Agreement Between Maternal Report and Medical Records During Pregnancy: Medications for Rheumatoid Arthritis and Asthma

Agreement between maternal report and medical records on use of medications during early pregnancy in New York

BACKGROUND

Studies evaluating associations between medication use in pregnancy and birth outcomes rely on various sources of exposure information. We sought to assess agreement between self-reported use of medications during early pregnancy and medication information in prenatal medical records to understand the reliability of each of these information sources.

METHODS

We compared self-reported prescription medication use in early pregnancy to medical records from 184 New York women with deliveries in 2018 who participated in the Birth Defects Study To Evaluate Pregnancy exposureS. We assessed medications used chronically and episodically, and medications within 12 therapeutic groups. We calculated agreement using kappa (κ) coefficients, sensitivity, and specificity. We assessed differences by case/control status, maternal age, education, time to interview, and interview language.

RESULTS

Medications used chronically showed substantial agreement between self-report and medical records (κ = 0.75, 0.61-0.88), with agreement for therapeutic groups used chronically ranging from κ = 0.61 for antidiabetics to κ = 1.00 for antihypertensives. Prescription medications used episodically showed worse agreement (κ = 0.40, 0.25-0.54), with the lowest agreement for opioid analgesics (κ = 0.20) and anti-infectives (κ = 0.33). Agreement did not differ by the characteristics examined, although we observed potential differences by interview language.

CONCLUSIONS

Among our sample, we observed good agreement between self-report and medical records for medications used chronically and substantially less agreement for medications used episodically. Differences by source may be due to poor recall in self-reports, non-adherence with prescribed medications and lack of complete prescription information within medical records. Limitations should be considered when assessing prescription medication exposures during early pregnancy in epidemiologic studies.

Associations of prenatal exposure to non-steroidal anti-inflammatory drugs with preterm birth and small for gestational age infants among women with autoimmune disorders

PURPOSE

Estimate associations between prenatal non-steroidal anti-inflammatory (NSAID) exposure and preterm birth and small for gestational age among women with autoimmune conditions.

METHODS

Participants were enrolled in the MotherToBaby cohort and had an autoimmune disorder and singleton live birth >20 weeks gestation (n = 2007). We characterized self-reported NSAID exposure over gestation for timing, duration, and average daily dose. Outcomes were preterm birth (i.e., <37 weeks' gestation) and small for gestational age infants (SGA; <10th percentile birthweight). We used Poisson regression to estimate associations between NSAID exposure and study outcomes adjusting for demographics, co-use of other medications (Model 1), and disease severity at baseline (Model 2). Secondarily, we considered the role of acetaminophen use by individually matching NSAID users to controls on cumulative dose of acetaminophen exposure.

RESULTS

Overall, 15% of women reported NSAID use in pregnancy, with most use in the first trimester. No NSAID use exposure variables were associated with risk of preterm birth. Any NSAID use was associated with 1.7 (95% CI 1.2, 2.5) times greater risk of SGA and this estimate was attenuated to 1.5 (95% CI 1.0, 2.3) after adjustment for baseline disease severity. NSAID exposure in the first trimester was most strongly associated with SGA. After matching on acetaminophen exposure, associations between any NSAID use and preterm birth and SGA were 0.9 (95% CI 0.6, 1.4) and 1.8 (95% CI 1.1, 2.9).

CONCLUSIONS

NSAID use in pregnancy is associated with SGA but not preterm birth. Future research should explore mechanisms that may explain these findings. Future research must also consider alternative explanations for these associations.

Nondifferential Treatment Misclassification Biases Toward the Null? Not a Safe Bet for Active Comparator Studies

Active comparator studies are increasingly common, particularly in pharmacoepidemiology. In such studies, the parameter of interest is a contrast (difference or ratio) in the outcome risks between the treatment of interest and the selected active comparator. While it may appear treatment is dichotomous, treatment is actually polytomous as there are at least 3 levels: no treatment, the treatment of interest, and the active comparator. Because misclassification may occur between any of these groups, independent nondifferential treatment misclassification may not be toward the null (as expected with a dichotomous treatment). In this work, we describe bias from independent nondifferential treatment misclassification in active comparator studies with a focus on misclassification that occurs between each active treatment and no treatment. We derive equations for bias in the estimated outcome risks, risk difference, and risk ratio, and we provide bias correction equations that produce unbiased estimates, in expectation. Using data obtained from US insurance claims data, we present a hypothetical comparative safety study of antibiotic treatment to illustrate factors that influence bias and provide an example probabilistic bias analysis using our derived bias correction equations.

Determining antenatal medicine exposures in South African women: a comparison of three methods of ascertainment

BACKGROUND

In the absence of clinical trials, data on the safety of medicine exposures in pregnancy are dependent on observational studies conducted after the agent has been licensed for use. This requires an accurate history of antenatal medicine use to determine potential risks. Medication use is commonly determined by self-report, clinician records, and electronic pharmacy data; different data sources may be more informative for different types of medication and resources may differ by setting. We compared three methods to determine antenatal medicine use (self-report, clinician records and electronic pharmacy dispensing records [EDR]) in women attending antenatal care at a primary care facility in Cape Town, South Africa in a setting with high HIV prevalence.

METHODS

Structured, interview-administered questionnaires recorded self-reported medicine use. Data were collected from clinician records and EDR on the same participants. We determined agreement between these data sources using Cohen's kappa and, lacking a gold standard, used Latent Class Analysis to estimate sensitivity, specificity and positive predictive value (PPV) for each data source.

RESULTS

Between 55% and 89% of 967 women had any medicine use documented depending on the data source (median number of medicines/participant = 5 [IQR 3-6]). Agreement between the datasets was poor regardless of class except for antiretroviral therapy (ART; kappa 0.6-0.71). Overall, agreement was better between the EDR and self-report than with either dataset and the clinician records. Sensitivity and PPV were higher for self-report and the EDR and were similar for the two. Self-report was the best source for over-the-counter, traditional and complementary medicines; clinician records for vaccines and supplements; and EDR for chronic medicines.

CONCLUSIONS

Medicine use in pregnancy was common and no single data source included all the medicines used. ART was the most consistently reported across all three datasets but otherwise agreement between them was poor and dependent on class. Using a single data collection method will under-estimate medicine use in pregnancy and the choice of data source should be guided by the class of the agents being investigated.

Differences in the association between oral corticosteroids and risk of preterm birth by data source: Reconciling the results

OBJECTIVE

To investigate causes of discrepancies in the association between early pregnancy oral corticosteroid (OCS) use and preterm birth (PTB) risk among women with rheumatoid arthritis (RA) in health care utilization [California Medicaid (Medi-Cal)] and prospective cohort (MotherToBaby Pregnancy Studies) data.

METHODS

Separately, we estimated risk ratios (RR) between OCS exposure before gestational day 140 and PTB risk in Medi-Cal (2007-2013; n=844) and MotherToBaby (2003-2014; n=528) data. We explored differences in socio-economic status, OCS dose distribution, exposure misclassification, and confounding by RA severity across the data sources.

RESULTS

PTB risk in women without OCS's was 17.3% in Medi-Cal and was 9.7% in MotherToBaby. There was no association between OCS and PTB in Medi-Cal (adjusted (a)RR: 1.00 (95% CI: 0.71, 1.42)), and a 1.85-fold (95% CI: 1.20, 2.84) increased PTB risk in MotherToBaby. When restricting each sample to women with a high school degree or less, PTB risk following no OCS exposure was 15.9% in Medi-Cal and 16.7% in MotherToBaby; aRR's were 1.16 (95% CI: 0.74, 1.80) in Medi-Cal and 0.81 (95% CI: 0.25, 2.64) in MotherToBaby. Cumulative OCS dose was higher in MotherToBaby (median: 684 mg) than Medi-Cal (median: 300 mg). OCS dose ≤300 mg was not associated with increased PTB risk. Exposure misclassification and confounding by RA severity were unlikely explanations of differences.

DISCUSSION

Higher baseline PTB risk and lower OCS dose distribution in Medi-Cal may explain the discrepancies. Studies are needed to understand the effects of autoimmune disease severity and under-treatment on PTB risk in low-income populations.

Prenatal acetaminophen use in women with autoimmune disorders and adverse pregnancy and birth outcomes

OBJECTIVES

Most women may have temporary pain for which they use analgesics, but those with autoimmune disorders have chronic pain that may be exacerbated for some during pregnancy. This study aimed to determine whether prenatal acetaminophen use was associated with an increased risk of adverse pregnancy and birth outcomes in women with autoimmune disorders.

METHODS

Participants were enrolled between 2004 and 2018 in the MotherToBaby cohort study and limited to women with an autoimmune disorder (n = 1,821). Self-reported acetaminophen use was characterized over gestation for indication, timing of use and duration. Cumulative acetaminophen use through 20 and 32 weeks was categorized into quintiles, with no acetaminophen use as the reference category. The association between acetaminophen quintile and preeclampsia or pregnancy induced hypertension, small for gestational age (SGA), and preterm birth was examined using adjusted multiple log-linear regression.

RESULTS

Overall, 74% of women reported acetaminophen use during pregnancy. The most often reported indication for using acetaminophen was headache/migraines, followed by pain and injury. Risk of preeclampsia was 1.62 times greater for those in the fifth quintile of cumulative acetaminophen use through 20 weeks compared with those with no acetaminophen use (95% CI: 1.10, 2.40). There were no associations with lower use quintiles, nor for the other outcomes.

CONCLUSION

The highest quintile of cumulative acetaminophen was associated with a modestly increased risk for preeclampsia. Some women with autoimmune conditions have pain throughout pregnancy; clinicians and patients should discuss approaches to best avoid high levels of acetaminophen in their pain management strategies.

Interaction between Maternal Immune Activation and Antibiotic Use during Pregnancy and Child Risk of Autism Spectrum Disorder

Prenatal exposure to maternal immune activation (MIA) has been implicated as a risk factor for the development of autism spectrum disorder (ASD), though the conditions under which this elevated risk occurs are unclear. Animal literature demonstrates that antibiotic use, which affects the composition of the maternal gut microbiota, modifies the effect of MIA on neurodevelopmental outcomes in the offspring. The aim of this study was to assess whether antibiotic use during pregnancy modifies the association between MIA and subsequent risk of ASD, in a prospective birth cohort with 116 ASD cases and 860 typically developing (TD) child controls. There was no evidence of interaction between fever or genitourinary infection and antibiotic use on the odds of ASD in unadjusted or adjusted analyzes. However, we found evidence of an interaction between flu, specifically in second trimester, and antibiotic use at any point during pregnancy on the odds of ASD in the child. Among women who received an antibiotic during pregnancy, flu in trimester two was not associated with ASD (adjusted odds ratio [aOR] = 0.99 [0.43-2.28]). Among women who were not exposed to an antibiotic at any point during pregnancy, flu in second trimester was significantly associated with increased odds of ASD (aOR = 4.05 [1.14-14.38], P = .03), after adjustment for child sex, child birth year, maternal age, gestational age, C-section delivery, and low birthweight. These findings should be treated as hypothesis-generating and suggest that antibiotic use may modify the influence that MIA has on autism risk in the child. LAY SUMMARY: We looked at whether the association between activation of the immune system during pregnancy and risk of the child developing autism spectrum disorder (ASD) differed among women who did or did not take an antibiotic at any point during pregnancy. We examined 116 children with ASD and 860 without ASD and found that flu in second trimester was associated with increased ASD, but only among women who did not take an antibiotic during pregnancy. No other immune activation exposures seemed to interact with antibiotic use.

Oral corticosteroid use during pregnancy and risk of preterm birth

OBJECTIVE

To evaluate the associations between oral corticosteroid (OCS) dose early and late in pregnancy and preterm birth (PTB) among women with RA.

METHODS

Pregnant women in the MotherToBaby Pregnancy Studies (2003-2014) with RA (n = 528) were included in the primary analysis. Information was collected by phone interview and from medical records. We estimated risk ratios (RR) for OCS dose trajectories and other disease-related medications before gestational day 140 and hazard ratios (HR) for time-varying exposures after gestational day 139.

RESULTS

PTB risk was 15.5% overall. Compared with no OCS, PTB risk was increased in high (adjusted (a)RR: 4.77 (95% CI: 2.76, 8.26)) and medium (aRR: 1.81 (95% CI: 1.10, 2.97)) cumulative OCS dose trajectories during the first 139 gestational days. The low cumulative trajectory group was associated with an increased risk of PTB that was not statistically significant (aRR: 1.38 (95% CI: 0.79, 2.38)), and DMARDs were not associated with PTB (biologic DMARDs aHR: 1.08 (95% CI: 0.70, 1.66); non-biologic DMARDs aHR: 0.87 (95% CI: 0.55, 1.38)). OCS exposure to ⩾10 mg of prednisone equivalent daily dose after gestational day 139 vs none was associated with increased PTB rate (aHR: 2.45 (95% CI: 1.32, 4.56)), whereas <10 mg was associated with a modestly increased rate of PTB that was not statistically significant (aHR: 1.18 (95% CI: 0.60, 2.30)).

CONCLUSION

Higher OCS doses vs no OCS use, both earlier and later in pregnancy, were associated with an increase in PTB among women with RA.

Acetaminophen use in pregnancy: Examining prevalence, timing, and indication of use in a prospective birth cohort

BACKGROUND

Previous studies of prenatal acetaminophen use have not addressed what indications and maternal co-factors describe acetaminophen use.

OBJECTIVE

The objective of this study was to describe these parameters in a well-characterised, prospective birth cohort.

METHODS

Data were drawn from the MotherToBaby study of pregnant women enrolled from 2004 to 2018. Daily acetaminophen diaries were calculated for all exposed women with complete dose and duration information. Descriptive statistics were used to assess maternal characteristics associated with acetaminophen use. Prevalence by 2-year interval was described, and linear regression was used to test for trend. Indication of use and dose per indication were summarised.

RESULTS

Of 2441 subjects, 1515 (62%) reported use of acetaminophen. Over the 15-year period, there was a decline in use of 2.5% for each 2-year period (test for trend = 0.001) with 58% reporting acetaminophen use in 2017-2018. Among women with acetaminophen use in pregnancy (n = 1515), 58% reported <10 days of use, 13% reported 10-19 days of use, 9% reported 20-44 days of use, and 9% reported 45 or more days of use. Twelve per cent had undefined duration of use. Increasing duration of exposure was associated with tobacco use, obesity, self-reported depression or anxiety, and antidepressant use. The most frequently reported indication was headache, however, indication varied by duration of use, with more women reporting use for sleep or pain/injury in the categories with the longest duration of use. Median dose per exposed day was highest among those reporting use for sleep, and higher doses were more frequently reported for arthritis, injury, and pain.

CONCLUSION

Acetaminophen is used by the majority of pregnant women, and some continue to use for many weeks in pregnancy. Given the heterogeneity in duration of use, indication, and dose, studies that estimate the risk of adverse outcomes associated with acetaminophen must carefully consider these factors.

Parental role in decision-making for pediatric surgery: Perceptions of involvement in consultations for tonsillectomy

OBJECTIVE

Parental role in decision-making has implications for quality of care. We describe roles of parent participation in decision-making for tonsillectomy.

METHODS

Parents reported preferred role in decision-making before consultations for tonsillectomy and the role they experienced after their consult. Parents completed questionnaires, including items evaluating clinician/parent communication. Clinicians rated perception of parents' preferred role in decision-making. Congruence between parent and clinician responses was evaluated via kappa analysis. Logistic regression identified associations between decision-making roles and socioemotional and communication factors.

RESULTS

Consults between 63 parents and 8 otolaryngologists were analyzed.There was inadequate agreement between clinician and parent ratings of preferred roles (37%, p = 0.6, 95% CI [-0.09, 0.001]). Parents perceived greater involvement when clinicians discussed reasons to have (OR = 4.3, p = 0.03) or not have (OR = 4.1, p = 0.005) surgery. Parents perceived less involvement when clinicians used jargon (OR = 0.1, p = 0.03), and when parents trusted clinicians (OR = 0.4, p = 0.049), or experienced greater decisional conflict (OR = 0.9, p = 0.03).

CONCLUSIONS

Parents and clinicians perceived parental preference for decision-making involvement differently during consultations for tonsillectomy. Clinician information-sharing, jargon use, and parent trust in clinician predicted extent of perceived engagement.

PRACTICE IMPLICATIONS

Findings may enhance understanding of strategies to effectively communicate and engage parents in shared decision-making for pediatric surgical care.

Inhaled corticosteroid use during pregnancy among women with asthma: A systematic review and meta-analysis

BACKGROUND

Studies demonstrate the prescription rate for inhaled corticosteroids (ICS) decreases in early pregnancy, possibly increasing exacerbation risk. This could be related to non-adherence to prescribed asthma medication or medication cessation by the patient or doctor. ICS use during pregnancy has not previously been summarized in a systematic review.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the use of ICS during pregnancy among asthmatic women, specifically: (1) the prevalence of use, (2) changes of use during pregnancy compared with pre-pregnancy and (3) medication adherence among ICS users.

METHODS

We systematically searched literature in Embase, MEDLINE, CINAL and Cochrane, using terms related to asthma, pregnancy and medication use. All English articles reporting ICS among pregnant women with asthma were included. Prevalence, changes in ICS use during pregnancy and ICS adherence were pooled using STATA (version 15.0, StataCorp USA).

RESULTS

A total of 4237 references were retrieved in the initial search. Screening and review led to the inclusion of 52 articles for one or more aims (Aim 1: N = 45; Aim 2, N = 13; and Aim 3, N = 5). The pooled prevalence of ICS use during pregnancy was 41% (95%CI 36%-45%); 49% (95%CI 44%-55%) in Europe, 39% (95%CI 32%-47%) in Australia and 34% (95%CI 27%-41%) in North America. In eight prescription databases, ICS prescription rates lowered in the first trimester of pregnancy, compared with pre-pregnancy, increased in the second trimester and decreased in the third trimester. Five studies reported ICS adherence among pregnant women, using four measures of self-reported non-adherence. In two comparable studies, pooled ICS non-adherence was 40% (95%CI 36%-44%).

CONCLUSIONS

The prevalence of ICS use among pregnant women with asthma is 41% and varies widely between countries and continents, and prescription rates for ICS change throughout pregnancy. More studies are needed to investigate ICS adherence during pregnancy in women with asthma.

Maternal use of thyroid hormone replacement therapy before, during, and after pregnancy: agreement between self-report and prescription records and group-based trajectory modeling of prescription patterns

Purpose

A reliable definition of exposure and knowledge about long-term medication patterns is important for drug safety studies during pregnancy. Few studies have investigated these measures for thyroid hormone replacement therapy (THRT). The purpose of this study was to 1) calculate the agreement between self-report and dispensed prescriptions of THRT and 2) classify women with similar adherence patterns to THRT into disjoint longitudinal trajectories.

Methods

Our analysis used data from the Norwegian Mother and Child Cohort Study (MoBa), a prospective population-based cohort study. MoBa was linked to prescription records from the Norwegian Prescription Database (NorPD). We estimated Cohen’s kappa coefficients (k) and approximate 95% CIs for agreement between self-report and prescription records for the 6-month period prior to pregnancy and for each pregnancy trimester. Using group-based trajectory models (GBTMs), we estimated adherence trajectories among women who self-reported and had a THRT prescription.

Results

There were 56,148 women in MoBa, who had both a record in NorPD and available prescription history up to 1 year prior to pregnancy. Of these, 1,171 (2.1%) self-reported and received a prescription for THRT. Agreement was “perfect” in the 6-month period prior to pregnancy (k=0.86; CI 0.85–0.88), in the first (k=0.83; CI 0.82–0.85) and in the second trimesters (k=0.89; CI 0.87–0.90), while this was moderate (k=0.57; CI 0.54–0.59) in the third trimester. Among the subset of the 1,171 women, we identified four disjoint GBTM adherence groups: Constant-High (50.2%), Constant-Medium (32.9%), Increasing-Medium (11.0%), and Decreasing-Low (5.8%).

Conclusion

Agreement between self-report and prescription records was high for THRT in the early pregnancy period. Based on our GBTM results, about one in two women with hypothyroidism had adequate adherence to prescribed THRT throughout pregnancy. Given the potential consequences, evidence of low adherence in 5.8% of pregnant women with hypothyroidism is of concern.

Patterns of prednisone use during pregnancy in women with rheumatoid arthritis: Daily and cumulative dose

PURPOSE

To characterize prednisone use in pregnant women with rheumatoid arthritis using individual-level heat-maps and clustering individual trajectories of prednisone dose, and to evaluate the association between prednisone dose trajectory groups and gestational length.

METHODS

This study included pregnant women with rheumatoid arthritis who enrolled in the MotherToBaby Autoimmune Diseases in Pregnancy Study (2003-2014) before gestational week 20 and reported prednisone use without another oral glucocorticoid during pregnancy (n = 254). Information on medication use and pregnancy outcomes was collected by telephone interview plus by medical record review. Prednisone daily dose and cumulative dose were plotted by gestational day using a heat map for each individual. K-means clustering was used to cluster individual trajectories of prednisone dose into groups. The associations between trajectory group and demographics, disease severity measured by the Health Assessment Questionnaire at enrollment, and gestational length were evaluated.

RESULTS

Women used prednisone 3 to 292 days during pregnancy, with daily doses ranging from <1 to 60 mg. Total cumulative dose ranged from 8 to 6225 mg. Disease severity, non-biologic disease modifying anti-rheumatic drug use, and gestational length varied significantly by trajectory group. After adjusting for disease severity, non-biologic disease modifying anti-rheumatic drug use, and other covariates, the highest vs lowest daily dose trajectory group was associated with reduced gestational age at delivery (β: -2.3 weeks (95%: -3.4, -1.3)), as was the highest vs lowest cumulative dose trajectory group (β: -2.6 weeks (95%: -3.6, -1.5)).

CONCLUSIONS

In pregnant women with rheumatoid arthritis, patterns of higher prednisone dose were associated with shorter gestational length compared with lower dose.