Identifying patients with chronic conditions using pharmacy data in Switzerland: an updated mapping approach to the classification of medications

Association of two geriatric treatment systems with anti-osteoporotic drug treatment and second hip fracture in patients with an index hip fracture: retrospective cohort study

BACKGROUND

In Germany, geriatricians deliver acute geriatric care during acute hospital stay and post-acute rehabilitation after transfer to a rehabilitation clinic. The rate patients receive acute geriatric care (AGC) or are transferred to post-acute rehabilitation (TPR) differs between hospitals. This study analyses the association between the two geriatric treatment systems (AGC, TPR) and second hip fracture in patients following an index hip fracture.

METHODS

Nationwide health insurance data are used to identify the rate of AGC and TPR per hospital following hip fracture surgery in patients aged ≥ 80 years. Outcomes are a second hip fracture after surgery or after discharge within 180 or 360 days and new specific anti-osteoporotic drugs. Cox proportional hazard models and generalised linear models are applied.

RESULTS

Data from 29,096 hip fracture patients from 652 hospitals were analysed. AGC and TPR are not associated with second hip fracture when follow-up started after surgery. However, during the first months after discharge patients from hospitals with no AGC or low rates of TPR have higher rates of second hip fracture than patients from hospitals with high rates of AGC or high rates of TPR (Hazard Ratio (95% CI) 1.35 (1.01-1.80) or 1.35 (1.03-1.79), respectively). Lower rates of AGC are associated with lower probabilities of new prescriptions of specific anti-osteoporotic drugs.

CONCLUSIONS

Our study suggests beneficial relationships of geriatric treatment after hip fracture with a) the risk of second hip fractures during the first months after discharge and b) an improvement of anti-osteoporotic drug treatment.

Explaining why increases in generic use outpace decreases in brand name medicine use in multisource markets and the role of regulation

BACKGROUND

Healthcare systems worldwide face escalating pharmaceutical expenditures despite interventions targeting pricing and generic substitution. Existing studies often overlook unwarranted volume increases in multisource markets due to differential physician perceptions of brand name and generics.

OBJECTIVE

This study aims to explain the outpacing of generic medicine use over brand name use in multisource markets and assess the regulatory role, specifically examining the impact of reference pricing on volume and intensity increases.

METHODS

Analyzing German multisource prescription medicine markets from 2011 to 2014, we evaluate regulatory mechanisms and explore whether brand name and generic medicines constitute separate market segments. Using an Oaxaca-Blinder decomposition approach, we divide the differential in brand name versus generic medicine use rates into market structure and unobserved segment effects.

RESULTS

Generic use rates surpass same-market brand name substitution by 3.87 prescriptions per physician and medicine, on average. Reference pricing mitigated volume increase, treatment intensity and expenditure. Disparities in quantity and expenditure dynamics between brand name and generic segments are partially explained by market structure and segment effects.

CONCLUSION

Generic medicine use effectively reduces expenditures but contributes to increased net prescription rates. Reference pricing may control medicine use, but divergent physician perceptions of brand name and generics, revealed by identified segment effects, call for nuanced policy interventions.

Outpatient glucocorticoid use and COVID-19 outcomes: a population-based study

INTRODUCTION

Owing to controversy information surrounds effect of glucocorticoids on the evolution of COVID-19, we evaluate the effects of outpatient glucocorticoid use on the severity and progression of COVID-19 and risk of infection and analyse the effect of window of exposure and dose.

METHODS

We conducted a population-based case - control study, involving 4 substudies: (i) Hospitalisation; (ii) Mortality, using subjects hospitalised with a PCR + as cases and subjects without a PCR + as controls; (iii) Progression, including subjects with a PCR + (hospitalised versus non-hospitalised); and (iv) Susceptibility, with all subjects with a PCR + and subjects without a PCR + . Adjusted odds ratios (ORa) and their 95% confidence intervals (95% CI) were calculated.

RESULTS

The outpatient glucocorticoid use was associated with an increased risk of hospitalisation (aOR 1.79; 95% CI 1.56-2.05), mortality (aOR 2.30; 95% CI 1.68-3.15), progression (aOR 1.69; 95% CI 1.43-2.00) and susceptibility (aOR 1.29, 95% CI 1.19-1.41). Furthermore, the effects was observed to be greater at higher doses and the closer that drug use approached the outcome date, with an almost fourfold increase in mortality among users in the previous month (aOR 3.85; 95% CI 2.63-5.62).

CONCLUSIONS

According to the results of this real-world data study, outpatient glucocorticoid use should be considered in making decisions about intrahospital treatment.

Temporal Trends in Cardiac Rehabilitation Participation and Its Core Components: A Nationwide Cohort Study From the Netherlands

PURPOSE

Patient- and disease-specific data on cardiac rehabilitation (CR) participation and changes over time are limited. The objective of this study was to describe time trends in CR participation between 2013 and 2019 and provides insights into the utilization of CR components.

METHODS

Patients with cardiovascular disease (CVD) with an indication for CR were enrolled between 2013 and 2019. Dutch health insurance claims data were used to identify CR participation and its components.

RESULTS

In total, 106 212 patients with CVD were included of which 37% participated in CR. Participation significantly increased from 28% in 2013 to 41% in 2016 but remained unchanged thereafter. Participation was highest in the youngest age groups (<50 yrs 52%; 50-65 yrs 50%), men (48%), patients with ST-segment elevation myocardial infarction (73%), non-ST-segment elevation myocardial infarction (59%), and coronary artery bypass grafting (82%). In contrast, it was the lowest in the oldest age group (≥85 yrs 8%), women (30%), and in patients with heart failure (11%). Most participants in CR received referral plus an admission session (97%) and exercise training (82%), whereas complementary services related to dietary (14%) and mental health counseling (10%) had a low utilization.

CONCLUSIONS

CR participation rates increased to 41% in 2016 but remained unchanged thereafter. Participation modulators included age, sex, CVD diagnosis, and undergoing a cardiothoracic procedure. Education and exercise sessions were frequently adopted, but dietary and mental health counseling had a low utilization rate. These findings suggest the need for reinvigorated referral and novel enrollment strategies in specific CVD subgroups to further promote CR participation and its associated underutilized adjunctive services.

Temporal and spatial changes in the provision of mental health care during the COVID-19 pandemic in Germany: a claims-based cohort study on patients with severe mental disorders

PURPOSE

Major lockdowns were imposed in Germany from March until May 2020 and from December 2020 until May 2021. We studied the influence of these lockdowns, the strain on intensive care units and the strictness of COVID-19-related containment strategies on the utilization of mental health care among patients with severe mental disorders.

METHODS

We used health insurance claims data to identify n = 736,972 patients with severe mental disorders shortly before the pandemic and n = 735,816 patients a year earlier. We applied entropy balancing to adjust for baseline differences by district. For a 12-month follow-up, we modeled monthly changes in utilization through meta-analytic models using both the COVID-19 stringency index and intensive care unit cases per 100,000 inhabitants as predictors. Our outcomes were changes in psychiatric hospital days and time treated by outpatient psychiatrists.

RESULTS

Psychiatric hospital days declined by at least 7.7% in all calender month during the pandemic. Peak reduction rates were observed in April (- 27.9%), May (- 22.3%) 2020 and January 2021 (- 18.3%). Utilization changes were associated with the stringency index and the second lockdown. Time treated by psychiatrists was shorter in April (- 16.2%) and May (- 11.5%) 2020 and in January 2021 (- 10.5%), which was partially offset by higher utilization in June and September 2020. These utilization changes were associated with the stringency index and the strain on intensive care units during both lockdowns.

CONCLUSION

Hospitals did not maintain the level of utilization during the pandemic, while outpatient psychiatrists adapted more quickly, presumably due to digital and telemedical care.

Association of Traditional and Nontraditional Risk Factors in the Development of Strokes Among Young Adults by Sex and Age Group: A Retrospective Case-Control Study

BACKGROUND

Despite women having fewer traditional risk factors (eg, hypertension, diabetes), strokes are more common in women than men aged ≤45 years. This study examined the contributions of traditional and nontraditional risk factors (eg, migraine, thrombophilia) in the development of strokes among young adults.

METHODS

This retrospective case-control study used Colorado's All Payer Claims Database (2012-2019). We identified index stroke events in young adults (aged 18-55 years), matched 1:3 to stroke-free controls, by (1) sex, (2) age±2 years, (3) insurance type, and (4) prestroke period. All traditional and nontraditional risk factors were identified from enrollment until a stroke or proxy-stroke date (defined as the prestroke period). Conditional logistic regression models stratified by sex and age group first assessed the association of stroke with counts of risk factors by type and then computed their individual and aggregated population attributable risks.

RESULTS

We included 2618 cases (52% women; 73.3% ischemic strokes) and 7827 controls. Each additional traditional and nontraditional risk factors were associated with an increased risk of stroke in all sex and age groups. In adults aged 18 to 34 years, more strokes were associated with nontraditional (population attributable risk: 31.4% men and 42.7% women) than traditional risk factors (25.3% men and 33.3% women). The contribution of nontraditional risk factors declined with age (19.4% men and 27.9% women aged 45-55 years). The contribution of traditional risk factors peaked among patients aged 35 to 44 years (32.8% men and 39.7% women). Hypertension was the most important traditional risk factor and increased in contribution with age (population attributable risk: 27.8% men and 26.7% women aged 45 to 55 years). Migraine was the most important nontraditional risk factor and decreased in contribution with age (population attributable risk: 20.1% men and 34.5% women aged 18-35 years).

CONCLUSIONS

Nontraditional risk factors were as important as traditional risk factors in the development of strokes for both young men and women and have a stronger association with the development of strokes in adults younger than 35 years of age.

Outpatient Antipsychotic Use and Severe COVID-19: Avoiding the Impact of Age in a Real-World Data Study

BACKGROUND

The association between use of antipsychotics and COVID-19 outcomes is inconsistent, which may be linked to use of these drugs in age-related diseases. Furthermore, there is little evidence regarding their effect in the nongeriatric population. We aim to assess the association between antipsychotic use and risk of disease progression and hospitalization due to COVID-19 among the general population, stratifying by age.

METHODS

We conducted a population-based, multiple case-control study to assess risk of hospitalization, with cases being patients with a PCR(+) test who required hospitalization and controls being individuals without a PCR(+) test; and risk of progression to hospitalization, with cases being the same as those used in the hospitalization substudy and controls being nonhospitalized PCR(+) patients. We calculated adjusted odds-ratios (aOR) and 95% confidence intervals (CI), both overall and stratified by age.

RESULTS

Antipsychotic treatment in patients younger than 65 years was not associated with a higher risk of hospitalization due to COVID-19 (aOR 0.94 [95%CI = 0.69-1.27]) and disease progression among PCR(+) patients (aOR 0.96 [95%CI = 0.70-1.33]). For patients aged 65 years or older, however, there was a significant, increased risk of hospitalization (aOR 1.58 [95% CI = 1.38-1.80]) and disease progression (aOR 1.31 [95% CI = 1.12-1.55]).

CONCLUSIONS

The results of our large-scale real-world data study suggest that antipsychotic use is not associated with a greater risk of hospitalization due to COVID-19 and progression to hospitalization among patients younger than 65 years. The effect found in the group aged 65 years or older might be associated with off-label use of antipsychotics.

Impact of prior use of antiplatelets on COVID-19 susceptibility, progression, and severity: a population-based study

INTRODUCTION AND OBJECTIVES

Hypercoagulability and thromboembolism are processes that arise from severe acute respiratory syndrome coronavirus 2 infection and are responsible for a high degree of coronavirus disease 2019 (COVID-19)-related morbidity and mortality. This study sought to assess the effect of antiplatelet drugs on COVID-19 severity (risk of hospitalization and mortality), susceptibility to severe acute respiratory syndrome coronavirus 2 infection, and progression to severe COVID-19.

METHODS

We conducted a population-based case-control study in a northwestern region of Spain in 2020. The study involved 3060 participants with a positive polymerase chain reaction test who were hospitalized, 26 757 participants with a positive polymerase chain reaction test who were not hospitalized, and 56 785 healthy controls.

RESULTS

Triflusal seemed to be associated with a significant increase in risk of hospitalization (aOR, 1.97; 95%CI, 1.27-3.04) and susceptibility to infection (OR, 1.45; 95%CI, 1.07-1.96). It also appeared to lead to a nonsignificant increase in the risk of mortality (OR, 2.23; 95%CI, 0.89-5.55) and/or progression to more severe disease stages (OR, 1.42; 95%CI, 0.8-2.51). Aspirin seemed to be associated with a statistically significant decrease in susceptibility to severe acute respiratory syndrome coronavirus 2 infection (OR, 0.92; 95%CI, 0.86-0.98).

CONCLUSIONS

Triflusal use appears to increase the risk of susceptibility to COVID-19 infection and an even higher risk of hospitalization, whereas the other antiplatelets could be associated with a reduction in the risk of the various outcomes or have no effect on risk. These findings could support reconsideration of triflusal prescription in COVID-19 pandemic situations.

Evaluation of costs, osteoporosis treatment, and re-fractures in German collaborative orthogeriatric care after fragility fractures

Orthogeriatric co-management (OGCM) may provide benefits for geriatric fragility fracture patients in terms of more frequent osteoporosis treatment and fewer re-fractures. Yet, we did not find higher costs in OGCM hospitals for re-fractures or antiosteoporotic medication for most fracture sites within 12 months, although antiosteoporotic medication was more often prescribed.

PURPOSE

Evidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence for other fractures is rare. The aim of our study was to conduct an evaluation of economic and health outcomes after the German OGCM for geriatric fragility fracture patients.

METHODS

This retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a fragility fracture in 2014-2018, and were treated in hospitals certified for OGCM (ATZ group), providing OGCM without certification (OGCM group) or usual care (control group). Healthcare costs from payer perspective, prescribed medications, and re-fractures were investigated within 6 and 12 months. We used weighted gamma and two-part models and applied entropy balancing to account for the lack of randomization. All analyses were stratified per fracture site.

RESULTS

We observed 206,273 patients within 12-month follow-up, of whom 14,100 were treated in ATZ, 133,353 in OGCM, and 58,820 in other hospitals. Total average inpatient costs per patient were significantly higher in the OGCM and particularly ATZ group for all fracture sites, compared to control group. We did not find significant differences in costs for re-fractures or antiosteoporotic medication for most fracture sites, although antiosteoporotic medication was significantly more often observed in the OGCM and particularly ATZ group for hip, pelvic, and humerus fractures.

CONCLUSION

The observed healthcare costs were higher in ATZ and OGCM hospitals within 12 months. Antiosteoporotic medication was prescribed more often in both groups for most fracture sites, although the corresponding medication costs did not increase.

The development of suicide risk in people with severe mental disorders during the first year of the COVID-19 pandemic: a claims-based cohort study

PURPOSE

In this study, we assess how the first and second waves of the COVID-19 pandemic influenced the suicide risk of patients with severe mental disorders in Germany.

METHODS

We analyzed German health insurance claims data to compare the suicide risk of patients with severe mental disorders before and during the pandemic. We included n = 690,845 patients between October 2019 and March 2020 and n = 693,457 patients the corresponding period of the previous year and applied entropy balancing to adjust for confounding covariates. Given that the cause of death was unknown, we defined potential suicides as deaths of patients with a history of intentional self-harm whose passing could not be explained by COVID-19. Potential suicides were tracked in both cohorts over one year and compared using logistic regression.

RESULTS

128 potential suicides were identified in the period during and 101 before the pandemic. This corresponded to a significant increase in the risk for potential suicide of 27.4% compared to the control period (β = 0.24, z = 1.82, p < 0.05).

CONCLUSION

The noticeable increase in the risk for potential suicide for patients with severe pre-existing mental disorders emphasizes the call for additional efforts to prevent suicide and to help patients cope with their mental illness in the aftermath of the COVID-19 crisis.

Initial prescriptions and medication switches of biological products: an analysis of prescription pathways and determinants in the Swiss healthcare setting

OBJECTIVES

Biological products have contributed to extraordinary advances in disease treatments over the last decade. However, the cost-saving potential of imitator products, so-called biosimilars, is still under-researched in Switzerland. This study aims to assess biosimilars' prescriptions at treatment initiation and their determinants, as well as biological therapy switches.

DESIGN

The study included all patients who had at least one biosimilar available on the market at the time when they were prescribed a biological product. We analysed longitudinal data for biosimilar prescriptions in Switzerland using descriptive statistics and logistic regression to quantify the associations with individual, pharmaceutical and provider-related variables.

SETTING

The analysis is based on de-identified claims data of patients with mandatory health insurance at Helsana, one of the Swiss health insurance companies with a substantial enrollee base in mandatory health insurance.

PARTICIPANTS

Overall, 18 953 patients receiving at least one biological product between 2016 and 2021 were identified.

OUTCOME MEASURES

We differentiated between initial prescriptions and follow-up prescriptions. Our regression focused on initial prescriptions due to evidence indicating that patients tend to follow the medication prescribed at therapy initiation.

RESULTS

Although biosimilars' market share was low (28.6%), the number of prescriptions has increased (from 1016 in 2016 to 6976 in 2021). Few patients with medication switches (n=1492, 8.5%) were detected. Increased relative price difference (difference in the price of available biosimilars relative to price of corresponding reference product) was associated with decreased probability of biosimilar prescriptions, whereas male sex, an increase of available imitator drugs on the market, larger packaging sizes, and prescriptions from specialists or physicians in outpatient settings were associated with increased biosimilar use.

CONCLUSION

The low number of biosimilar prescriptions, despite the proliferating biosimilar market, indicates a high potential for biosimilar diffusion. The findings indicate that patients typically adhere to the therapy options initially chosen and are less inclined to make changes following the initiation of treatment. Our research highlights the need for awareness initiatives to improve understanding among patients and physicians, enabling informed, shared decision-making about biosimilar prescriptions.

Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study

BACKGROUND

Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption.

OBJECTIVE

We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF.

METHODS

We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use.

RESULTS

Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring.

CONCLUSIONS

The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.

Importance of different electronic medical record components for chronic disease identification in a Swiss primary care database: a cross-sectional study

BACKGROUND

Primary care databases collect electronic medical records with routine data from primary care patients. The identification of chronic diseases in primary care databases often integrates information from various electronic medical record components (EMR-Cs) used by primary care providers. This study aimed to estimate the prevalence of selected chronic conditions using a large Swiss primary care database and to examine the importance of different EMR-Cs for case identification.

METHODS

Cross-sectional study with 120,608 patients of 128 general practitioners in the Swiss FIRE ("Family Medicine Research using Electronic Medical Records") primary care database in 2019. Sufficient criteria on three individual EMR-Cs, namely medication, clinical or laboratory parameters and reasons for encounters, were combined by logical disjunction into definitions of 49 chronic conditions; then prevalence estimates and measures of importance of the individual EMR-Cs for case identification were calculated.

RESULTS

A total of 185,535 cases (i.e. patients with a specific chronic condition) were identified. Prevalence estimates were 27.5% (95% CI: 27.3-27.8%) for hypertension, 13.5% (13.3-13.7%) for dyslipidaemia and 6.6% (6.4-6.7%) for diabetes mellitus. Of all cases, 87.1% (87.0-87.3%) were identified via medication, 22.1% (21.9-22.3%) via clinical or laboratory parameters and 19.3% (19.1-19.5%) via reasons for encounters. The majority (65.4%) of cases were identifiable solely through medication. Of the two other EMR-Cs, clinical or laboratory parameters was most important for identifying cases of chronic kidney disease, anorexia/bulimia nervosa and obesity whereas reasons for encounters was crucial for identifying many low-prevalence diseases as well as cancer, heart disease and osteoarthritis.

CONCLUSIONS

The EMR-C medication was most important for chronic disease identification overall, but identification varied strongly by disease. The analysis of the importance of different EMR-Cs for estimating prevalence revealed strengths and weaknesses of the disease definitions used within the FIRE primary care database. Although prioritising specificity over sensitivity in the EMR-C criteria may have led to underestimation of most prevalences, their sex- and age-specific patterns were consistent with published figures for Swiss general practice.

Association between Johns Hopkins Adjusted Clinical Groups risk scores and self-reported outcome measures: an observational study among individuals with complex or long-term conditions in Norway

OBJECTIVE

Investigate the association between Johns Hopkins Adjusted Clinical Groups (ACG) risk scores and low scores in self-reported outcome measures (SROMs) among individuals with complex or long-term conditions.

DESIGN

Longitudinal study using five ACG risk scores based on diagnoses from general practitioner (GP) visits in 1 year and responses to a survey including three SROMs 4 months later.

SETTING

Four adjacent municipalities in Central Norway.

PARTICIPANTS

Non-institutionalised individuals ≥18 years with ≥1 diagnosis code indicating a complex or long-term condition, ≥1 visit to a GP, and who participated in the survey (n=2944).

MEASURES

Dependent variables were low scores in the three SROMs (threshold for being defined as a low score in parentheses): Patient Activation Measure (level 1-2), EQ-5D (<0.4) or self-rated health ('Poor'). Independent variables were five ACG variables.

RESULTS

The individuals with the lowest scores in the three SROMs were mostly three separate groups. The lowest Patient Activation Measure scores were associated with high scores in the ACG variables unscaled total cost predicted risk (adjusted odds ratio (adjOR) 1.80) and positive frailty flag (adjOR 1.76). The lowest EQ-5D scores were associated with high scores in the ACG variables unscaled concurrent risk (adjOR 1.60) and probability persistent high user scores (adjOR 2.83). The lowest self-rated health scores were associated with high scores in the ACG variable unscaled concurrent risk scores (adjOR 1.77), unscaled total cost predicted risk scores (adjOR 2.14) and receiving a positive frailty flag (adjOR 1.82).

CONCLUSIONS

There were associations between ACG risk scores and subsequent low SROM scores. This suggests a potential to use diagnosis-based risk stratification systems as a proxy for SROMs to identify individuals with complex or long-term conditions for person-centred healthcare intervention.

Estimating the cost impact of atrial fibrillation using a prospective cohort study and population-based controls

AIMS

Atrial fibrillation (AF) costs are expected to be substantial, but cost comparisons with the general population are scarce. Using data from the prospective Swiss-AF cohort study and population-based controls, we estimated the impact of AF on direct healthcare costs from the Swiss statutory health insurance perspective.

METHODS

Swiss-AF patients, enrolled from 2014 to 2017, had documented, prevalent AF. We analysed 5 years of follow-up, where clinical data, and health insurance claims in 42% of the patients were collected on a yearly basis. Controls from a health insurance claims database were matched for demographics and region. The cost impact of AF was estimated using five different methods: (1) ordinary least square regression (OLS), (2) OLS-based two-part modelling, (3) generalised linear model-based two-part modelling, (4) 1:1 nearest neighbour propensity score matching and (5) a cost adjudication algorithm using Swiss-AF data non-comparatively and considering clinical data. Cost of illness at the Swiss national level was modelled using obtained cost estimates, prevalence from the Global Burden of Disease Project, and Swiss population data.

RESULTS

The 1024 Swiss-AF patients with available claims data were compared with 16 556 controls without known AF. AF patients accrued CHF5600 (EUR5091) of AF-related direct healthcare costs per year, in addition to non-AF-related healthcare costs of CHF11100 (EUR10 091) per year accrued by AF patients and controls. All five methods yielded comparable results. AF-related costs at the national level were estimated to amount to 1% of Swiss healthcare expenditure.

CONCLUSIONS

We robustly found direct medical costs of AF patients were 50% higher than those of population-based controls. Such information on the incremental cost burden of AF may support healthcare capacity planning.

Effect of dapagliflozin on COVID-19 infection and risk of hospitalization

BACKGROUND

Dapagliflozin has been proposed as a potential treatment for coronavirus disease 2019 (COVID-19) by reducing cytokine production and inflammation. However, there are limited data on its effectiveness. We aimed to evaluate the impact of dapagliflozin on COVID-19 severity (including hospitalization risk, ICU admission, in-hospital death and progression to severe COVID-19) and its potential on susceptibility to COVID-19 infection.

METHODS

We conducted a population-based case-control study. For aim 1, we assessed COVID-19 severity in cases (positive PCR patients requiring hospitalization) and matched controls (negative PCR patients or positive PCR patients not requiring hospitalization). For aim 2, we compared positive PCR cases (hospitalized and non-hospitalized) with controls. Adjusted odds ratios (aORs) were calculated using a generalized linear mixed model.

RESULTS

We analysed 86 602 subjects: 3060 were hospitalized cases, 26 757 were non-hospitalized cases and 56 785 were controls. Among the hospitalized COVID-19 patients, 228 were admitted to the ICU and 413 died. Dapagliflozin had no effect on the risk of hospitalization (aOR 0.98; 95% CI 0.65-1.48; P = 0.915), ICU admissions (aOR 1.21; 95% CI 0.34-4.25; P = 0.767) or in-hospital death (aOR 1.33; 95% CI 0.53-3.30; P = 0.543). Dapagliflozin reduced the risk of progression to severe COVID-19 by 35%, but this was not statistically significant (aOR 0.65; 95% CI 0.40-1.06; P = 0.086). Dapagliflozin was associated with a 30% increased risk of susceptibility to COVID-19 infection (aOR 1.31; 95% CI 1.05-1.62; P = 0.015).

CONCLUSIONS

Use of dapagliflozin prior to SARS-CoV-2 infection was not associated with an increased risk of hospitalization, ICU admission, mortality or progression to severe COVID-19. However, it was associated with an increased risk of susceptibility to COVID-19 infection.

Inequalities in the impact of having a chronic disease on entering permanent paid employment: a registry-based 10-year follow-up study

BACKGROUND

This study aimed to investigate among unemployed persons (1) the impact of having a chronic disease on entering paid employment and obtaining a permanent contract and (2) whether these associations differed by educational attainment.

METHODS

Register data from Statistics Netherlands on employment status, contract type, medication and sociodemographic characteristics were linked. Dutch unemployed persons between 18 and 64 years (n=667 002) were followed up for 10 years (2011-2020). Restricted mean survival time analyses (RMSTs) were used to investigate differences in average months until entering paid employment and until obtaining a permanent contract between persons with and without cardiovascular diseases, inflammatory conditions, diabetes, respiratory illness, common mental disorders and psychotic disorders. Interaction terms were included for education.

RESULTS

One-third of the unemployed persons at baseline entered paid employment during follow-up. Persons with chronic diseases spent more months in non-employment compared with persons without chronic diseases (difference ranging from 2.50 months (95% CI 1.97 to 3.03 months) to 10.37 months (95% CI 9.98 to 10.77 months)), especially for persons with higher education. Conditional on entering paid employment, the time until a permanent contract was longer for persons with cardiovascular diseases (4.42 months, 95% CI 1.85 to 6.99 months), inflammatory conditions (4.80 months, 95% CI 2.02 to 7.59 months) and diabetes (8.32 months, 95% CI 4.26 to 12.37 months) than for persons without these diseases. These latter differences were similar across educational attainment.

CONCLUSIONS

Having a chronic disease is a barrier to entering permanent paid employment. The findings underline the need to prevent chronic diseases and promote an inclusive workforce.

Outpatient atorvastatin use and severe COVID-19 outcomes: A population-based study

Evidence of the effect of statins on patients with coronavirus disease (2019) COVID-19 is inconsistent. The aim of this study was to evaluate the association between chronic use of statins-both overall and by active ingredient-and severe outcomes of COVID-19 (risk of hospitalization and mortality), progression to severe outcomes, and susceptibility to the virus. We conducted a population-based case-control study with data from electronic records to assess the risk of (1) hospitalization: cases were patients admitted due to COVID-19 and controls were subjects without COVID-19; (2) mortality: cases were hospitalized patients who died due to COVID-19 and controls were subjects without COVID-19; (3) progression: cases were hospitalized COVID-19 subjects and controls were nonhospitalized COVID-19 patients; and (4) susceptibility: cases were patients with COVID-19 (both hospitalized and nonhospitalized) and controls were subjects without COVID-19. We collected data on 2821 hospitalized cases, 26 996 nonhospitalized cases, and 52 318 controls. Chronic use of atorvastatin was associated with a decreased risk of hospitalization (adjusted odds ratios [aOR] = 0.83; 95% confidence interval [CI]: 0.74-0.92) and mortality (aOR = 0.70; 95% CI: 0.53-0.93), attributable in part to a lower risk of susceptibility to the virus (aOR = 0.91; 95% CI: 0.86-0.96). Simvastatin was associated with a reduced risk of mortality (aOR = 0.59; 95% CI: 0.40-0.87). The wide degree of heterogeneity observed in the estimated odds ratios (ORs) of the different statins suggests that there is no class effect. The results of this real-world study suggest that chronic use of atorvastatin (and to a lesser degree, of simvastatin) is associated with a decrease in risk of severe COVID-19 outcomes.

Comparing self-reported health interview survey and pharmacy billing data in determining the prevalence of diabetes, hypertension, and hypercholesterolemia in Belgium

BACKGROUND

Administrative and health surveys are used in monitoring key health indicators in a population. This study investigated the agreement between self-reported disease status from the Belgian Health Interview Survey (BHIS) and pharmaceutical insurance claims extracted from the Belgian Compulsory Health Insurance (BCHI) in ascertaining the prevalence of diabetes, hypertension, and hypercholesterolemia.

METHODS

Linkage was made between the BHIS 2018 and the BCHI 2018, from which chronic condition was ascertained using the Anatomical Therapeutic Chemical (ATC) classification and defined daily dose. The data sources were compared using estimates of disease prevalence and various measures of agreement and validity. Multivariable logistic regression was performed for each chronic condition to identify the factors associated to the agreement between the two data sources.

RESULTS

The prevalence estimates computed from the BCHI and the self-reported disease definition in BHIS, respectively, are 5.8% and 5.9% diabetes cases, 24.6% and 17.6% hypertension cases, and 16.2% and 18.1% of hypercholesterolemia cases. The overall agreement and kappa coefficient between the BCHI and the self-reported disease status is highest for diabetes and is equivalent to 97.6% and 0.80, respectively. The disagreement between the two data sources in ascertaining diabetes is associated with multimorbidity and older age categories.

CONCLUSION

This study demonstrated the capability of pharmacy billing data in ascertaining and monitoring diabetes in the Belgian population. More studies are needed to assess the applicability of pharmacy claims in ascertaining other chronic conditions and to evaluate the performance of other administrative data such as hospital records containing diagnostic codes.

Multimorbidity patterns: obesity as the main modifiable risk factor in adult women in Southern Brazil

Objective

To identify multimorbidity patterns in women in southern Brazil, and its relationship with sociodemographic, lifestyle characteristics, and nutritional status, as well as to explore the main independent risk factor for the identified patterns.

Subjects and methods

This is a cross-sectional, population-based study with 1,128 women (20-69 years), southern Brazil. Chronic conditions were identified using the therapeutic and chemical anatomical classification of continuous use of medications. Multimorbidity was assessed as ≥2 or ≥3 chronic conditions to identify dyads and triads. Poisson regression was used to explore risk factors in the different adjustment models. As independent variables evaluated, in addition to sociodemographic characteristics, lifestyle variables were included: consumption of fruits and vegetables, physical activity, alcohol consumption, smoking and nutritional status.

Results

Eleven dyads (frequencies between 2.0% and 6.4%) and three triads (frequencies between 1.9% and 2.1%) of morbidities were identified in the study. Aging was related to a higher prevalence of all patterns, and obesity was a risk factor for multimorbidity patterns that contained conditions related to the cardiovascular and metabolic system and mental health. After adjustment, obesity increased the probability of "hypertension + common mental disorders (CMD)" (PR 3.63; 95% CI 1.94-6.78) and "dyslipidemia + CMD" (PR 3.69; 95% CI 1.08-12.65) by more than three times.

Conclusion

This study identified common and important diseases in the patterns, associated with a common risk factor, obesity, that must be addressed by public health policies to prevent multimorbidity.

Repurposing selective serotonin reuptake inhibitors for severity of COVID-19: a population-based study

The World Health Organization has proposed that a search be made for alternatives to vaccines for the prevention and treatment of COVID-19, with one such alternative being selective serotonin reuptake inhibitors (SSRIs). This study thus sought to assess: the impact of previous treatment with SSRI antidepressants on the severity of COVID-19 (risk of hospitalisation, admission to an intensive care unit [ICU], and mortality), its influence on susceptibility to SARS-CoV-2 and progression to severe COVID-19. We conducted a population-based multiple case-control study in a region in the north-west of Spain. Data were sourced from electronic health records. Adjusted odds ratios (aORs) and 95%CIs were calculated using multilevel logistic regression. We collected data from a total of 86 602 subjects: 3060 cases PCR+, 26 757 non-hospitalised cases PCR+ and 56 785 controls (without PCR+). Citalopram displayed a statistically significant decrease in the risk of hospitalisation (aOR=0.70; 95% CI 0.49-0.99, p=0.049) and progression to severe COVID-19 (aOR=0.64; 95% CI 0.43-0.96, p=0.032). Paroxetine was associated with a statistically significant decrease in risk of mortality (aOR=0.34; 95% CI 0.12 – 0.94, p=0.039). No class effect was observed for SSRIs overall, nor was any other effect found for the remaining SSRIs. The results of this large-scale, real-world data study indicate that, citalopram, could be a candidate drug for being repurposed as preventive treatment aimed at reducing COVID-19 patients’ risk of progressing to severe stages of the disease.

Opioid prescriptions after knee replacement: a retrospective study of pathways and prognostic factors in the Swiss healthcare setting

OBJECTIVES

The optimal use of opioids after knee replacement (KR) remains to be determined, given the growing evidence that opioids are no more effective than other analgesics and that their adverse effects can impair quality of life. Therefore, the objective is to examine opioid prescriptions after KR.

DESIGN

In this retrospective study, we used descriptive statistics and estimated the association of prognostic factors using generalised negative binomial models.

SETTING

The study is based on anonymised claims data of patients with mandatory health insurance at Helsana, a leading Swiss health insurance.

PARTICIPANTS

Overall, 9122 patients undergoing KR between 2015 and 2018 were identified.

PRIMARY AND SECONDARY OUTCOME MEASURES

Based on reimbursed bills, we calculated the dosage (morphine equivalent dose, MED) and the episode length (acute: <90 days; subacute: ≥90 to <120 days or <10 claims; chronic: ≥90 days and ≥10 claims or ≥120 days). The incidence rate ratios (IRRs) for postoperative opioids were calculated.

RESULTS

Of all patients, 3445 (37.8%) received opioids in the postoperative year. A large majority had acute episodes (3067, 89.0%), 2211 (65.0%) had peak MED levels above 100 mg/day and most patients received opioids in the first 10 postoperative weeks (2881, 31.6%). Increasing age (66-75 and >75 vs 18-65) was associated with decreased IRR (0.776 (95% CI 0.7 to 0.859); 0.723 (95% CI 0.649 to 0.805)), whereas preoperative non-opioid analgesics and opioids were associated with higher IRR (1.271 (95% CI 1.155 to 1.399); 3.977 (95% CI 4.409 to 3.591)).

CONCLUSION

The high opioid demand is unexpected given that current recommendations advise using opioids only when other pain therapies are ineffective. To ensure medication safety, it is important to consider alternative treatment options and ensure that benefits outweigh potential risks.

Identification of a Link between Suspected Metabolic Syndrome and Cognitive Impairment within Pharmaceutical Care in Adults over 75 Years of Age

The prevalence of metabolic syndrome (MetS) and cognitive impairment (CI) is increasing with age. MetS reduces overall cognition, and CI predicts an increased risk of drug-related problems. We investigated the impact of suspected MetS (sMetS) on cognition in an aging population receiving pharmaceutical care in a different state of old age (60-74 vs. 75+ years). Presence or absence of sMetS (sMetS+ or sMetS-) was assessed according to criteria modified for the European population. The Montreal Cognitive Assessment (MoCA) score, being ≤24 points, was used to identify CI. We found a lower MoCA score (18.4 ± 6.0) and a higher rate of CI (85%) in the 75+ group when compared to younger old subjects (23.6 ± 4.3; 51%; p < 0.001). In the age group of 75+, a higher occurrence, of MoCA ≤ 24 points, was in sMetS+ (97%) as compared to sMetS- (80% p < 0.05). In the age group of 60-74 years, a MoCA score of ≤24 points was identified in 63% of sMetS+ when compared to 49% of sMetS- (NS). Conclusively, we found a higher prevalence of sMetS, the number of sMetS components and lower cognitive performance in subjects aged 75+. This age, the occurrence of sMetS and lower education can predict CI.

Effect of Previous Anticoagulant Treatment on Risk of COVID-19

INTRODUCTION

Little is known about the role played by anticoagulants in COVID-19.

OBJECTIVE

The aim of this study was to assess the impact of previous anticoagulant treatment on risk of hospitalization due to COVID-19, progression to severe COVID-19 and susceptibility to COVID-19 infection.

METHODS

We conducted a multiple population-based case-control study in northwest Spain, in 2020, to assess (1) risk of hospitalization: cases were all patients admitted due to COVID-19 with PCR confirmation, and controls were a random matched sample of subjects without a positive PCR; (2) progression: cases were hospitalized COVID-19 subjects, and controls were all non-hospitalized COVID-19 patients; and (3) susceptibility: cases were patients with a positive PCR (hospitalized and non-hospitalized), and the controls were the same as for the hospitalization model. Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using a generalized linear mixed model.

RESULTS

The consumption of antivitamin K and direct-acting anticoagulants apparently was not associated with the risk of progression to severe COVID-19 (OR 0.93 [95% CI 0.74-1.17] and OR 1.04 [95% CI 0.79-1.36], respectively). Antivitamin K anticoagulants were associated with a significantly lower risk of hospitalization (OR 0.77 [95% CI 0.64-0.93]), which, in part, can be explained by a decreased risk of susceptibility to infection (OR 0.83 [95% CI 0.74-0.92]). The use of direct-acting anticoagulants was not associated with the risk of hospitalization, although it also seems to decrease susceptibility (OR 0.85 [95% CI 0.74-0.98]). It has also been observed that low-molecular-weight heparins were associated with an increased risk of progression to severe COVID-19 (OR 1.25 [95% CI 1.01-1.55]).

CONCLUSION

The results of this study have shown that antivitamin K anticoagulants and direct-acting anticoagulants do not increase the risk of progression to more severe stages. Antivitamin K consumption was associated with a lower risk of hospitalization and susceptibility to infection.

Association between acute care collaborations and health care utilization as compared to stand-alone facilities in the Netherlands: a quasi-experimental study

Health systems invest in coordination and collaboration between emergency departments (ED) and after-hours primary care providers (AHPCs) to alleviate pressure on the acute care chain. There are substantial gaps in the existing evidence, limited in sample size, follow-up care, and costs. We assess whether acute care collaborations (ACCs) are associated with decreased ED utilization, hospital admission rates, and lower costs per patient journey, compared with stand-alone facilities. The design is a quasi-experimental study using claims data. The study included 610 845 patients in the Netherlands (2017). Patient visits in ACCs were compared to stand-alone EDs and AHPCs. The number of comorbidities was similar in both groups. Multiple logistic and gamma regressions were used to determine whether patient visits to ACCs were negatively associated with ED utilization, hospital admission rates, and costs. Logistic regression analysis did not find an association between patients visiting ACCs and ED utilization compared to patients visiting stand-alone facilities [odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03]. However, patients in ACCs were associated with an increase in hospital admissions (OR, 1.07; 95% CI, 1.04-1.09). ACCs were associated with higher total costs incurred during the patient journey (OR, 1.02; 95% CI, 1.01-1.03). Collaboration between EDs and AHPCs was not associated with ED utilization, but was associated with increased hospital admission rates, and higher costs. These collaborations do not seem to improve health systems' financial sustainability.

The influence of onset of disease on exit from paid employment among workers in The Netherlands: A longitudinal register-based study with 9 years follow-up

OBJECTIVES

This study investigates the influence of onset of disease on exit from paid employment and whether this differs across diseases and sociodemographic groups.

METHODS

Register data from Statistics Netherlands on medication prescription was linked to information on employment status and demographics. Persons who were employed in 2009 and 2010 and who did not use medication for the selected disease in 2009 (N=5 889 036) were followed-up over nine years. Six diseases were identified based on medication prescription in 2010 and 2011: cardiovascular diseases, inflammatory diseases, diabetes mellitus, respiratory diseases, common mental disorders, and psychotic disorders. Four pathways out of paid employment were defined: disability benefits, unemployment, no income, and early retirement. Early exit from paid employment was defined as exiting paid employment before retirement age. Cause-specific Cox proportional hazards regression analyses were performed, with interaction terms for age, sex, and migration background.

RESULTS

Onset of disease increased the likelihood of exit from paid employment, with the strongest associations for psychotic disorders [hazard ratio (HR) 2.88, 95% confidence interval (CI) 2.78-2.98] and common mental disorders (HR 2.00, 95% CI 1.97-2.03). Onset of disease was most strongly associated with disability benefits, followed by unemployment. The influence of common mental and psychotic disorders on disability increased until around middle-age, after which it decreased. The influence of mental health problems on exit from paid employment was stronger for persons with a non-native Dutch background and males.

CONCLUSION

Onset of diseases, especially mental health disorders, is a risk for exiting paid employment before the retirement age. Effective interventions are needed to enhance an inclusive workforce and prevent involuntary loss of paid employment.

Dietary patterns and prevalence of multimorbidity in women in southern Brazil

OBJECTIVE

This study aimed to investigate the association between dietary patterns and prevalence of multimorbidity in women.

METHODS

This population-based cross-sectional study was conducted in 2015 and included 1,128 women aged 20 to 69 years living in the urban area of São Leopoldo municipality, southern Brazil. Multimorbidity was defined as the presence of two or more chronic conditions, among the 26 identified. Poisson regression with robust variance was used to investigate the association between the three dietary patterns (healthy, risk, and Brazilian), using different models adjusted for sociodemographic, behavioral, and nutritional status variables.

RESULTS

The results showed differences in the prevalence of adherence to different dietary patterns and multimorbidity across age groups, with a prevalence of multimorbidity and a healthy dietary pattern showing a direct linear trend with age, whereas the risk dietary pattern showed an inverse linear trend with age. The prevalence of the Brazilian dietary pattern remained constant despite differences in age. After adjustment, we found that women with greater adherence to the Brazilian dietary pattern showed a 40% reduction in the prevalence of multimorbidity compared with those with less adherence (prevalence ratio, 0.60; 95% confidence interval, 0.40-0.86).

CONCLUSION

The results revealed that the prevalence of multimorbidity was significantly lower in women with greater adherence to the Brazilian dietary pattern and highlight the importance of dietary interventions in early adulthood as a way to prevent multimorbidity in women.

Evaluation of the Effect of a Multifunctional Telemedicine Device on Health Care Use and Costs: A Nonrandomized Pragmatic Trial

Background: Telemedicine health insurance models are highly prevalent in the Swiss health care system. Nevertheless, the potential of telemedicine is only partly being achieved, since current telemedicine health insurance models are limited to an initial contact by telephone and a gatekeeper role that organizes access to health care providers such as general practitioners, specialists, or hospitals. Against this background, a telemedicine device with diverse visual and auscultatory examination functions was made available to 2,000 telemedicine-insured clients. This device allowed diagnostic information to be sent to a medical care provider and used for telemedical consultation. Objective: To determine whether the additional implementation of a multifunctional telemedicine examination device resulted in fewer physical consultations, reduced service utilization, and lower health care expenditures among telemedicine-insured clients. Methods: Our analysis is based on claims data from 135,636 clients insured in a telemedicine call center model covering the years 2019 and 2020. We compare the use of health care and health care costs of clients who received a telemedicine device with those without such a device, using multivariable regression to adjust for group differences due to self-selection. Results: We found lower total health care expenditures of -229 (Swiss Francs) and lower inpatient costs of -160 (Swiss Francs) on the part of clients with the telemedicine device. However, the implementation of the telemedicine device did not lead to a statistically significant reduction in service utilization. Conclusions: The treatment of telemedicine-insured clients was on average more cost-effective when they received the multifunctional telemedicine device. Accordingly, complementing the existing telemedicine model with telemedicine devices that allow for improved telemedical consultations has the potential to increase the cost-saving potential of the existing telemedicine call center models.

The association of specific industry-related air pollution with occurrence of chronic diseases: A register-based study

Air pollution may contribute to onset and progression of chronic diseases such as cardiovascular and respiratory diseases. Most studies have focused on the contribution of traffic-related exposure to PM₁₀ or PM_2.5. Our aim was to investigate the association of different components of industry-related air pollution on the occurrence of chronic diseases. A register-based repeated cross-sectional study was conducted among 89,714 subjects (2012) with 536,599 annual observations (2012-2017) living in the vicinity of a large industrial area in the Netherlands. Information from the dispensed medication registration was linked with a dispersion model to characterize annual individual-level exposure of all subjects at place of residence. Associations between annual exposure (concentration and duration) to particulate matter (PM₁₀), nitrogen oxides (NO_X), sulphur dioxide (SO₂), and volatile organic compounds (VOC) with annual dispensed medication for cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions were investigated by multivariate logistic regression analysis with generalized estimating equations (GEE) while controlling for confounders. Exposure to PM₁₀ and to NO_X (per μg/m³) were significantly associated with medication for cardiovascular diseases (OR 1.06, 95CI% 1.06-1.06 and OR 1.01, 95%CI 1.01-1.01 respectively). Exposures to PM₁₀ and SO₂ (per μg/m³) were significantly associated with medication for inflammatory conditions (OR 1.05, 95%CI 1.00-1.09 and OR 1.07, 95%CI 1.01-1.14 respectively). Exposure to SO₂ was inversely associated with respiratory diseases (OR 0.91, 95%CI 0.86-0.97). Except for inflammatory conditions, exposure duration (years) was significantly associated with the other three chronic diseases (OR varying from 1.01 to 1.03). This study indicates that specific air pollution components caused by industry may contribute to the occurrence of cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions.

Association of two geriatric treatment systems on care home admission and mortality in patients with hip fracture

BACKGROUND

In Germany, geriatricians deliver acute geriatric care during an acute hospital stay and subacute rehabilitation after transfer to a rehabilitation clinic. However, the proportion of patients who receive acute geriatric care (AGC) or are transferred to subacute rehabilitation (TSR) differs considerably between hospitals. The aim of this study was to analyse the association between the two geriatric treatment systems and care home admission or mortality in patients following hip fracture.

METHODS

Health insurance claims data were used to identify the rate of AGC per hospital and the rate of TSR per hospital following hip fracture surgery in patients aged ≥ 80 years. Outcomes were cumulative admission to a care home and cumulative mortality within 6 months after hospital admission.

RESULTS

Data from 23,046 hip fracture patients from 561 hospitals were analysed. The rate of AGC was not associated with care home admission. However, compared to high rates of AGC medium rates or no AGC were associated with increased death rates by 12% or 20%, respectively. Treatment in hospitals with low rates of TSR was associated with a 8% higher risk of care home admission and a 10% increased risk of death compared to treatment in hospitals with high rates of TSR.

CONCLUSIONS

Our study suggests potential effects of geriatric treatment: reduction of mortality in hospitals with high rates of AGC or reduction of care home admission and mortality in hospitals with high rates of TSR.

Lifestyle, high Body Mass Index, and markers of socioeconomic conditions associated with multimorbidity in women

OBJECTIVE

This study aimed to identify the prevalence of multimorbidity and its associated factors in women in southern Brazil.

METHODS

We conducted a cross-sectional, population-based study with a sample of 1,128 women (age 20-69 years), living in São Leopoldo, southern Brazil. Multimorbidity was defined as two or more chronic conditions measured using the therapeutic and chemical anatomical classification of continuous use medications prescribed by a physician. Poisson regression model with robust variance was used to assess the association between sociodemographic and lifestyle variables and multimorbidity.

RESULTS

The prevalence of multimorbidity was 21.7% (95%CI 19.3-24.2), and 26 chronic conditions were identified. A direct linear association was observed with age and income and an inverse association with education. Being unemployed was a risk factor for multimorbidity (PR 1.95; 95%CI 1.51-2.52). Alcohol consumption (moderate or excessive) had a protective effect. Overweight and obese women were 53% (PR 1.53; 95%CI 1.09-2.15) and 76% (PR 1.76; 95%CI 1.27-2.45) more likely to have multimorbidity than eutrophic women.

CONCLUSION

Over 20% of the adult women had multimorbidity, and its occurrence was strongly associated with socioeconomic characteristics, such as fewer years of schooling, higher income, and not having an occupation. The results regarding alcohol consumption are still insufficient to propose a public policy for the prevention of multimorbidity. Excess weight was an independent risk factor and should be addressed in public health policies for the prevention and management of multimorbidity.

Health Literacy and Clinical Trial Participation in French Cancer Patients: A National Survey

Few studies have explored the relationship between health literacy (HL) and trial participation. In this context, we aimed to study this relationship in French cancer patients. We used data from the French national VIe après le CANcer (VICAN) survey. Two questionnaire items focused on previous invitations to participate in clinical trials and subsequent enrollment. The Single Item Literacy Screener was used to measure functional HL. In total, 1954 cancer patients responded to both VICAN surveys (two and five years after diagnosis). Mean age was 54.1 ± 12.7 years at diagnosis, and 37.6% were classified as having limited HL. One in ten (10.3%) respondents reported having been previously invited to participate in a clinical trial. Of these, 75.5% had enrolled. Limited HL was associated with fewer trial invitations but not with enrollment once invited. Multivariate analysis confirmed the negative effect of limited HL on clinical trial invitation (adjOR = 0.55 (0.39 to 0.77), p < 0.001) after adjustment for multiple characteristics. Patients with limited HL received fewer invitations to participate in trials but were likely to enroll when asked. Addressing HL is necessary to create a more inclusive health system and to reduce inequalities not only in access to innovative cancer care, but to health inequalities in general.

Therapy patterns and surveillance measures of Inflammatory Bowel Disease patients beyond disease-related hospitalization: a claims-based cohort study

Introduction

Medical care and surveillance of inflammatory bowel disease (IBD) patients have been shown to be far from satisfactory. Data on therapy patterns and surveillance measures in IBD patients are scarce. We, therefore, aimed to compare the therapy patterns and surveillance management of IBD patients in the year before and after IBD-related hospitalization.

Methods

We examined medical therapy, surveillance management (influenza vaccination, dermatologist visits, Pap smear screening, creatinine measurements, iron measurements, and ophthalmologist visits) and healthcare utilization in 214 ulcerative colitis (UC) and 259 Crohn's disease (CD) patients who underwent IBD-related hospitalization from 2012 to 2014.

Results

IBD-related drug classes changed in 64.5% of IBD patients following hospitalization. During the 1-year follow-up period, biological treatment increased in UC and CD patients, while steroid use decreased. Following hospitalization, 63.1% of UC and 27.0% of CD patients received 5-ASA. Only 21.6% of all IBD patients had a flu shot, and 19.6% of immunosuppressed IBD patients were seen by a dermatologist in the follow-up; other surveillance measures were more frequent. Surveillance before hospital admission and consultations by gastroenterologists were strongly correlated with surveillance during the postoperative follow-up, while gender and diagnosis (UC vs. CD) were not. During the 1-year follow-up, 20.5% of all IBD patients had no diagnostic or disease-monitoring procedure.

Discussion/Conclusion

Surveillance measures for IBD patients are underused in Switzerland. Further research is needed to examine the impact of annual screenings and surveillance on patient outcomes.

[Frequency of Prescription of Non-steroidal Anti-inflammatory Drugs: Analysis of Compulsory Health Insurance Billing Data]

Frequency of Prescription of Non-steroidal Anti-inflammatory Drugs: Analysis of Compulsory Health Insurance Billing Data Abstract. According to the nephrology recommendation in the Choosing Wisely campaign, non-steroidal anti-inflammatory drugs should be avoided in people with cardiac and renal diseases. This study provides quantitative data on the use of NSAIDs in Switzerland as well as indications of how the billing frequency of NSAIDs in high-risk individuals has changed since the introduction of the recommendation.

METHOD

Secondary analysis of billing data from compulsory health insurance. The frequency of NSAID use was stratified by sociodemographics and the comorbidities "cardiology" and "renal insufficiency".

RESULTS

It was shown for the first time that 33.6% of the total study population, 42.1% of the cardiac risk population and 18% of the renal risk population used NSAIDs. There was a slight tendency for the billing frequency to decrease after the introduction of the recommendation.

DISCUSSION

Further studies are needed as a matter of priority to quantify the use of potentially harmful NSAIDs in other risk groups and, on the basis of the ensuing study results, a wider use of the Choosing Wisely recommendations must be considered, especially in the general population.

Continuity of care and multimorbidity in the 50+ Swiss population: An analysis of claims data

Objective

To assess the relationship between continuity of care (COC) and multimorbidity in the older general population in Switzerland, accounting for relevant determinants of COC, and to apply various expressions of multimorbidity derived from claims data.

Methods

We used data on 240′000 insured individuals aged 50+ for the period 2015–2018, received from one of the largest Swiss health insurance company. We calculated Bice-Boxerman index based on all doctor visits (overall COC) and visits to the general practitioners (COC GP). We analyzed the relationship between COC and multimorbidity using generalized linear and probit models. To express multimorbidity, we applied three approaches based on pharmacy-cost groups (PCGs) assigned to an individual. First, we used simple PCG counts. Second, we expressed multimorbidity via clinically relevant disease groups derived from PCGs. Finally, a data-driven approach allowed defining distinct clusters representing different patient complexities.

Results

The association between overall COC and multimorbidity expressed in PCG counts was modest: COC among individuals with 3+ PCGs was 2 percentage points higher than COC among individuals with 0 PCGs. The approach of clinically relevant disease groups showed larger variation in COC and its association with multimorbidity. The data-driven approach showed that most complex (“high-cost high-need”) individuals tended to have higher overall COC. Additionally, 70% of the sample visited exclusively one general practitioner (COC GP = 1.0). Other important factors associated with COC in the Swiss context were insurance model with gatekeeping, level of deductibles, and region of residence.

Conclusions

Multimorbid patients require regular medical attention often involving multiple healthcare providers, which can lead to varying COC, depending on types of doctors seen and specific condition of the patient. Insurance models with gatekeeping may facilitate COC, prompting developments of better-designed models of care. This represents important implications for policymakers, health insurance representatives, medical professionals and hospital managers.

•

We investigated the relationship between multimorbidity and COC, using claims-based data.

•

We applied three approaches of expressing multimorbidity in claims data: simple counts, expert-based and data-driven.

•

Association between COC and multimorbidity expressed in simple counts was modest, while expert-based approach showed larger heterogeneity.

•

Data-driven approach revealed that most complex individuals tended to have higher COC.

Blood sampling frequency as a proxy for comorbidity indices when identifying patient samples for review of reference intervals

OBJECTIVES

Indirect data mining methods have been proposed for review of published reference intervals (RIs), but methods for identifying patients with a low likelihood of disease are needed. Many indirect methods extract test results on patients with a low frequency blood sampling history to identify putative healthy individuals. Although it is implied there has been no attempt to validate if patients with a low frequency blood sampling history are healthy and if test results from these patients are suitable for RI review.

METHODS

Danish nationwide health registers were linked with a blood sample database, recording a population of 316,337 adults over a ten-year period. Comorbidity indexes were defined from registrations of hospital diagnoses and redeemed prescriptions of drugs. Test results from patients identified as having a low disease burden were used for review of RIs from the Nordic Reference Interval Project (NORIP).

RESULTS

Blood sampling frequency correlated with comorbidity Indexes and the proportion of patients without disease conditions were enriched among patients with a low number of blood samples. RIs based on test results from patients with only 1-3 blood samples per decade were for many analytes identical compared to NORIP RIs. Some analytes showed expected incongruences and gave conclusive insights into how well RIs from a more than 10 years old multi-center study (NORIP) performed on current pre-analytical and analytical methods.

CONCLUSIONS

Blood sampling frequency enhance the selection of healthy individuals for reviewing reference intervals, providing a simple method solely based on laboratory data without the addition of clinical information.

Does a pharmacist-led medication use review improve medication adherence in polymedicated aged patients? Methodological choices matter!

RATIONALE, AIMS AND OBJECTIVES

The rise in chronic diseases urges for an identification of interventions that improve adherence. However, no golden standard exists for evaluating adherence in polymedicated patients. The objectives were to investigate the impact of a pharmacist-led medication use review (MUR) service on adherence implementation rates for chronic medication, and to evaluate the appropriateness of two adherence calculation approaches in this regard.

METHOD

Before-after study (SIMENON study) including ambulatory, aged, polymedicated patients. Refill data were used to calculate the proportion of days covered (PDC) per medication before and after the MUR. Adherence was assessed for chronic, solid, oral medication using a prescription-based and interval-based approach, and the performance of both approaches was compared.

RESULTS

Adherence was evaluated for 1483 medications from 316 patients. The median baseline PDC per medication was 0.95 (prescription-based method) and 0.91 (interval-based approach). Pearson correlation between both approaches was 0.616 (P < .0001). The prescription-based approach found less medication below the adherence threshold of 0.80 (319 medications; 21.5% vs 481 medications; 32.4%). Using the prescription-based approach, the proportion of non-adherent patients at baseline was 61.7% (195/316 patients), of which 54.9% (107/195 patients) was only non-adherent for one medication. Median PDC scores increased significantly from 0.95 to 0.99 and 0.91 to 0.99 with the prescription-based and interval-based approach respectively (both P < .0001). Only considering the 319 medications with baseline PDC scores <0.8 using the prescription-based approach, the median PDC scores significantly increased from 0.67 to 0.84 (P < .0001), with a median score improvement of 18.3%.

CONCLUSIONS

Although baseline adherence was high in this population of polymedicated aged patients, both calculation methods showed the MUR significantly improved adherence. The prescription-based approach was considered the most appropriate method. Based on these findings and literature evidence, it is recommended to implement the MUR service in Belgium and target non-adherent patients for maximal effect.

Social and sexual health of thyroid cancer survivors 2 and 5 years after diagnosis: the VICAN survey

PURPOSE

Thyroid cancer (TC) incidence is increasing. With its good prognosis and the young population concerned, the number of survivors is rising. However, their quality of life appears worse than expected. This study aims to assess the social and sexual health (SSH) of TC survivors and associated factors after a 2- and 5-year follow-up.

METHODS

This study belongs to the National VICAN Survey implemented in France among TC patients diagnosed between January and June 2010. Data were collected via phone interviews, medical surveys, and from medico-administrative register in 2012 and 2015. We used multivariable logistic regressions to qualify TC impact on SSH.

RESULTS

Across 146 patients, 121 were women, 50.7% were less than 42 years old, 77.5% were diagnosed at an early-stage, and 97.6% underwent thyroidectomy. At 2 years, 60.0% experienced social life discomfort because of cancer, 40.6% reported a decreased sexual desire, 37.4% fewer intercourse, 31.9% felt dissatisfied with this frequency, 30% reported difficulties achieving orgasm, and 15.2% considered that cancer had a negative influence for procreation. No significant difference was observed at 5 years. SSH was never discussed with medical professionals for 96.7% patients, as it was not proposed as a topic of concern (79.1%). In multivariable analysis, depression, embarrassment regarding their physical appearance since treatment, and reduced gestures of affection remained associated with decreased sexual desire.

CONCLUSION

This study highlights that TC is associated with an alteration of SSH which remains even at 5 years post-diagnosis. SSH should be discussed during diagnosis and considered during follow-up.

Decomposition of outpatient health care spending by disease - a novel approach using insurance claims data

Background

Decomposing health care spending by disease, type of care, age, and sex can lead to a better understanding of the drivers of health care spending. But the lack of diagnostic coding in outpatient care often precludes a decomposition by disease. Yet, health insurance claims data hold a variety of diagnostic clues that may be used to identify diseases.

Methods

In this study, we decompose total outpatient care spending in Switzerland by age, sex, service type, and 42 exhaustive and mutually exclusive diseases according to the Global Burden of Disease classification. Using data of a large health insurance provider, we identify diseases based on diagnostic clues. These clues include type of medication, inpatient treatment, physician specialization, and disease specific outpatient treatments and examinations. We determine disease-specific spending by direct (clues-based) and indirect (regression-based) spending assignment.

Results

Our results suggest a high precision of disease identification for many diseases. Overall, 81% of outpatient spending can be assigned to diseases, mostly based on indirect assignment using regression. Outpatient spending is highest for musculoskeletal disorders (19.2%), followed by mental and substance use disorders (12.0%), sense organ diseases (8.7%) and cardiovascular diseases (8.6%). Neoplasms account for 7.3% of outpatient spending.

Conclusions

Our study shows the potential of health insurance claims data in identifying diseases when no diagnostic coding is available. These disease-specific spending estimates may inform Swiss health policies in cost containment and priority setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07262-x.

Change in Colorectal Cancer Tests Submitted for Reimbursement in Switzerland 2012-2018: Evidence from Claims Data of a Large Insurance

Objectives: Guidelines recommend colorectal cancer (CRC) screening by fecal occult blood test (FOBT) or colonoscopy. In 2013, Switzerland introduced reimbursement of CRC screening by mandatory health insurance for 50-69-years-olds, after they met their deductible. We hypothesized that the 2013 reimbursement policy increased testing rate.

Methods: In claims data from a Swiss insurance, we determined yearly CRC testing rate among 50-75-year-olds (2012–2018) and the association with socio-demographic, insurance-, and health-related covariates with multivariate-adjusted logistic regression models. We tested for interaction of age (50–69/70–75) on testing rate over time.

Results: Among insurees (2012:355′683; 2018:348′526), yearly CRC testing rate increased from 2012 to 2018 (overall: 8.1–9.9%; colonoscopy: 5.0–7.6%; FOBT: 3.1–2.3%). Odds ratio (OR) were higher for 70–75-year-olds (2012: 1.16, 95%CI 1.13–1.20; 2018: 1.05, 95%CI 1.02–1.08). Deductible interacted with changes in testing rate over time (p < 0.001). The increase in testing rate was proportionally higher among 50-69-years-olds than 70-75-year-olds over the years.

Conclusions: CRC testing rate in Switzerland increased from 2012 to 2018, particularly among 50-69-years-olds, the target population of the 2013 law. Future studies should explore the effect of encouraging FOBT or waiving deductible.

Exploring patient multimorbidity and complexity using health insurance claims data: a cluster analysis approach (Preprint)

Background

Although the trend of progressing morbidity is widely recognized, there are numerous challenges when studying multimorbidity and patient complexity. For multimorbid or complex patients, prone to fragmented care and high health care use, novel estimation approaches need to be developed.

Objective

This study aims to investigate the patient multimorbidity and complexity of Swiss residents aged ≥50 years using clustering methodology in claims data.

Methods

We adopted a clustering methodology based on random forests and used 34 pharmacy-based cost groups as the only input feature for the procedure. To detect clusters, we applied hierarchical density-based spatial clustering of applications with noise. The reasonable hyperparameters were chosen based on various metrics embedded in the algorithms (out-of-bag misclassification error, normalized stress, and cluster persistence) and the clinical relevance of the obtained clusters.

Results

Based on cluster analysis output for 18,732 individuals, we identified an outlier group and 7 clusters: individuals without diseases, patients with only hypertension-related diseases, patients with only mental diseases, complex high-cost high-need patients, slightly complex patients with inexpensive low-severity pharmacy-based cost groups, patients with 1 costly disease, and older high-risk patients.

Conclusions

Our study demonstrated that cluster analysis based on pharmacy-based cost group information from claims-based data is feasible and highlights clinically relevant clusters. Such an approach allows expanding the understanding of multimorbidity beyond simple disease counts and can identify the population profiles with increased health care use and costs. This study may foster the development of integrated and coordinated care, which is high on the agenda in policy making, care planning, and delivery.

The distribution of disease in the Republic of Suriname - A pharmacoepidemiological analysis using the claims database of the State Health Foundation of the year 2017

The patterns of prescription drug use in Suriname in the year 2017 have been determined with the purpose of obtaining indications about the distribution of disease in the country. The claims database of the State Health Foundation (Staatsziekenfonds, SZF) of Suriname was used for calculations of prescription rates of the fifty most prescribed drugs overall and after stratification according to gender, age, and residence of the insured persons. Information in the database had been de-identified, and the prescribed medicines had been coded according to the Anatomic Therapeutic Chemical Classification System. Statistically significant differences among the prescription rates were assessed with the two samples test of proportions using normal theory method and χ² Goodness of Fit tests (p < 0.05). Additionally, the Bonferroni adjustment was used to adjust for type 1 error inflation resulting from multiple comparisons. Overall, drugs for the cardiovascular, respiratory, and musculo-skeletal systems had the highest prescription rates (p < 0.001). Furthermore, rates were generally higher in females than in males, in the older age groups than in younger individuals, and in the coastal regions compared to the country's interior (p < 0.001). These findings are largely in line with data found in the literature and support the use of this pharmacoepidemiological approach to assess the distribution of disease in Suriname.

Returning to work by thyroid cancer survivors 5 years after diagnosis: the VICAN survey

PURPOSE

Return to work (RTW) following cancer diagnosis is a challenge for both the patient and society. As thyroid cancer (TC) incidence is increasing, this study aims to assess difficulties in returning to work and income changes in TC survivors 5 years post-diagnosis.

METHODS

This study belongs to the national VICAN survey conducted in France among TC patients diagnosed between January and June 2010. Data were collected through phone interviews, medical surveys and from the national medico-administrative register in 2012 and 2015. We used multivariate logistic regressions to investigate TC impact on employment and income changes.

RESULTS

Of 146 patients, 121(82.9%) were women; the mean age was 42 years (SD = 8.34), 119 (81.3%) were diagnosed at an early stage, and 142(97.6%) underwent thyroidectomy. At 5 years post-diagnosis, 116 (79.7%) of the TC survivors were professionally active, 22 (15.4%) were unemployed and 8 (4.90%) were receiving disability. Among the patients employed at the time of diagnosis (n = 122), 15 (12.3%) had not returned to work 5 years post-diagnosis. Between 2 and 5 years post-diagnosis, there was no significant improvement in rates of RTW. At 5 years post-diagnosis, 90 (61.6%) reported an income decline. All TC survivors who have not returned to work were women and declared higher fatigue. Moreover, in multivariate analyses, not returning to work was associated with weight gain (OR = 8.41 (1.21; 58.23)) and working arrangements (6.90 (1.18-38.48)), while income decline was associated with comorbidities (OR = 2.28 (1.07; 4.86)) and to be engaged in manual work (OR = 2.28 (1.07; 4.88)).

CONCLUSION

This study highlights that, despite a good prognostic, up to 12.3% of TC survivors had not returned to work and 61.6% reported an income decline, 5 years post-diagnosis. Weight gain, fatigue, to be a woman and working-type arrangement were associated with higher probability of not returning to work.

IMPLICATIONS FOR CANCER SURVIVORS

TC affects a young working population. Our study identified potentially vulnerable TC survivors and important modifiable factors which may help TC survivors to be professionally active and, therefore, increase their overall quality of life.

Health-economic evaluation of collaborative orthogeriatric care for patients with a hip fracture in Germany: a retrospective cohort study using health and long-term care insurance claims data

BACKGROUND

Evidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence on cost-effectiveness is limited and based on small datasets. The aim of our study was to conduct an economic evaluation of the German OGCM for geriatric hip fracture patients.

METHODS

This retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a hip fracture in 2014, and were treated in hospitals providing OGCM (OGCM group) or standard care (control group). Health care costs from payer and societal perspective, life years gained (LYG) and cost-effectiveness were investigated within 1 year. We applied weighted gamma and two-part models, and entropy balancing to account for the lack of randomisation. We calculated incremental cost-effectiveness ratios (ICER) and employed the net-benefit approach to construct cost-effectiveness acceptability curves.

RESULTS

14,005 patients were treated in OGCM, and 10,512 in standard care hospitals. Total average health care costs per patient were higher in the OGCM group: €1181.53 (p < 0.001) from payer perspective, and €1408.21 (p < 0.001) from societal perspective. The ICER equalled €52,378.12/ LYG from payer and €75,703.44/ LYG from societal perspective. The probability for cost-effectiveness would be 95% if the willingness-to-pay was higher than €82,000/ LYG from payer, and €95,000/ LYG from societal perspective.

CONCLUSION

Survival improved in hospitals providing OGCM. Costs were found to increase, driven by inpatient and long-term care. The cost-effectiveness depends on the willingness-to-pay. The ICER is likely to improve with a longer follow-up.

Surgical procedures in inpatient versus outpatient settings and its potential impact on follow-up costs

OBJECTIVE

We examined real-world effects of cantonal legislations to direct surgery patients from the inpatient to the outpatient setting in Switzerland.

METHODS

Analyses were based on claims data of the Helsana Group, a leading Swiss health insurance. The study population consisted of 13'145 (in 2014), 12'455 (in 2016), and 12'875 (in 2018) insured persons aged >18 years who had haemorrhoidectomy, inguinal hernia repair, varicose vein surgery, knee arthroscopy/meniscectomy or surgery of the cervix/uterus. We assessed the proportion of inpatient procedures, index costs, length of hospital stays, outpatient costs and hospitalizations during follow-up, stratified by procedure, in-/outpatient setting, and the presence (enacted/effective in 2018) of a cantonal legislation. We used difference-in-differences methods to study the impact of cantonal legislations.

RESULTS

Overall, the proportion of procedures performed in the inpatient setting decreased between 2014 and 2018 (p < 0.001). The decrease between 2016 and 2018 was significantly steeper in cantons with a legislation (p < 0.001; effect size: 0.57; 95% CI: 0.51, 0.64), leading to steeper decreases in healthcare costs of index procedures in cantons with a legislation, with no impact on length of hospital stays. The legislation also had no impact on outpatient costs or hospitalizations during follow-up.

CONCLUSIONS

The cantonal legislations achieved the intended effects of inpatient surgery substitution by outpatient surgery, with no evidence suggesting negative effects on costs or hospitalizations during follow-up.

A narrative review of using prescription drug databases for comorbidity adjustment: A less effective remedy or a prescription for improved model fit?

BACKGROUND

The use of claims data for identifying comorbid conditions in patients for research purposes has been widely explored. Traditional measures of comorbid adjustment included diagnostic data (e.g., ICD-9-CM or ICD-10-CM codes), with the Charlson and Elixhauser methodology being the two most common approaches. Prescription data has also been explored for use in comorbidity adjustment, however early methodologies were disappointing when compared to diagnostic measures.

OBJECTIVE

The objective of this methodological review is to compare results from newer studies using prescription-based data with more traditional diagnostic measures.

METHODS

A review of studies found on PubMed, Medline, Embase or CINAHL published between January 1990 and December 2020 using prescription data for comorbidity adjustment. A total of 50 studies using prescription drug measures for comorbidity adjustment were found.

CONCLUSIONS

Newer prescription-based measures show promise fitting models, as measured by predictive ability, for research, especially when the primary outcomes are utilization or drug expenditure rather than diagnostic measures. More traditional diagnostic-based measures still appear most appropriate if the primary outcome is mortality or inpatient readmissions.

Beyond price: the effects of non-financial barriers on access to drugs and health outcomes

OBJECTIVES

We study the impact of the pharmacy dispensing channel (as a proxy for access to drugs) on the drug purchases, health outcomes, and health care utilization (emergency room visits or hospitalizations) of chronically ill patients in Liguria, Italy, in 2017.

METHODS

We use the coarsened exact matching algorithm to compare the health outcomes for a treated group of patients living in a local health authority (LHA) where drug distribution through community pharmacies was restricted. These patients were matched to a control group of patients living in other LHAs, where drugs were also dispensed through a broad network of community pharmacies. We exploit a unique administrative dataset with information on the socio-demographic characteristics and health care services utilization of Ligurian patients with chronic cardiovascular and respiratory ailments. We restrict our analysis to patients 65 years of age or older who were admitted to hospitals from 2013 to 2016 with either a principal or secondary diagnosis connected to chronic cardiovascular and respiratory diseases.

RESULTS

Reduced access to drugs leads to lowered drug consumption, a higher probability of adverse health outcomes including mortality, and a higher consumption of medical services in terms of hospitalizations and emergency room visits. These effects increase with patients' age.

CONCLUSION

The pharmacy dispensing channel significantly affects drug consumption and acts as a proxy for adherence among chronically ill patients. Thus, health outcomes and health care utilization should be carefully evaluated when comparing the costs of alternative dispensing channels.

Neuropsychiatric safety of varenicline in the general and COPD population with and without psychiatric disorders: a retrospective cohort study in a real-world setting

OBJECTIVES

To evaluate the real-world association between varenicline and neuropsychiatric adverse events (NPAEs) in general and chronic obstructive pulmonary disease (COPD) population with and without psychiatric disorders compared with nicotine replacement therapy (NRT) to strengthen the knowledge of varenicline safety.

DESIGN

A retrospective cohort study.

SETTING

Prescription database IADB.nl, the Netherlands.

PARTICIPANTS

New users of varenicline or NRT among general (≥18 years) and COPD (≥40 years) population. Psychiatric subcohort was defined as people prescribed psychotropic medications (≥2) within 6 months before the index date.

OUTCOME MEASURES

The incidence of NPAEs including depression, anxiety and insomnia, defined by new or naive prescriptions of related medications in IADB.nl within 24 weeks after the first treatment initiation of varenicline or NRT.

RESULTS

For the general population in non-psychiatric cohort, the incidence of total NPAEs in varenicline (4480) and NRT (1970) groups was 10.5% and 12.6%, respectively (adjusted OR (aOR) 0.85, 95% CI 0.72 to 1.00). For the general population in psychiatric cohort, the incidence of total NPAEs was much higher, 75.3% and 78.5% for varenicline (1427) and NRT (1200) groups, respectively (aOR 0.82, 95% CI 0.68 to 0.99). For the COPD population (1598), there were no differences in the incidence of NPAEs between comparison groups in both the psychiatric cohort (aOR 0.97, 95% CI 0.66 to 1.44) and non-psychiatric cohort (aOR 0.81, 95% CI 0.54 to 1.20). Results from subgroup or sensitivity analyses also did not reveal increased risks of NPAEs but showed decreased risk of some subgroup NPAEs associated with varenicline.

CONCLUSIONS

In contrast to the concerns of a possible increased risk of NPAEs among varenicline users, we found a relative decreased risk of total NPAEs in varenicline users of the general population in psychiatric or non-psychiatric cohorts compared with NRT and no difference for NPAEs between varenicline and NRT users in smaller population with COPD.