes on the risk of Barrett's esophagus

Animal and human models suggest associations between fat intake, fiber intake, and the risk of esophageal adenocarcinoma. We evaluated whether these factors may act early in the carcinogenic pathway as a risk factor for Barrett's esophagus, a potentially premalignant precursor to esophageal adenocarcinoma using a case-control design within the Kaiser Permanente, Northern California population. Incident Barrett's esophagus cases (n = 296) were matched to persons with gastroesophageal reflux disease (GERD) (n = 308) and to population controls (n = 309). Higher intakes of omega-3-fatty-acids [cases vs. population controls; OR = 0.46, 95% CI = 0.22-0.97, 4th vs. 1st quartiles of intake], polyunsaturated fat, total fiber (OR = 0.34, 95% CI = 0.15-0.76), and fiber from fruits and vegetables (OR = 0.47 95% CI = 0.25-0.88) were associated with a lower risk of Barrett's esophagus. Higher meat intakes were associated with a lower risk of long-segment Barrett's esophagus (OR = 0.25, 95% CI = 0.09-0.72). In contrast, higher trans-fat intakes were associated with increased risk (OR = 1.11; 95% CI = 1.03-1.21 per g/day). Total fat intake, barbecued foods, and fiber intake from sources other than fruits and vegetables were not associated with Barrett's esophagus. Future studies to evaluate whether dietary interventions might influence the risk of Barrett's esophagus or esophageal adenocarcinoma in high risk persons are needed.

Dietary antioxidants, fruits, and vegetables and the risk of Barrett's esophagus

OBJECTIVE

The present study evaluated the associations among antioxidants, fruit and vegetable intake, and the risk of Barrett's esophagus (BE), a potential precursor to esophageal adenocarcinoma.

METHODS

We conducted a case-control study within the Kaiser Permanente Northern California population. Incident BE cases (N = 296) were matched to persons with gastroesophageal reflux disease (GERD) (GERD controls N = 308) and to population controls (N = 309). Nutrient intake was measured using a validated 110-item food frequency questionnaire. The antioxidant results were stratified by dietary versus total intake of antioxidants.

RESULTS

Comparing cases to population controls, dietary intake of vitamin C and beta-carotene were inversely associated with the risk of BE (4th vs 1st quartile, adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.26-0.90; OR 0.56, 95% CI 0.32-0.99, respectively), and the inverse association was strongest for vitamin E (OR 0.25, 95% CI 0.11-0.59). The inverse trends for antioxidant index (total and dietary) and fruit and vegetable intake were statistically significant, while most total intakes were not associated with reduced risk. The use of antioxidant supplements did not influence the risk of BE, and antioxidants and fruits and vegetables were inversely associated with a GERD diagnosis.

CONCLUSION

Dietary antioxidants, fruits, and vegetables are inversely associated with the risk of BE, while no association was observed for supplement intake. Our results suggest that fruits and vegetables themselves or associated undetected confounders may influence early events in the carcinogenesis of esophageal adenocarcinoma.

Prevalence of GERD symptoms in a representative Israeli adult population

The prevalence of gastroesophageal reflux disease (GERD) symptoms in the general population is lower in Asian than Western countries. Data are lacking for countries in the Middle East. The aim of the study was to determine the prevalence and severity of GERD symptoms among Israeli Jews. A questionnaire including 8 specific questions for GERD symptoms was administered by telephone interview to a representative sample of the population. One thousand two hundred twenty-one of 1839 individuals were successfully contacted and 981 had valid, complete data. The mean age was 45.0 years and 55% were females. Over the previous year 34.8% of the respondents reported suffering any GERD symptom. Of these 11.6% reported retrosternal burning, 11.7% retrosternal pain, 19.0% an acid taste in the mouth, and 17.5% reflux of gastric content. In all, 6.5%, 5.2%, 10.4%, and 7.9%, respectively, suffered these symptoms at least once a week, and 2.0%, 1.8%, 2.4%, and 2.3%, respectively, defined their symptoms as frequent and severe. Male sex (P=0.01) and a functional lower gastrointestinal (GI) disorder (P<0.0001) contributed significantly to the severity of upper GI reflux-like symptoms. In conclusion, GERD symptoms are common among Israeli Jews. The symptoms are generally of mild-to-moderate severity and are significantly associated with lower functional GI disorders.

Pharmacy and medical claims data identified migraine sufferers with high specificity but modest sensitivity

OBJECTIVE

Claims data are often used to identify and monitor individuals with particular conditions, but many health conditions are not easily recognizable from claims data alone. Patient characteristics routinely available in claims data were used to develop model-based claims signatures to identify migraineurs.

STUDY DESIGN AND SETTING

A validated telephone interview was administered to 23,299 continuously enrolled managed care members aged 18-55 to identify 1,265 migraineurs and 1,178 controls. Responses were linked to medical and prescription claims. Claims variables were evaluated for sensitivity, specificity, and positive and negative predictive value in predicting migraine status. Regression models for predicting migraine status were developed.

RESULTS

Regression-based claims signature models were successful in case-finding, as indicated by fairly sizable odds ratios (OR). In the full model (including demographic, medical, pharmacy, and comorbidity claims variables), a claim for a migraine drug, gender, and a claims-based headache diagnosis were strongly associated with migraine case status (OR=3.9, 3.2, and 3.0, respectively).

CONCLUSION

Using either medical or pharmacy claims provided highly specific and moderately sensitive case-findings. Strategies that combined medical and pharmacy information improved sensitivity and may increase the usefulness of claims for identifying migraine and improving the quality of migraine care.

Framework for assessing causality in disease management programs: principles

To credibly state that a disease management (DM) program "caused" a specific outcome it is required that metrics observed in the DM population be compared with metrics that would have been expected in the absence of a DM intervention. That requirement can be very difficult to achieve, and epidemiologists and others have developed guiding principles of causality by which credible estimates of DM impact can be made. This paper introduces those key principles. First, DM program metrics must be compared with metrics from a "reference population." This population should be "equivalent" to the DM intervention population on all factors that could independently impact the outcome. In addition, the metrics used in both groups should use the same defining criteria (ie, they must be "comparable" to each other). The degree to which these populations fulfill the "equivalent" assumption and metrics fulfill the "comparability" assumption should be stated. Second, when "equivalence" or "comparability" is not achieved, the DM managers should acknowledge this fact and, where possible, "control" for those factors that may impact the outcome(s). Finally, it is highly unlikely that one study will provide definitive proof of any specific DM program value for all time; thus, we strongly recommend that studies be ongoing, at multiple points in time, and at multiple sites, and, when observational study designs are employed, that more than one type of study design be utilized. Methodologically sophisticated studies that follow these "principles of causality" will greatly enhance the reputation of the important and growing efforts in DM.

Care modes for the older adult with gastroesophageal reflux disease

Gastroesophageal reflux disease is a common chronic disease in the older population. Because of the cumulative effects of acid reflux and delayed gastric emptying, the older adult is at risk for such complications as peptic strictures, esophagitis, and Barrett's esophagus. Providing information on the current care modes (lifestyle, dietary, pharmacologic, and surgical interventions) will help identify relevant solutions and help the older adult generate alternative safe and effective solutions to manage the disease. Many people struggle to change their lives and may need assistance to break old habits.