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Zhang S, Chou LN, Swartz MD, Mehta HB, Goodwin JS, Kuo YF, Giordano SH, Tucker CA, Basen-Engquist KM, Lyons EJ, Downer B, Peterson SK, Cao T, Swartz MC. Association of cancer diagnosis with disability status among older survivors of colorectal cancer: a population-based retrospective cohort study. Front Oncol 2024; 14:1283252. [PMID: 38559557 PMCID: PMC10978737 DOI: 10.3389/fonc.2024.1283252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/29/2024] [Indexed: 04/04/2024] Open
Abstract
Background Older cancer survivors likely experience physical function limitations due to cancer and its treatments, leading to disability and early mortality. Existing studies have focused on factors associated with surgical complications and mortality risk rather than factors associated with the development of poor disability status (DS), a proxy measure of poor performance status, in cancer survivors. We aimed to identify factors associated with the development of poor DS among older survivors of colorectal cancer (CRC) and compare poor DS rates to an age-sex-matched, non-cancer cohort. Methods This retrospective cohort study utilized administrative data from the Texas Cancer Registry Medicare-linked database. The study cohort consisted of 13,229 survivors of CRC diagnosed between 2005 and 2013 and an age-sex-matched, non-cancer cohort of 13,225 beneficiaries. The primary outcome was poor DS, determined by Davidoff's method, using predictors from 12 months of Medicare claims after cancer diagnosis. Multivariable Cox proportional hazards regression was used to identify risk factors associated with the development of poor DS. Results Among the survivors of CRC, 97% were 65 years or older. After a 9-year follow-up, 54% of survivors of CRC developed poor DS. Significant factors associated with future poor DS included: age at diagnosis (hazard ratio [HR] = 3.50 for >80 years old), female sex (HR = 1.50), race/ethnicity (HR = 1.34 for Hispanic and 1.21 for Black), stage at diagnosis (HR = 2.26 for distant metastasis), comorbidity index (HR = 2.18 for >1), and radiation therapy (HR = 1.21). Having cancer (HR = 1.07) was significantly associated with developing poor DS in the pooled cohorts; age and race/ethnicity were also significant factors. Conclusions Our findings suggest that a CRC diagnosis is independently associated with a small increase in the risk of developing poor DS after accounting for other known factors. The study identified risk factors for developing poor DS in CRC survivors, including Hispanic and Black race/ethnicity, age, sex, histologic stage, and comorbidities. These findings underscore the importance of consistent physical function assessments, particularly among subsets of older survivors of CRC who are at higher risk of disability, to prevent developing poor DS.
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Affiliation(s)
- Shiming Zhang
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lin-Na Chou
- Department of Biostatistics and Data Science, The University of Texas Medical Branch, Galveston, TX, United States
| | - Michael D. Swartz
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States
| | - Hemalkumar B. Mehta
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - James S. Goodwin
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, United States
| | - Yong-Fang Kuo
- Department of Biostatistics and Data Science, The University of Texas Medical Branch, Galveston, TX, United States
| | - Sharon Hermes Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Carole A. Tucker
- Department of Physical Therapy, The University of Texas Medical Branch, Galveston, TX, United States
| | - Karen M. Basen-Engquist
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Elizabeth J. Lyons
- Department of Nutrition, Metabolism and Rehabilitation Sciences, The University of Texas Medical Branch, Galveston, TX, United States
| | - Brian Downer
- Department of Population Health and Health Disparities, The University of Texas Medical Branch, Galveston, TX, United States
| | - Susan K. Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Tru Cao
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, United States
| | - Maria C. Swartz
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Silva Almodóvar A, Keller MS, Lee J, Mehta HB, Manja V, Nguyen TPP, Pavon JM, Terman SW, Hoyle D, Mixon AS, Linsky AM. Deprescribing medications among patients with multiple prescribers: A socioecological model. J Am Geriatr Soc 2024; 72:660-669. [PMID: 37943070 PMCID: PMC10947820 DOI: 10.1111/jgs.18667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/14/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023]
Abstract
Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.
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Affiliation(s)
- Armando Silva Almodóvar
- Institute of Therapeutic Innovations and Outcomes (ITIO), The Ohio State University College of Pharmacy, Columbus, Ohio, USA
| | - Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jiha Lee
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Veena Manja
- Veterans Affairs Northern California Healthcare System, Mather, California, USA
- University of California Davis, Sacramento, California, USA
| | - Thanh Phuong Pham Nguyen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Juliessa M Pavon
- Division of Geriatrics, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Samuel W Terman
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Hoyle
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | - Amanda S Mixon
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy M Linsky
- General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Hwang YJ, Chang HY, Metkus T, Andersen KM, Singh S, Alexander GC, Mehta HB. Risk of Major Bleeding Associated with Concomitant Direct-Acting Oral Anticoagulant and Clopidogrel Use: A Retrospective Cohort Study. Drug Saf 2024; 47:251-260. [PMID: 38141156 PMCID: PMC10942724 DOI: 10.1007/s40264-023-01388-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND AND AIM Combined anticoagulant-antiplatelet therapy is often indicated in adults with cardiovascular disease and atrial fibrillation or venous thromboembolism. The study aim was to assess the comparative risk of bleeding between rivaroxaban and apixaban when combined with clopidogrel. METHODS We conducted a retrospective cohort study of commercially insured US adults newly treated with a combination of rivaroxaban+clopidogrel or apixaban+clopidogrel (2015-2018) using Merative™ Marketscan Research Databases. We used propensity score-based inverse probability of treatment weighting (IPTW) to balance the treatment groups. Weighted Cox proportional hazards regression was used to estimate the risk of major bleeding. RESULTS The study cohort included 2895 rivaroxaban+clopidogrel users and 3628 apixaban+clopidogrel users. The median (range) duration of follow up was 61 (73) days. Rivaroxaban+clopidogrel users had a similar risk of major bleeding compared with apixaban+clopidogrel users (IPTW incidence rate per 100 person-years 7.96 vs 7.38; IPTW hazard ratio [HR] 1.13 [95% CI 0.78-1.63]). In the subcohort of adults who were treated with DOAC or clopidogrel monotherapy prior to the combined therapy, the risk of major bleeding did not differ by the drug of monotherapy (IPTW HR for rivaroxaban+clopidogrel group: 0.66 [95% CI 0.33-1.32]; IPTW HR for apixaban+clopidogrel group: 1.10 [95% CI 0.55-2.23]) CONCLUSIONS: In our study of commercially insured US adults, the concomitant use of rivaroxaban+clopidogrel and apixaban+clopidogrel conferred a similar risk of major bleeding. DOAC versus clopidogrel monotherapy prior to the concomitant therapy did not influence the risk of major bleeding.
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Affiliation(s)
- Y Joseph Hwang
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA.
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 2024 E. Monument Street, 2-300A, Baltimore, MD, 21287, USA.
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Janssen Scientific Affairs LLC, Titusville, NJ, USA
| | - Thomas Metkus
- Divisions of Cardiology and Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen M Andersen
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sonal Singh
- UMass Chan Medical School, Worcester, MA, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 2024 E. Monument Street, 2-300A, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Xiao X, Mehta HB, Curran J, Garibaldi BT, Alexander GC. Potential drug-drug interactions among U.S. adults treated with nirmatrelvir/ritonavir: A cross-sectional study of the National Covid Cohort Collaborative (N3C). Pharmacotherapy 2023; 43:1251-1261. [PMID: 37539477 PMCID: PMC10838345 DOI: 10.1002/phar.2860] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 08/05/2023]
Abstract
STUDY OBJECTIVE To estimate the prevalence of potential moderate to severe drug-drug interactions (DDIs) involving nirmatrelvir/ritonavir, identify interacting medications, and evaluate risk factors associated with potential DDIs. DESIGN Cross-sectional study. DATA SOURCE Electronic health records from the National COVID Cohort Collaborative Enclave, one of the largest COVID-19 data resources in the United States. PATIENTS Outpatients aged ≥18 years and started nirmatrelvir/ritonavir between December 23, 2021 and March 31, 2022. INTERVENTION Nirmatrelvir/ritonavir. MEASUREMENTS The outcome is potential moderate to severe DDIs, defined as starting interacting medications reported by National Institutes of Health 30 days before or 10 days after starting nirmatrelvir/ritonavir. MAIN RESULTS Of 3214 outpatients who started nirmatrelvir/ritonavir, the mean age was 56.8 ± 17.1 years, 39.5% were male, and 65.8% were non-Hispanic white. Overall, 521 (16.2%) were potentially exposed to at least one moderate to severe DDI, most commonly to atorvastatin (19.2% of all DDIs), hydrocodone (14.0%), or oxycodone (14.0%). After adjustment for covariates, potential DDIs were more likely among individuals who were older (odds ratio [OR] 1.16 per 10-year increase, 95% confidence interval [CI] 1.08-1.25), male (OR 1.36, CI 1.09-1.71), smokers (OR 1.38, CI 1.10-1.73), on more co-medications (OR 1.35, CI 1.31-1.39), and with a history of solid organ transplant (OR 3.63, CI 2.05-6.45). CONCLUSIONS One in six of individuals receiving nirmatrelvir/ritonavir were at risk of a potential moderate or severe DDI, underscoring the importance of clinical and pharmacy systems to mitigate such risks.
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Affiliation(s)
- Xuya Xiao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hemalkumar B. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jill Curran
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Brian T. Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Hill EL, Mehta HB, Sharma S, Mane K, Singh SK, Xie C, Cathey E, Loomba J, Russell S, Spratt H, DeWitt PE, Ammar N, Madlock-Brown C, Brown D, McMurry JA, Chute CG, Haendel MA, Moffitt R, Pfaff ER, Bennett TD. Risk factors associated with post-acute sequelae of SARS-CoV-2: an N3C and NIH RECOVER study. BMC Public Health 2023; 23:2103. [PMID: 37880596 PMCID: PMC10601201 DOI: 10.1186/s12889-023-16916-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/05/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND More than one-third of individuals experience post-acute sequelae of SARS-CoV-2 infection (PASC, which includes long-COVID). The objective is to identify risk factors associated with PASC/long-COVID diagnosis. METHODS This was a retrospective case-control study including 31 health systems in the United States from the National COVID Cohort Collaborative (N3C). 8,325 individuals with PASC (defined by the presence of the International Classification of Diseases, version 10 code U09.9 or a long-COVID clinic visit) matched to 41,625 controls within the same health system and COVID index date within ± 45 days of the corresponding case's earliest COVID index date. Measurements of risk factors included demographics, comorbidities, treatment and acute characteristics related to COVID-19. Multivariable logistic regression, random forest, and XGBoost were used to determine the associations between risk factors and PASC. RESULTS Among 8,325 individuals with PASC, the majority were > 50 years of age (56.6%), female (62.8%), and non-Hispanic White (68.6%). In logistic regression, middle-age categories (40 to 69 years; OR ranging from 2.32 to 2.58), female sex (OR 1.4, 95% CI 1.33-1.48), hospitalization associated with COVID-19 (OR 3.8, 95% CI 3.05-4.73), long (8-30 days, OR 1.69, 95% CI 1.31-2.17) or extended hospital stay (30 + days, OR 3.38, 95% CI 2.45-4.67), receipt of mechanical ventilation (OR 1.44, 95% CI 1.18-1.74), and several comorbidities including depression (OR 1.50, 95% CI 1.40-1.60), chronic lung disease (OR 1.63, 95% CI 1.53-1.74), and obesity (OR 1.23, 95% CI 1.16-1.3) were associated with increased likelihood of PASC diagnosis or care at a long-COVID clinic. Characteristics associated with a lower likelihood of PASC diagnosis or care at a long-COVID clinic included younger age (18 to 29 years), male sex, non-Hispanic Black race, and comorbidities such as substance abuse, cardiomyopathy, psychosis, and dementia. More doctors per capita in the county of residence was associated with an increased likelihood of PASC diagnosis or care at a long-COVID clinic. Our findings were consistent in sensitivity analyses using a variety of analytic techniques and approaches to select controls. CONCLUSIONS This national study identified important risk factors for PASC diagnosis such as middle age, severe COVID-19 disease, and specific comorbidities. Further clinical and epidemiological research is needed to better understand underlying mechanisms and the potential role of vaccines and therapeutics in altering PASC course.
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Affiliation(s)
- Elaine L Hill
- Department of Public Health Sciences, University of Rochester Medical Center, 265 Crittenden Boulevard Box 420644, Rochester, NY, 14642, USA.
| | - Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA.
| | - Suchetha Sharma
- School of Data Science, University of Virginia, 3 Elliewood Ave, Charlottesville, VA, 22903, USA
| | - Klint Mane
- Department of Economics, University of Rochester, 1232 Mount Hope Ave, Rochester, NY, 14620, USA
| | - Sharad Kumar Singh
- Goergen Institute for Data Science, University of Rochester, 1209 Wegmans Hall, Rochester, NY, 14627, USA
| | - Catherine Xie
- CMC BOX 275184, University of Rochester, 500 Joseph C. Wilson Blvd, Rochester, NY, 14627-5184, USA
| | - Emily Cathey
- Ivy Foundations Building, Integrated Translational Health Research Institute of Virginia (iTHRIV), University of Virginia, 560 Ray C Hunt Drive RM 2153, Charlottesville, VA, 22903, USA
| | - Johanna Loomba
- Ivy Foundations Building, Integrated Translational Health Research Institute of Virginia (iTHRIV), University of Virginia, 560 Ray C Hunt Drive RM 2153, Charlottesville, VA, 22903, USA
| | - Seth Russell
- Department of Pediatrics, University of Colorado School of Medicine, 1890 N. Revere Court, Mail Stop 600, Aurora, CO, 80045, USA
| | - Heidi Spratt
- Department of Biostatistics and Data Science, Medical Branch, University of Texas, 301 University Blvd, Galveston, TX, 77555-1148, USA
| | - Peter E DeWitt
- Department of Pediatrics, University of Colorado School of Medicine, 1890 N. Revere Court, Mail Stop 600, Aurora, CO, 80045, USA
| | - Nariman Ammar
- Department of Diagnostic and Health Sciences, University of Tennessee Health Science Center, 50 N Dunlap St., Memphis, TN, 38103, USA
| | - Charisse Madlock-Brown
- Department of Diagnostic and Health Sciences, University of Tennessee Health Science Center, 930 Madison Avenue 6Th Floor, Memphis, TN, 38163, USA
| | - Donald Brown
- Integrated Translational Health Research Institute of Virginia (iTHRIV), University of Virginia, 151 Engineer's Way Olsson Hall Rm. 102E, PO Box 400747, Charlottesville, VA, USA
| | - Julie A McMurry
- Center for Health AI, University of Colorado School of Medicine, 12800 East 19Th Avenue, Aurora, CO, 80045, USA
| | - Christopher G Chute
- Schools of Medicine, Public Health, and Nursing, Johns Hopkins University, 2024 E Monument St. , Baltimore, MD, 21287, USA
| | - Melissa A Haendel
- Center for Health AI, University of Colorado School of Medicine, East 17Th Place Campus Box C290, Aurora, CO, 1300180045, USA
| | - Richard Moffitt
- Department of Biomedical Informatics, Stony Brook University, and Stony Brook Cancer Center, Stony Brook, NY, MART L7 081011794, USA
| | - Emily R Pfaff
- Department of Medicine, North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, 160 N Medical Drive, Chapel Hill, NC, 27599, USA
| | - Tellen D Bennett
- Department of Biomedical Informatics, University of Colorado School of Medicine, 1890 N. Revere Court, Mail Stop 600, Aurora, CO, 80045, USA
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Bhatia A, Preiss AJ, Xiao X, Brannock MD, Alexander GC, Chew RF, Fitzgerald M, Hill E, Kelly EP, Mehta HB, Madlock-Brown C, Wilkins KJ, Chute CG, Haendel M, Moffitt R, Pfaff ER. Effect of Nirmatrelvir/Ritonavir (Paxlovid) on Hospitalization among Adults with COVID-19: an EHR-based Target Trial Emulation from N3C. medRxiv 2023:2023.05.03.23289084. [PMID: 37205340 PMCID: PMC10187454 DOI: 10.1101/2023.05.03.23289084] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
This study leverages electronic health record data in the National COVID Cohort Collaborative's (N3C) repository to investigate disparities in Paxlovid treatment and to emulate a target trial assessing its effectiveness in reducing COVID-19 hospitalization rates. From an eligible population of 632,822 COVID-19 patients seen at 33 clinical sites across the United States between December 23, 2021 and December 31, 2022, patients were matched across observed treatment groups, yielding an analytical sample of 410,642 patients. We estimate a 65% reduced odds of hospitalization among Paxlovid-treated patients within a 28-day follow-up period, and this effect did not vary by patient vaccination status. Notably, we observe disparities in Paxlovid treatment, with lower rates among Black and Hispanic or Latino patients, and within socially vulnerable communities. Ours is the largest study of Paxlovid's real-world effectiveness to date, and our primary findings are consistent with previous randomized control trials and real-world studies.
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Affiliation(s)
- Abhishek Bhatia
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Xuya Xiao
- School of Medicine, Public Health, and Nursing, Johns Hopkins University, Baltimore, MD, USA
| | | | - G Caleb Alexander
- School of Medicine, Public Health, and Nursing, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Elaine Hill
- University of Rochester, Department of Public Health Sciences and Department of Economics, Rochester, NY, USA
| | | | - Hemalkumar B Mehta
- School of Medicine, Public Health, and Nursing, Johns Hopkins University, Baltimore, MD, USA
| | | | - Kenneth J Wilkins
- National Institute of Diabetes & Digestive & Kidney Diseases, Office of the Director, National Institutes of Health, Bethesda, MD, USA
- F. Edward Hébert School of Medicine, Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Christopher G Chute
- School of Medicine, Public Health, and Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Melissa Haendel
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Emily R Pfaff
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Xu H, Li S, Mehta HB, Hommel EL, Goodwin JS. Excess deaths from COVID-19 among Medicare beneficiaries with psychiatric diagnoses: Community versus nursing home. J Am Geriatr Soc 2023; 71:167-177. [PMID: 36137264 PMCID: PMC9537955 DOI: 10.1111/jgs.18062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Psychiatric illness may pose an additional risk of death for older adults during the COVID-19 pandemic. Older adults in the community versus institutions might be influenced by the pandemic differently. This study examines excess deaths during the COVID-19 pandemic among Medicare beneficiaries with and without psychiatric diagnoses (depression, anxiety, bipolar disorder, and schizophrenia) in the community versus nursing homes. METHODS This is a retrospective cohort study of a 20% random sample of 15,229,713 fee-for-service Medicare beneficiaries, from January 2019 through December 2021. Unadjusted monthly mortality risks, COVID-19 infection rates, and case-fatality rates after COVID-19 diagnosis were calculated. Excess deaths in 2020, compared to 2019 were estimated from multivariable logistic regressions. RESULTS Of all included Medicare beneficiaries in 2020 (N = 5,140,619), 28.9% had a psychiatric diagnosis; 1.7% lived in nursing homes. In 2020, there were 246,422 observed deaths, compared to 215,264 expected, representing a 14.5% increase over expected. Patients with psychiatric diagnoses had more excess deaths than those without psychiatric diagnoses (1,107 vs. 403 excess deaths per 100,000 beneficiaries, p < 0.01). The largest increases in mortality risks were observed among patients with schizophrenia (32.4% increase) and bipolar disorder (25.4% increase). The pandemic-associated increase in deaths with psychiatric diagnoses was only found in the community, not in nursing homes. The increased mortality for patients with psychiatric diagnoses was limited to those with medical comorbidities. The increase in mortality for psychiatric diagnoses was associated with higher COVID-19 infection rates (1-year infection rate = 7.9% vs. 4.2% in 2020), rather than excess case fatality. CONCLUSIONS Excess deaths during the COVID-19 pandemic were disproportionally greater in beneficiaries with psychiatric diagnoses, at least in part due to higher infection rates. Policy interventions should focus on preventing COVID-19 infections and deaths among community-dwelling patients with major psychiatric disorders in addition to those living the nursing homes.
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Affiliation(s)
- Huiwen Xu
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX;,Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX;,Corresponding author: Huiwen Xu, PhD, School of Public and Population Health and Sealy Center on Aging, University of Texas Medical Branch. 301 University Blvd., Galveston, TX 77555-1150. Phone: +1 409-772-5899; ; Twitter handle: @Dr_HuiwenXu
| | - Shuang Li
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - Hemalkumar B. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Erin L. Hommel
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX;,Department of Medicine, University of Texas Medical Branch, Galveston, TX
| | - James S. Goodwin
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX;,Department of Medicine, University of Texas Medical Branch, Galveston, TX
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Mehta HB, An H, Ardeshirrouhanifard S, Raji MA, Alexander GC, Segal JB. Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2022; 15:e008951. [PMID: 36453260 PMCID: PMC9772095 DOI: 10.1161/circoutcomes.122.008951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 10/27/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND While clinical guidelines recommend direct-acting oral anticoagulants (DOAC) over warfarin to treat isolated nonvalvular atrial fibrillation, guidelines are silent regarding nonvalvular atrial fibrillation treatment among individuals with cancer, reflecting the paucity of evidence in this setting. We quantified relative risk of ischemic stroke or systemic embolism and major bleeding (primary outcomes), and all-cause and cardiovascular death (secondary outcomes) among older individuals with cancer and nonvalvular atrial fibrillation comparing DOACs and warfarin. METHODS This retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry and linked US Medicare data from 2010 through 2016, and included individuals diagnosed with cancer and nonvalvular atrial fibrillation who newly initiated DOAC or warfarin. We used inverse probability of treatment weighting to control confounding. We used competing risk regression for primary outcomes and cardiovascular death, and Cox proportional hazard regression for all-cause death. RESULTS Among 7675 individuals included in the cohort, 4244 (55.3%) received DOACs and 3431 (44.7%) warfarin. In the inverse probability of treatment weighting analysis, there was no statistically significant difference among DOAC and warfarin users in the risk of ischemic stroke or systemic embolism (1.24 versus 1.19 events per 100 person-years, adjusted hazard ratio 1.41 [95% CI, 0.92-2.14]), major bleeding (3.08 versus 4.49 events per 100 person-years, adjusted hazard ratio 0.90 [95% CI, 0.70-1.17]), and cardiovascular death (1.88 versus 3.14 per 100 person-years, adjusted hazard ratio 0.82 [95% CI, 0.59-0.1.13]). DOAC users had significantly lower risk of all-cause death (7.09 versus 13.3 per 100 person-years, adjusted hazard ratio 0.81 [95% CI, 0.69-0.94]) compared to warfarin users. CONCLUSIONS Older adults with cancer and atrial fibrillation exposed to DOACs had similar risks of stroke and systemic embolism and major bleeding as those exposed to warfarin. Relative to warfarin, DOAC use was associated with a similar risk of cardiovascular death and a lower risk of all-cause death.
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Affiliation(s)
- Hemalkumar B. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Huijun An
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Shirin Ardeshirrouhanifard
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mukaila A. Raji
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD
| | - Jodi B. Segal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD
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9
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Mehta HB, Li S, An H, Goodwin JS, Alexander GC, Segal JB. Development and Validation of the Summary Elixhauser Comorbidity Score for Use With ICD-10-CM-Coded Data Among Older Adults. Ann Intern Med 2022; 175:1423-1430. [PMID: 36095314 PMCID: PMC9894164 DOI: 10.7326/m21-4204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Older adults have many comorbidities contributing to mortality. OBJECTIVE To develop a summary Elixhauser (S-Elixhauser) comorbidity score to predict 30-day, in-hospital, and 1-year mortality in older adults using the 38 comorbidities operationalized by the Agency for Healthcare Research and Quality (AHRQ). DESIGN Retrospective cohort study. SETTING Medicare beneficiaries from 2017 to 2019. PATIENTS Persons hospitalized in 2018 (n = 899 844) and 3 disease-specific hospitalized cohorts. MEASUREMENTS Weights were derived for 38 comorbidities to predict 30-day, in-hospital, and 1-year mortality. The S-Elixhauser score was internally validated and calibrated. Individual Elixhauser comorbidity indicators (38 comorbidities), the modified application of the AHRQ-derived Elixhauser summary score, the Charlson comorbidity indicators (17 comorbidities), and the Charlson summary score were externally validated. The c-statistic was used to evaluate discrimination of a comorbidity score model. RESULTS The S-Elixhauser score was well calibrated and internally validated, with a c-statistic of 0.705 (95% CI, 0.703 to 0.707) in predicting 30-day mortality, 0.654 (CI, 0.651 to 0.657) for in-hospital mortality, and 0.743 (CI, 0.741 to 0.744) for 1-year mortality. In external validation of other comorbidity indices for 30-day mortality, the c-statistic was 0.711 (CI, 0.709 to 0.713) for the individual Elixhauser comorbidity indicators, 0.688 (CI, 0.686 to 0.690) for the AHRQ Elixhauser score, 0.696 (CI, 0.694 to 0.698) for the Charlson comorbidity indicators, and 0.690 (CI, 0.688 to 0.693) for the Charlson summary score. In 3 disease-specific populations, the discrimination of the S-Elixhauser score in predicting 30-day mortality ranged from 0.657 to 0.732. LIMITATION Validation of the S-Elixhauser comorbidity score and head-to-head comparison with other comorbidity scores in an external population are needed to evaluate comparative performance. CONCLUSION The S-Elixhauser comorbidity score is well calibrated and internally validated but its advantage over the AHRQ Elixhauser and Charlson summary scores is unclear. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Hemalkumar B Mehta
- Center for Drug Safety & Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (H.B.M., H.A.)
| | - Shuang Li
- Sealy Center on Aging, Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas (S.L., J.S.G.)
| | - Huijun An
- Center for Drug Safety & Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (H.B.M., H.A.)
| | - James S Goodwin
- Sealy Center on Aging, Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas (S.L., J.S.G.)
| | - G Caleb Alexander
- Center for Drug Safety & Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, and Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland (G.C.A., J.B.S.)
| | - Jodi B Segal
- Center for Drug Safety & Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, and Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland (G.C.A., J.B.S.)
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10
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Mehta HB, Li S, Goodwin JS. Effectiveness of COVID-19 Booster on the Risk of Hospitalization Among Medicare Beneficiaries. Mayo Clin Proc 2022; 97:1780-1793. [PMID: 36202492 PMCID: PMC9273609 DOI: 10.1016/j.mayocp.2022.06.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/23/2022] [Accepted: 06/30/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To determine the effectiveness of booster vaccinations on the risk of hospitalization with coronavirus disease 2019 (COVID-19) and how it varies by enrollee characteristics and interval from the initial vaccination to receipt of a booster. PATIENTS AND METHODS This cohort study used 100% Medicare claims from January 1, 2020, through December 31, 2021, and matched 3,940,475 individuals who received boosters to 3,940,475 controls based on week and type of original COVID-19 vaccine and demographic and clinical characteristics. We compared the association of booster vs no booster with COVID-19 hospitalization using Cox proportional hazards regression models controlling for patient characteristics. We also determined the association of time from original vaccine to booster with COVID-19 hospitalization. RESULTS Over a maximum of 130 days of follow-up, boosted enrollees had 8.20 (95% CI, 7.81 to 8.60) COVID-19 hospitalizations per million days vs 43.70 (95% CI, 42.79 to 44.64) for controls (81% effectiveness). Effectiveness varied by race, prior hospitalizations, and certain comorbidities, for example, leukemia/lymphoma (53% effectiveness), autoimmune disease (73%), and dementia (73%). Boosters received between 6 and 9 months after original vaccination varied between 81% and 85% effectiveness, while boosters received at 5 to 6 months (62%) or less than 5 months (58%) were less effective. CONCLUSION Boosters are highly effective in the Medicare population. Approximately 69,225 hospitalizations would be prevented by boosters in the 15 million individuals aged 65 years or older currently not boosted in a period similar to the September 2020 through January 2021 period studied. Boosters provided the greatest benefits if they were received between 6 and 9 months following original vaccinations. However, boosters were associated with substantial decreases in COVID-19 hospitalizations in all categories of enrollees.
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Affiliation(s)
- Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Shuang Li
- Sealy Center on Aging and Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - James S Goodwin
- Sealy Center on Aging and Department of Internal Medicine, University of Texas Medical Branch, Galveston
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11
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Andersen KM, Joseph CS, Mehta HB, Streiff MB, Betz JF, Bollinger RC, Fisher AM, Gupta A, LeMaistre CF, Robinson ML, Xu Y, Ng DK, Alexander GC, Garibaldi BT. Thromboprophylaxis in people hospitalized with COVID-19: Assessing intermediate or standard doses in a retrospective cohort study. Res Pract Thromb Haemost 2022; 6:e12753. [PMID: 35859579 PMCID: PMC9287673 DOI: 10.1002/rth2.12753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/09/2022] [Accepted: 05/27/2022] [Indexed: 11/08/2022] Open
Abstract
Background and Objectives Current clinical guidelines recommend thromboprophylaxis for adults hospitalized with coronavirus disease 2019 (COVID-19), yet it is unknown whether higher doses of thromboprophylaxis offer benefits beyond standard doses. Methods We studied electronic health records from 50 091 adults hospitalized with COVID-19 in the United States between February 2020 and February 2021. We compared standard (enoxaparin 30 or 40 mg/day, fondaparinux 2.5 mg, or heparin 5000 units twice or thrice per day) versus intermediate (enoxaparin 30 or 40 mg twice daily, or up to 1.2 mg/kg of body weight daily, heparin 7500 units thrice per day or heparin 10 000 units twice or thrice per day) thromboprophylaxis. We separately examined risk of escalation to therapeutic anticoagulation, severe disease (first occurrence of high-flow nasal cannula, noninvasive positive pressure ventilation or invasive mechanical ventilation), and death. To summarize risk, we present hazard ratios (HRs) with 95% confidence intervals (CIs) using adjusted time-dependent Cox proportional hazards regression models. Results People whose first dose was high intensity were younger, more often obese, and had greater oxygen support requirements. Intermediate dose thromboprophylaxis was associated with increased risk of therapeutic anticoagulation (HR, 3.39; 95% CI, 3.22-3.57), severe disease (HR, 1.22; 95% CI, 1.17-1.28), and death (HR, 1.37; 95% CI, 1.21-1.55). Increased risks associated with intermediate-dose thromboprophylaxis persisted in subgroup and sensitivity analyses varying populations and definitions of exposures, outcomes, and covariates. Conclusions Our findings do not support routine use of intermediate-dose thromboprophylaxis to prevent clinical worsening, severe disease, or death among adults hospitalized with COVID-19.
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Affiliation(s)
- Kathleen M Andersen
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA.,Center for Drug Safety and Effectiveness Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Corey S Joseph
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA.,Center for Drug Safety and Effectiveness Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Hemalkumar B Mehta
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA.,Center for Drug Safety and Effectiveness Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Michael B Streiff
- Division of Hematology Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Joshua F Betz
- Department of Biostatistics Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Robert C Bollinger
- Division of Infectious Diseases Johns Hopkins University School of Medicine Baltimore Maryland USA.,Center for Clinical Global Health Education Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Arielle M Fisher
- Sarah Cannon, Genospace, HCA Healthcare Research Institute Nashville Tennessee USA
| | - Amita Gupta
- Division of Infectious Diseases Johns Hopkins University School of Medicine Baltimore Maryland USA.,Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Charles F LeMaistre
- Sarah Cannon, Genospace, HCA Healthcare Research Institute Nashville Tennessee USA
| | - Matthew L Robinson
- Division of Infectious Diseases Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Yanxun Xu
- Department of Applied Mathematics and Statistics Johns Hopkins University Baltimore Maryland USA
| | - Derek K Ng
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - G Caleb Alexander
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA.,Center for Drug Safety and Effectiveness Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA.,Division of General Internal Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
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12
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Ardeshirrouhanifard S, An H, Goyal RK, Raji MA, Segal JB, Alexander GC, Mehta HB. Use of oral anticoagulants among individuals with cancer and atrial fibrillation in the United States, 2010-2016. Pharmacotherapy 2022; 42:375-386. [PMID: 35364622 PMCID: PMC9302858 DOI: 10.1002/phar.2679] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 01/12/2023]
Abstract
Background Anticoagulation among patients with cancer and atrial fibrillation is challenging due to elevated risk of bleeding and stroke. We characterized use of oral anticoagulants among patients with cancer and non‐valvular atrial fibrillation (NVAF). Methods We used Surveillance, Epidemiology, and End Results (SEER)‐Medicare data and included patients with cancer aged ≥66 years with an incident diagnosis of NVAF from 2010 to 2016. We used a Cox proportional hazard model and multivariable logistic regression to identify factors associated with anticoagulant use versus no use and direct oral anticoagulants (DOACs) versus warfarin use, respectively. Results Of 27,702 patients with cancer and NVAF, 4469 (16.1%) used DOACs and 3577 (12.9%) used warfarin. Among 8046 anticoagulant users, DOACs use increased from 21.8% in 2011 to 76.2% in 2016, with a corresponding decline in warfarin use from 78.2% to 23.8%. Nearly 7 out of 10 patients with cancer and NVAF did not initiate anticoagulation in 2016. Anticoagulant use was more likely among those with higher CHA₂DS₂‐VASc scores (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.27–1.90 for score ≥6 vs. 1) or with lower HAS‐BLED scores (HR 1.96, 95% CI 1.67–2.30 for score 1 vs. ≥6). Among anticoagulant users, DOAC use was less likely than warfarin in those with higher CHA₂DS₂‐VASc scores (odds ratio [OR] 0.53, 95% CI 0.33–0.84 for score ≥6 vs. 1). Conclusions Nearly 7 out of 10 patients with cancer and NVAF did not receive anticoagulation. Use of DOACs increased from 2010 to 2016, with a corresponding decline in warfarin use. DOACs are used less than warfarin among those at higher risk of stroke.
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Affiliation(s)
- Shirin Ardeshirrouhanifard
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Huijun An
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ravi K Goyal
- College of Pharmacy, University of Houston, Houston, Texas, USA.,RTI Health Solutions, Durham, North Carolina, USA
| | - Mukaila A Raji
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Jodi B Segal
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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13
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Malagaris I, Mehta HB, Goodwin JS. Trends and variation in benzodiazepine use in nursing homes in the USA. Eur J Clin Pharmacol 2022; 78:489-496. [PMID: 34727210 PMCID: PMC9138049 DOI: 10.1007/s00228-021-03244-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Because of toxicities, benzodiazepines are not usually recommended in older adults. We therefore sought to describe the trends in benzodiazepine use in long-term care and examine the variation in benzodiazepine use among nursing homes. METHODS In this retrospective repeated cross-sectional analysis of Medicare Parts A, B, and D claims data linked to the Minimum Data Set from 2013 to 2018, we included long-term residents who stayed in a nursing home for at least one entire quarter of a calendar year in 2013-2018. The outcome was whether residents were prescribed a benzodiazepine drug for at least 30 days during each quarter stay. We use mixed effects logistic regression models to assess the variation in benzodiazepine use among nursing homes, adjusting for patient and nursing home characteristics. RESULTS The cohort for the time trend analysis included 270,566 unique residents and 1,843,580 quarter stays for 2013-2018. Prescribing rates for short-acting benzodiazepines were stable over 2013-2016, then declined from 12.1% in 2016 to 10.6% in 2018. The rate of long-acting benzodiazepine use remained relatively steady at around 4% over 2013-2018. During 2017-2018, the variation among nursing homes in benzodiazepine use was 7.2% for short-acting vs. 9.3% for long-acting benzodiazepines, after controlling for resident characteristics. CONCLUSION Prescribing for short-acting benzodiazepines in long-term care declined after 2016, while long-acting benzodiazepine use did not change. The variation in benzodiazepine use among nursing homes is substantial. Identifying factors that explain this variation may help in developing strategies for deprescribing benzodiazepines in nursing home residents.
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Affiliation(s)
- Ioannis Malagaris
- Sealy Center On Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street E7640, Baltimore, MD, 21205, USA.
| | - James S Goodwin
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
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14
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Dang A, Thakker R, Li S, Hommel E, Mehta HB, Goodwin JS. Hospitalizations and Mortality From Non-SARS-CoV-2 Causes Among Medicare Beneficiaries at US Hospitals During the SARS-CoV-2 Pandemic. JAMA Netw Open 2022; 5:e221754. [PMID: 35262712 PMCID: PMC8908076 DOI: 10.1001/jamanetworkopen.2022.1754] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The increased hospital mortality rates from non-SARS-CoV-2 causes during the SARS-CoV-2 pandemic are incompletely characterized. OBJECTIVE To describe changes in mortality rates after hospitalization for non-SARS-CoV-2 conditions during the COVID-19 pandemic and how mortality varies by characteristics of the admission and hospital. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study from January 2019 through September 2021 using 100% of national Medicare claims, including 4626 US hospitals. Participants included 8 448 758 individuals with non-COVID-19 medical admissions with fee-for-service Medicare insurance. MAIN OUTCOMES AND MEASURES Outcome was mortality in the 30 days after admission with adjusted odds generated from a 3-level (admission, hospital, and county) logistic regression model that included diagnosis, demographic variables, comorbidities, hospital characteristics, and hospital prevalence of SARS-CoV-2. RESULTS There were 8 448 758 non-SARS-CoV-2 medical admissions in 2019 and from April 2020 to September 2021 (mean [SD] age, 73.66 [12.88] years; 52.82% women; 821 569 [11.87%] Black, 438 453 [6.34%] Hispanic, 5 351 956 [77.35%] White, and 307 218 [4.44%] categorized as other). Mortality in the 30 days after admission increased from 9.43% in 2019 to 11.48% from April 1, 2020, to March 31, 2021 (odds ratio [OR], 1.20; 95% CI, 1.19-1.21) in multilevel logistic regression analyses including admission and hospital characteristics. The increase in mortality was maintained throughout the first 18 months of the pandemic and varied by race and ethnicity (OR, 1.27; 95% CI, 1.23-1.30 for Black enrollees; OR, 1.25; 95% CI, 1.23-1.27 for Hispanic enrollees; and OR, 1.18; 95% CI, 1.17-1.19 for White enrollees); Medicaid eligibility (OR, 1.25; 95% CI, 1.24-1.27 for Medicaid eligible vs OR, 1.18; 95% CI, 1.16-1.18 for noneligible); and hospital quality score, measured on a scale of 1 to 5 stars with 1 being the worst and 5 being the best (OR, 1.27; 95% CI, 1.22-1.31 for 1 star vs OR, 1.11; 95% CI, 1.08-1.15 for 5 stars). Greater hospital prevalence of SARS-CoV-2 was associated with greater increases in odds of death from the prepandemic period to the pandemic period; for example, comparing mortality in October through December 2020 with October through December 2019, the OR was 1.44 (95% CI, 1.39-1.49) for hospitals in the top quartile of SARS-CoV-2 admissions vs an OR of 1.19 (95% CI, 1.16-1.22) for admissions to hospitals in the lowest quartile. This association was mostly limited to admissions with high-severity diagnoses. CONCLUSIONS AND RELEVANCE The prolonged elevation in mortality rates after hospital admission in 2020 and 2021 for non-SARS-CoV-2 diagnoses contrasts with reports of improvement in hospital mortality during 2020 for SARS-CoV-2. The results of this cohort study suggest that, with the continued impact of SARS-CoV-2, it is important to implement interventions to improve access to high-quality hospital care for those with non-SARS-CoV-2 diseases.
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Affiliation(s)
- Alexander Dang
- Department of Medicine and the Sealy Center on Aging, The University of Texas Medical Branch at Galveston
| | - Ravi Thakker
- Department of Medicine and the Sealy Center on Aging, The University of Texas Medical Branch at Galveston
| | - Shuang Li
- Department of Medicine and the Sealy Center on Aging, The University of Texas Medical Branch at Galveston
| | - Erin Hommel
- Department of Medicine and the Sealy Center on Aging, The University of Texas Medical Branch at Galveston
| | - Hemalkumar B. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - James S. Goodwin
- Department of Medicine and the Sealy Center on Aging, The University of Texas Medical Branch at Galveston
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15
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Hwang YJ, Alexander GC, Moore TJ, Mehta HB. Author Response: Risk of Hospitalization and Death Associated With Pimavanserin Use in Older Adults With Parkinson Disease. Neurology 2022; 98:49-50. [PMID: 34965990 PMCID: PMC10501790 DOI: 10.1212/wnl.0000000000013043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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16
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Andersen KM, Bates BA, Rashidi ES, Olex AL, Mannon RB, Patel RC, Singh J, Sun J, Auwaerter PG, Ng DK, Segal JB, Garibaldi BT, Mehta HB, Alexander GC. Long-term use of immunosuppressive medicines and in-hospital COVID-19 outcomes: a retrospective cohort study using data from the National COVID Cohort Collaborative. Lancet Rheumatol 2022; 4:e33-e41. [PMID: 34806036 PMCID: PMC8592562 DOI: 10.1016/s2665-9913(21)00325-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Many individuals take long-term immunosuppressive medications. We evaluated whether these individuals have worse outcomes when hospitalised with COVID-19 compared with non-immunosuppressed individuals. METHODS We conducted a retrospective cohort study using data from the National COVID Cohort Collaborative (N3C), the largest longitudinal electronic health record repository of patients in hospital with confirmed or suspected COVID-19 in the USA, between Jan 1, 2020, and June 11, 2021, within 42 health systems. We compared adults with immunosuppressive medications used before admission to adults without long-term immunosuppression. We considered immunosuppression overall, as well as by 15 classes of medication and three broad indications for immunosuppressive medicines. We used Fine and Gray's proportional subdistribution hazards models to estimate the hazard ratio (HR) for the risk of invasive mechanical ventilation, with the competing risk of death. We used Cox proportional hazards models to estimate HRs for in-hospital death. Models were adjusted using doubly robust propensity score methodology. FINDINGS Among 231 830 potentially eligible adults in the N3C repository who were admitted to hospital with confirmed or suspected COVID-19 during the study period, 222 575 met the inclusion criteria (mean age 59 years [SD 19]; 111 269 [50%] male). The most common comorbidities were diabetes (23%), pulmonary disease (17%), and renal disease (13%). 16 494 (7%) patients had long-term immunosuppression with medications for diverse conditions, including rheumatological disease (33%), solid organ transplant (26%), or cancer (22%). In the propensity score matched cohort (including 12 841 immunosuppressed patients and 29 386 non-immunosuppressed patients), immunosuppression was associated with a reduced risk of invasive ventilation (HR 0·89, 95% CI 0·83-0·96) and there was no overall association between long-term immunosuppression and the risk of in-hospital death. None of the 15 medication classes examined were associated with an increased risk of invasive mechanical ventilation. Although there was no statistically significant association between most drugs and in-hospital death, increases were found with rituximab for rheumatological disease (1·72, 1·10-2·69) and for cancer (2·57, 1·86-3·56). Results were generally consistent across subgroup analyses that considered race and ethnicity or sex, as well as across sensitivity analyses that varied exposure, covariate, and outcome definitions. INTERPRETATION Among this cohort, with the exception of rituximab, there was no increased risk of mechanical ventilation or in-hospital death for the rheumatological, antineoplastic, or antimetabolite therapies examined. FUNDING None.
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Affiliation(s)
- Kathleen M Andersen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Benjamin A Bates
- Rutgers Center for Pharmacoepidemiology and Treatment Science, New Brunswick, NJ, USA
| | - Emaan S Rashidi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy L Olex
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, USA
| | - Roslyn B Mannon
- Division of Nephrology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Rena C Patel
- Department of Medicine and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jasvinder Singh
- Medicine Service, VA Medical Center, Birmingham, AL, USA
- Department of Medicine, School of Medicine and Division of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jing Sun
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
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17
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Garibaldi BT, Wang K, Robinson ML, Betz J, Alexander GC, Andersen KM, Joseph CS, Mehta HB, Korwek K, Sands KE, Fisher AM, Bollinger RC, Xu Y. Real-World Effectiveness Of Remdesivir In Adults Hospitalized With Covid-19: A Retrospective, Multicenter Comparative Effectiveness Study. Clin Infect Dis 2021; 75:e516-e524. [PMID: 34910128 PMCID: PMC8754724 DOI: 10.1093/cid/ciab1035] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background There is an urgent need to understand the real-world effectiveness of remdesivir in the treatment of SARS-CoV-2. Methods This was a retrospective comparative effectiveness study. Individuals hospitalized in a large private healthcare network in the US from February 23, 2020 through February 11, 2021 with a positive test for SARS-CoV-2 and ICD-10 diagnosis codes consistent with symptomatic COVID-19 were included. Remdesivir recipients were matched to controls using time-dependent propensity scores. The primary outcome was time to improvement with a secondary outcome of time to death. Results Of 96,859 COVID-19 patients, 42,473 (43.9%) received at least one remdesivir dose. The median age of remdesivir recipients was 65 years, 23,701 (55.8%) were male and 22,819 (53.7%) were non-white. Matches were found for 18,328 patients (43.2%). Remdesivir recipients were significantly more likely to achieve clinical improvement by 28 days (adjusted hazard ratio [1.19, 95% confidence interval (CI), 1.16-1.22]). Remdesivir patients on no oxygen (aHR 1.30, 95% CI 1.22-1.38) or low-flow oxygen (aHR 1.23, 95% CI 1.19-1.27) were significantly more likely to achieve clinical improvement by 28 days. There was no significant impact on the likelihood of mortality overall (aHR 1.02, 95% CI 0.97-1.08). Remdesivir recipients on low-flow oxygen were significantly less likely to die than controls (aHR 0.85, 95% CI 0.77-0.92; 28-day mortality 8.4% [865 deaths] for remdesivir patients, 12.5% [1,334 deaths] for controls). Conclusions These results support the use of remdesivir for hospitalized COVID-19 patients on no or low-flow oxygen. Routine initiation of remdesivir in more severely ill patients is unlikely to be beneficial.
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Affiliation(s)
- Brian T Garibaldi
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore MD, USA.,COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA
| | - Kunbo Wang
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA
| | - Matthew L Robinson
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Division of Infectious Disease, Johns Hopkins University School of Medicine, USA
| | - Joshua Betz
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Division of Biostatistics, Johns Hopkins Bloomberg School of Public Health, USA
| | - G Caleb Alexander
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Kathleen M Andersen
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Corey S Joseph
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Hemalkumar B Mehta
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | - Kimberly Korwek
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Clinical Operations Group, HCA Healthcare, Nashville TN, USA
| | - Kenneth E Sands
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Clinical Operations Group, HCA Healthcare, Nashville TN, USA
| | - Arielle M Fisher
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Genospace, Sarah Cannon, Boston, MA, USA
| | - Robert C Bollinger
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Division of Infectious Disease, Johns Hopkins University School of Medicine, USA
| | - Yanxun Xu
- COVID-19 Consortium of HCA Healthcare and Academia for Research GEneration, USA.,Department of Applied Mathematics and Statistics, Johns Hopkins University, Baltimore, MD, USA.,Division of Biostatistics and Bioinformatics at The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Andersen KM, Mehta HB, Palamuttam N, Ford D, Garibaldi BT, Auwaerter PG, Segal J, Alexander GC. Association Between Chronic Use of Immunosuppresive Drugs and Clinical Outcomes From Coronavirus Disease 2019 (COVID-19) Hospitalization: A Retrospective Cohort Study in a Large US Health System. Clin Infect Dis 2021; 73:e4124-e4130. [PMID: 33410884 PMCID: PMC7953980 DOI: 10.1093/cid/ciaa1488] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND It is unclear whether chronic use of immunosuppressive drugs worsens or improves the severity of coronavirus disease 2019 (COVID-19), with plausible mechanisms for both. METHODS Retrospective cohort study in 2121 consecutive adults with acute inpatient hospital admission between 4 March and 29 August 2020 with confirmed or suspected COVID-19 in a large academic health system, with adjustment for confounding with propensity score-derived stabilized inverse probability of treatment weights. Chronic immunosuppression was defined as prescriptions for immunosuppressive drugs current at the time of admission. Outcomes included mechanical ventilation, in-hospital mortality, and length of stay. RESULTS There were 2121 patients admitted with laboratory-confirmed (1967, 93%) or suspected (154, 7%) COVID-19 during the study period, with a median age of 55 years (interquartile range, 40-67). Of these, 108 (5%) were classified as immunosuppressed before COVID-19, primarily with prednisone (>7.5 mg/day), tacrolimus, or mycophenolate mofetil. Among the entire cohort, 311 (15%) received mechanical ventilation; the median (interquartile range) length of stay was 5.2 (2.5-10.6) days, and 1927 (91%) survived to discharge. After adjustment, there were no significant differences in the risk of mechanical ventilation (hazard ratio [HR], .79; 95% confidence interval [CI], .46-1.35), in-hospital mortality (HR, .66; 95% CI, .28-1.55), or length of stay (HR, 1.16; 95% CI, .92-1.47) among individuals with immunosuppression and counterparts. CONCLUSIONS Chronic use of immunosuppressive drugs was neither associated with worse nor better clinical outcomes among adults hospitalized with COVID-19 in one US health system.
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Affiliation(s)
- Kathleen M Andersen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Natasha Palamuttam
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel Ford
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Brian T Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jodi Segal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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19
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Mehta HB, An H, Andersen KM, Mansour O, Madhira V, Rashidi ES, Bates B, Setoguchi S, Joseph C, Kocis PT, Moffitt R, Bennett TD, Chute CG, Garibaldi BT, Alexander GC. Use of Hydroxychloroquine, Remdesivir, and Dexamethasone Among Adults Hospitalized With COVID-19 in the United States : A Retrospective Cohort Study. Ann Intern Med 2021; 174:1395-1403. [PMID: 34399060 PMCID: PMC8372837 DOI: 10.7326/m21-0857] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Relatively little is known about the use patterns of potential pharmacologic treatments of COVID-19 in the United States. OBJECTIVE To use the National COVID Cohort Collaborative (N3C), a large, multicenter, longitudinal cohort, to characterize the use of hydroxychloroquine, remdesivir, and dexamethasone, overall as well as across individuals, health systems, and time. DESIGN Retrospective cohort study. SETTING 43 health systems in the United States. PARTICIPANTS 137 870 adults hospitalized with COVID-19 between 1 February 2020 and 28 February 2021. MEASUREMENTS Inpatient use of hydroxychloroquine, remdesivir, or dexamethasone. RESULTS Among 137 870 persons hospitalized with confirmed or suspected COVID-19, 8754 (6.3%) received hydroxychloroquine, 29 272 (21.2%) remdesivir, and 53 909 (39.1%) dexamethasone during the study period. Since the release of results from the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial in mid-June, approximately 78% to 84% of people who have had invasive mechanical ventilation have received dexamethasone or other glucocorticoids. The use of hydroxychloroquine increased during March 2020, peaking at 42%, and started declining by April 2020. By contrast, remdesivir and dexamethasone use gradually increased over the study period. Dexamethasone and remdesivir use varied substantially across health centers (intraclass correlation coefficient, 14.2% for dexamethasone and 84.6% for remdesivir). LIMITATION Because most N3C data contributors are academic medical centers, findings may not reflect the experience of community hospitals. CONCLUSION Dexamethasone, an evidence-based treatment of COVID-19, may be underused among persons who are mechanically ventilated. The use of remdesivir and dexamethasone varied across health systems, suggesting variation in patient case mix, drug access, treatment protocols, and quality of care. PRIMARY FUNDING SOURCE National Center for Advancing Translational Sciences; National Heart, Lung, and Blood Institute; and National Institute on Aging.
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Affiliation(s)
- Hemalkumar B Mehta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (H.B.M., H.A., K.M.A., E.S.R., C.J.)
| | - Huijun An
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (H.B.M., H.A., K.M.A., E.S.R., C.J.)
| | - Kathleen M Andersen
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (H.B.M., H.A., K.M.A., E.S.R., C.J.)
| | | | | | - Emaan S Rashidi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (H.B.M., H.A., K.M.A., E.S.R., C.J.)
| | - Benjamin Bates
- Rutgers Center for Pharmacoepidemiology and Treatment Science, New Brunswick, New Jersey (B.B., S.S.)
| | - Soko Setoguchi
- Rutgers Center for Pharmacoepidemiology and Treatment Science, New Brunswick, New Jersey (B.B., S.S.)
| | - Corey Joseph
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (H.B.M., H.A., K.M.A., E.S.R., C.J.)
| | - Paul T Kocis
- Penn State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania (P.T.K.)
| | | | - Tellen D Bennett
- University of Colorado School of Medicine, University of Colorado, Aurora, Colorado (T.D.B.)
| | - Christopher G Chute
- Schools of Medicine, Public Health, and Nursing, Johns Hopkins University, Baltimore, Maryland (C.G.C.)
| | - Brian T Garibaldi
- Johns Hopkins University School of Medicine, Baltimore, Maryland (B.T.G.)
| | - G Caleb Alexander
- Johns Hopkins Bloomberg School of Public Health and Johns Hopkins School of Medicine, Baltimore, Maryland (G.C.A.)
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20
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Hwang YJ, Alexander GC, An H, Moore TJ, Mehta HB. Risk of Hospitalization and Death Associated With Pimavanserin Use in Older Adults With Parkinson Disease. Neurology 2021; 97:e1266-e1275. [PMID: 34389652 DOI: 10.1212/wnl.0000000000012601] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/12/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the risk of hospitalization and death associated with pimavanserin use. METHODS We conducted a retrospective cohort study of adults 65 years and older with Parkinson's disease between November 1, 2015 and December 31, 2018 using an administrative dataset on residents of Medicare-certified long-term care facilities and linked Medicare claims data. Propensity score-based inverse probability of treatment weighting (IPTW) was used to balance pimavanserin users and nonusers on 24 baseline characteristics. Fine-Gray competing risk and Cox proportional hazards regression models were used to estimate the risk of hospitalization and death up to one year, respectively. RESULTS The study cohort included 2,186 pimavanserin users and 18,212 nonusers. There was a higher risk of 30-day hospitalization with pimavanserin use vs. nonuse (IPTW adjusted hazard ratio [aHR] 1.24, 95% confidence intervals [CI] 1.06-1.43). There was no association of pimavanserin use with 90-day hospitalization (aHR 1.10, CI 0.99-1.24) nor with 30-day mortality (aHR 0.76, CI 0.56-1.03). Pimavanserin use vs. nonuse was associated with an increased 90-day mortality (aHR 1.20, CI 1.02-1.41) that persisted after 180 days (aHR 1.28, CI 1.13-1.45) and 1 year (aHR 1.56, CI 1.42-1.72). CONCLUSIONS Pimavanserin use vs. nonuse in older adults was associated with an increased risk of hospitalization at one month of initiation and a higher risk of death for up to one year following initiation. These findings, in a large real-world cohort within long-term care facilities, may help to inform decisions regarding its risk-benefit balance among patients with Parkinson's disease. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in patients with Parkinson's disease who are 65 or older and residing in Medicare-certified long-term care facilities, pimavanserin prescribing is associated with an increased risk of 30-day hospitalization and higher 90-, 180-, and, 365-day mortality.
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Affiliation(s)
- Y Joseph Hwang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD .,Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD
| | - G Caleb Alexander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Huijun An
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Thomas J Moore
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD.,Institute for Safe Medication Practices, Alexandria, VA.,Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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21
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Mehta HB, Kuo YF, Raji MA, Westra J, Boyd C, Alexander GC, Goodwin JS. State Variation in Chronic Opioid Use in Long-Term Care Nursing Home Residents. J Am Med Dir Assoc 2021; 22:2593-2599.e4. [PMID: 34022153 DOI: 10.1016/j.jamda.2021.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Policies and regulations on opioid use have evolved from being primarily state-to federally based. We examined the trends and variation in chronic opioid use among states and nursing homes. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS We used the nursing home Minimum Data Set and Medicare claims from 2014 to 2018 and included long-term care nursing home residents from each year who had at least 120 days of consecutive stay. MEASUREMENTS Chronic opioid use was defined as use for ≥90 days. Three-level hierarchical logistic regression models (resident, nursing home, state) were constructed to estimate intraclass correlation coefficient (ICC) at the state level and at the nursing home level. The ICC shows the proportion of variation in chronic opioid use that is attributable to states or nursing homes. All models were constructed separately for each calendar year and controlled for resident, nursing home, and state characteristics. RESULTS We included 3,245,714 nursing home stays from 2014 to 2018, representing 1,502,131 unique residents. The stays ranged from 676,413 in 2014 to 594,874 in 2018, with residents contributing a maximum of 1 stay per year. Chronic opioid use among nursing home residents declined from 14.1% in 2014 to 11.4% in 2018. The variation (ICC) in chronic opioid use among states declined from 2.5% in 2014 to 1.7% in 2018. In contrast, the variation (ICC) among nursing homes increased from 5.6% in 2014 to 6.5% in 2018. CONCLUSIONS AND IMPLICATIONS Variation in chronic opioid use declined by one-third at the state level but not at the nursing home level. National guidelines on opioid use and federal policies on opioid use may have contributed to reducing state-level variation in chronic opioid use.
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Affiliation(s)
- Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Yong-Fang Kuo
- Office of Biostatistics, Department of Preventive Medicine and Population Health, University of Texas Medical Branch at Galveston, TX, USA
| | - Mukaila A Raji
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jordan Westra
- Office of Biostatistics, Department of Preventive Medicine and Population Health, University of Texas Medical Branch at Galveston, TX, USA
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James S Goodwin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
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22
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Mehta HB, Malagaris I, Goodwin JS. Reply to "Comment on: Decrease of anticholinergic drug use in nursing home residents in the United States". J Am Geriatr Soc 2021; 69:2035-2036. [PMID: 33930179 DOI: 10.1111/jgs.17181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ioannis Malagaris
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, Texas, USA.,Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas, USA
| | - James S Goodwin
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, Texas, USA.,Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas, USA
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23
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Mehta HB, Wang L, Malagaris I, Duan Y, Rosman L, Alexander GC. More than two-dozen prescription drug-based risk scores are available for risk adjustment: A systematic review. J Clin Epidemiol 2021; 137:113-125. [PMID: 33838274 DOI: 10.1016/j.jclinepi.2021.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 02/10/2021] [Accepted: 03/16/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE While several prescription drug-based risk indices have been developed, their design, performance, and application has not previously been synthesized. STUDY DESIGN AND SETTING We searched Ovid MEDLINE, CINAHL and Embase from inception through March 3, 2020 and included studies that developed or updated a prescription drug-based risk index. Two reviewers independently performed screening and extracted information on data source, study population, cohort sizes, outcomes, study methodology and performance. Predictive performance was evaluated using C statistics for binary outcomes and R2 for continuous outcomes. The PROSPERO ID for this review is CRD42020165498. RESULTS Of 19,112 articles that were retrieved, 124 were full-text screened and 25 were included, each of which represented a de novo or updated drug-based index. The indices were customized to varied age groups and clinical populations and most commonly evaluated outcomes including mortality (36%), hospitalization (24%) and healthcare costs (24%). C statistics ranged from 0.62 to 0.92 for mortality and 0.59 to 0.72 for hospitalization, while adjusted R2 for healthcare costs ranged from 0.06 to 0.62. Seven of the 25 risk indices included used global drug classification algorithms. CONCLUSIONS More than two-dozen prescription drug-based risk indices have been developed and they differ significantly in design, performance and application.
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Affiliation(s)
- Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Lin Wang
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ioannis Malagaris
- Department of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Yanjun Duan
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lori Rosman
- Welch Medical Library, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Mehta HB, Li S, Goodwin JS. Risk Factors Associated With SARS-CoV-2 Infections, Hospitalization, and Mortality Among US Nursing Home Residents. JAMA Netw Open 2021; 4:e216315. [PMID: 33787905 PMCID: PMC8013796 DOI: 10.1001/jamanetworkopen.2021.6315] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/25/2021] [Indexed: 12/16/2022] Open
Abstract
Importance Nursing home residents account for approximately 40% of deaths from SARS-CoV-2. Objective To identify risk factors for SARS-CoV-2 incidence, hospitalization, and mortality among nursing home residents in the US. Design, Setting, and Participants This retrospective longitudinal cohort study was conducted in long-stay residents aged 65 years or older with fee-for-service Medicare residing in 15 038 US nursing homes from April 1, 2020, to September 30, 2020. Data were analyzed from November 22, 2020, to February 10, 2021. Main Outcomes and Measures The main outcome was risk of diagnosis with SARS-CoV-2 (per International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes) by September 30 and hospitalization or death within 30 days after diagnosis. Three-level (resident, facility, and county) logistic regression models and competing risk models conditioned on nursing home facility were used to determine association of patient characteristics with outcomes. Results Among 482 323 long-stay residents included, the mean (SD) age was 82.7 (9.2) years, with 326 861 (67.8%) women, and 383 838 residents (79.6%) identifying as White. Among 137 119 residents (28.4%) diagnosed with SARS-CoV-2 during follow up, 29 204 residents (21.3%) were hospitalized, and 26 384 residents (19.2%) died within 30 days. Nursing homes explained 37.2% of the variation in risk of infection, while county explained 23.4%. Risk of infection increased with increasing body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) (eg, BMI>45 vs BMI 18.5-25: adjusted hazard ratio [aHR], 1.19; 95% CI, 1.15-1.24) but varied little by other resident characteristics. Risk of hospitalization after SARS-CoV-2 increased with increasing BMI (eg, BMI>45 vs BMI 18.5-25: aHR, 1.40; 95% CI, 1.28-1.52); male sex (aHR, 1.32; 95% CI, 1.29-1.35); Black (aHR, 1.28; 95% CI, 1.24-1.32), Hispanic (aHR, 1.20; 95% CI, 1.15-1.26), or Asian (aHR, 1.46; 95% CI, 1.36-1.57) race/ethnicity; impaired functional status (eg, severely impaired vs not impaired: aHR, 1.15; 95% CI, 1.10-1.22); and increasing comorbidities, such as renal disease (aHR, 1.21; 95% CI, 1.18-1.24) and diabetes (aHR, 1.16; 95% CI, 1.13-1.18). Risk of mortality increased with age (eg, age >90 years vs 65-70 years: aHR, 2.55; 95% CI, 2.44-2.67), impaired cognition (eg, severely impaired vs not impaired: aHR, 1.79; 95% CI, 1.71-1.86), and functional impairment (eg, severely impaired vs not impaired: aHR, 1.94; 1.83-2.05). Conclusions and Relevance These findings suggest that among long-stay nursing home residents, risk of SARS-CoV-2 infection was associated with county and facility of residence, while risk of hospitalization and death after SARS-CoV-2 infection was associated with facility and individual resident characteristics. For many resident characteristics, there were substantial differences in risk of hospitalization vs mortality. This may represent resident preferences, triaging decisions, or inadequate recognition of risk of death.
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Affiliation(s)
- Hemalkumar B. Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Shuang Li
- Sealy Center on Aging, Department of Internal Medicine, The University of Texas Medical Branch, Galveston
| | - James S. Goodwin
- Sealy Center on Aging, Department of Internal Medicine, The University of Texas Medical Branch, Galveston
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Abstract
OBJECTIVE This study aimed to quantify the association between pharmaceutical industry payments to physicians for pimavanserin and both pimavanserin prescription volume and Medicare expenditures. METHODS This retrospective cross-sectional study used 2016 and 2017 data from Open Payments and the Medicare Part D Prescriber Public Use Files. The authors used Poisson regression models to quantify the association between physician payments for pimavanserin and pimavanserin prescription volume and linear regression models to quantify the association with Medicare expenditures for pimavanserin. RESULTS Of 1,609 physicians who prescribed pimavanserin, 45% received payments, which totaled to $6,369,922. Each $10,000 in physician payments was associated with a 14% increase in pimavanserin prescription volume (incident rate ratio=1.14, 95% confidence interval [CI]=1.13-1.14). Every $100 in physician payments was associated with a $175.84 increase in Medicare pimavanserin expenditures (95% CI=$161.55-$190.13). CONCLUSIONS Extensive physician payments have been associated with increased pimavanserin prescription volume and Medicare expenditures.
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Affiliation(s)
- Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (Mehta, Alexander); Institute for Safe Medication Practices, Alexandria, Virginia, and Department of Epidemiology, Milken Institute of Public Health, George Washington University, Washington, D.C. (Moore); Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore (Alexander)
| | - Thomas J Moore
- Center for Drug Safety and Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (Mehta, Alexander); Institute for Safe Medication Practices, Alexandria, Virginia, and Department of Epidemiology, Milken Institute of Public Health, George Washington University, Washington, D.C. (Moore); Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore (Alexander)
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness and Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore (Mehta, Alexander); Institute for Safe Medication Practices, Alexandria, Virginia, and Department of Epidemiology, Milken Institute of Public Health, George Washington University, Washington, D.C. (Moore); Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore (Alexander)
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Bagheri I, Shan Y, Klaassen Z, Kamat AM, Konety B, Mehta HB, Baillargeon JG, Srinivas S, Tyler DS, Swanson TA, Kaul S, Hollenbeck BK, Williams SB. Comparing Costs of Radical Versus Partial Cystectomy for Patients Diagnosed with Localized Muscle-Invasive Bladder Cancer: Understanding the Value of Surgical Care. Urol Oncol 2020. [DOI: 10.1016/j.urolonc.2020.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Stevenson JM, Alexander GC, Palamuttam N, Mehta HB. Projected Utility of Pharmacogenomic Testing Among Individuals Hospitalized With COVID-19: A Retrospective Multicenter Study in the United States. Clin Transl Sci 2020; 14:153-162. [PMID: 33085221 PMCID: PMC7877860 DOI: 10.1111/cts.12919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/07/2020] [Indexed: 12/24/2022] Open
Abstract
Many academic institutions are collecting blood samples from patients seeking treatment for coronavirus disease 2019 (COVID‐19) to build research biorepositories. It may be feasible to extract pharmacogenomic (PGx) information from biorepositories for clinical use. We sought to characterize the potential value of multigene PGx testing among individuals hospitalized with COVID‐19 in the United States. We performed a cross‐sectional analysis of electronic health records from consecutive individuals hospitalized with COVID‐19 at a large, urban academic health system. We characterized medication orders, focusing on medications with actionable PGx guidance related to 14 commonly assayed genes (CYP2C19, CYP2C9, CYP2D6, CYP3A5, DPYD, G6PD, HLA‐A, HLA‐B, IFNL3, NUDT15, SLCO1B1, TPMT, UGT1A1, and VKORC1). A simulation analysis combined medication data with population phenotype frequencies to estimate how many treatment modifications would be enabled if multigene PGx results were available. Sixty‐four unique medications with PGx guidance were ordered at least once in the cohort (n = 1,852, mean age 60.1 years). Nearly nine in 10 individuals (89.7%) had at least one order for a medication with PGx guidance and 427 patients (23.1%) had orders for 4 or more actionable medications. Using a simulation, we estimated that 17 treatment modifications per 100 patients would be enabled if PGx results were available. The genes CYP2D6 and CYP2C19 were responsible for the majority of treatment modifications, and the medications most often affected were ondansetron, oxycodone, and clopidogrel. PGx results would be relevant for nearly all individuals hospitalized with COVID‐19 and would provide the opportunity to improve clinical care.
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Affiliation(s)
- James M Stevenson
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Natasha Palamuttam
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Williams SB, Shan Y, Jazzar U, Kerr PS, Okereke I, Klimberg VS, Tyler DS, Putluri N, Lopez DS, Prochaska JD, Elferink C, Baillargeon JG, Kuo YF, Mehta HB. Proximity to Oil Refineries and Risk of Cancer: A Population-Based Analysis. JNCI Cancer Spectr 2020; 4:pkaa088. [PMID: 33269338 PMCID: PMC7691047 DOI: 10.1093/jncics/pkaa088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/11/2020] [Accepted: 09/22/2020] [Indexed: 11/15/2022] Open
Abstract
Background The association between proximity to oil refineries and cancer rate is largely unknown. We sought to compare the rate of cancer (bladder, breast, colon, lung, lymphoma, and prostate) according to proximity to an oil refinery in Texas. Methods A total of 6 302 265 persons aged 20 years or older resided within 30 miles of an oil refinery from 2010 to 2014. We used multilevel zero-inflated Poisson regression models to examine the association between proximity to an oil refinery and cancer rate. Results We observed that proximity to an oil refinery was associated with a statistically significantly increased risk of incident cancer diagnosis across all cancer types. For example, persons residing within 0-10 (risk ratio [RR] = 1.13, 95% confidence interval [CI] = 1.07 to 1.19) and 11-20 (RR = 1.05, 95% CI = 1.00 to 1.11) miles were statistically significantly more likely to be diagnosed with lymphoma than individuals who lived within 21-30 miles of an oil refinery. We also observed differences in stage of cancer at diagnosis according to proximity to an oil refinery. Moreover, persons residing within 0-10 miles were more likely to be diagnosed with distant metastasis and/or systemic disease than people residing 21-30 miles from an oil refinery. The greatest risk of distant disease was observed in patients diagnosed with bladder cancer living within 0-10 vs 21-30 miles (RR = 1.30, 95% CI = 1.02 to 1.65), respectively. Conclusions Proximity to an oil refinery was associated with an increased risk of multiple cancer types. We also observed statistically significantly increased risk of regional and distant/metastatic disease according to proximity to an oil refinery.
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Affiliation(s)
- Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Yong Shan
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Usama Jazzar
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Preston S Kerr
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Ikenna Okereke
- Department of Surgery, Division of Thoracic Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - V Suzanne Klimberg
- Department of Surgery, Division of Surgical Oncology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Nagireddy Putluri
- Department of Molecular and Cellular Biology, Dan L. Duncan Cancer Center, Advanced Technology Core, Alkek Center for Molecular Discovery, Baylor College of Medicine, Houston, TX, USA
| | - David S Lopez
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - John D Prochaska
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Cornelis Elferink
- Department of Pharmacology and Toxicology, Center for Environmental Toxicology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Jacques G Baillargeon
- Department of Medicine, Division of Epidemiology, Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Yong-Fang Kuo
- Department of Medicine, Division of Epidemiology, Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Hemalkumar B Mehta
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Bagheri I, Shan Y, Klaassen Z, Kamat AM, Konety B, Mehta HB, Baillargeon JG, Srinivas S, Tyler DS, Swanson TA, Kaul S, Hollenbeck BK, Williams SB. Comparing Costs of Radical Versus Partial Cystectomy for Patients Diagnosed With Localized Muscle-Invasive Bladder Cancer: Understanding the Value of Surgical Care. Urology 2020; 147:127-134. [PMID: 32980405 DOI: 10.1016/j.urology.2020.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/21/2020] [Accepted: 08/09/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To compare costs associated with radical versus partial cystectomy. Prior studies noted substantial costs associated with radical cystectomy, however, they lack surgical comparison to partial cystectomy. METHODS A total of 2305 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 to December 31, 2011 were included. Total Medicare costs within 1 year of diagnosis following radical versus partial cystectomy were compared using inverse probability of treatment-weighted propensity score models. Cox regression and competing risks analysis were used to determine overall and cancer-specific survival, respectively. RESULTS Median total costs were not significantly different for radical than partial cystectomy in 90 days ($73,907 vs $65,721; median difference $16,796, 95% CI $10,038-$23,558), 180 days ($113,288 vs $82,840; median difference $36,369, 95% CI $25,744-$47,392), and 365 days ($143,831 vs $107,359; median difference $34,628, 95% CI $17,819-$53,558), respectively. Hospitalization, surgery, pathology/laboratory, pharmacy, and skilled nursing facility costs contributed largely to costs associated with either treatment. Patients who underwent partial cystectomy had similar overall survival but had worse cancer-specific survival (Hazard Ratio 1.45, 95% Confidence Interval, 1.34-1.58, P < .001) than patients who underwent radical cystectomy. CONCLUSION While treatments for bladder cancer are associated with substantial costs, we showed radical cystectomy had comparable total costs when compared to partial cystectomy among patients with muscle-invasive bladder cancer. However, partial cystectomy resulted in worse cancer-specific survival further supporting radical cystectomy as a high-value surgical procedure for muscle-invasive bladder cancer.
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Affiliation(s)
- Iyla Bagheri
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX
| | - Yong Shan
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Augusta University, Augusta, GA
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Jacques G Baillargeon
- Department of Medicine, Division of Epidemiology, Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Sunay Srinivas
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston, TX
| | - Sapna Kaul
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX.
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Malagaris I, Mehta HB, Li S, Goodwin JS. Decrease of Anticholinergic Drug Use in Nursing Home Residents in the United States, 2009 to 2017. J Am Geriatr Soc 2020; 68:2797-2804. [PMID: 32798337 DOI: 10.1111/jgs.16776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/07/2020] [Accepted: 07/11/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the time course of anticholinergic drug use in nursing home residents and assess if any temporal change in anticholinergic use varied by nursing home quality rating. DESIGN Retrospective repeated cross-sectional analysis of Medicare enrollment, Parts A, B, and D, claims data linked to the Minimum Data Set from 2009 to 2017. SETTING Medicare-certified nursing homes. PARTICIPANTS Long-term residents 65 years or older with nursing home stay of at least 100 consecutive days within a given calendar year. MEASUREMENTS Estimates of anticholinergic drug prescription rates between 2009 and 2017 were based on a binary variable indicating whether a resident received a drug with high anticholinergic activity, as defined by the Anticholinergic Cognitive Burden scale, for at least 1 day during the initial 100 consecutive days of nursing home stay in a given calendar year. We used mixed effects logistic regression models to determine adjusted rates of anticholinergic use each year and test the interaction between nursing home quality rating and year, while adjusting for patient and nursing home characteristics. RESULTS The cohort included 786,858 100-day nursing home stays (299,354 unique residents) in 6,703 nursing homes for the years 2009 to 2017. Prescription rates were stable at approximately 34% to 35% between 2009 and 2011, then gradually decreased to 24.3% in 2017 (P < .0001), with the decline being more pronounced in nursing homes having high quality ratings (P < .0001). Rates for anticholinergic drugs in nursing homes with 4 to 5 star quality rating (33.7% in 2011 to 23.3% in 2017) showed a steeper decline over time relative to nursing homes with 1 to 2 star quality rating (34.2% in 2011 to 25.2% in 2017) (P < .0001). CONCLUSIONS The use of drugs with high anticholinergic activity has declined from 2009 to 2017, with a greater decline in higher-quality nursing homes.
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Affiliation(s)
- Ioannis Malagaris
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, Texas
| | - Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Shuang Li
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, Texas
| | - James S Goodwin
- Sealy Center on Aging, The University of Texas Medical Branch, Galveston, Texas.,Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas
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Golla V, Shan Y, Mehta HB, Klaassen Z, Tyler DS, Baillargeon J, Kamat AM, Freedland SJ, Gore JL, Chamie K, Kuo YF, Williams SB. Impact of Diagnosing Urologists and Hospitals on the Use of Radical Cystectomy. EUR UROL SUPPL 2020; 19:27-36. [PMID: 34337452 PMCID: PMC8317809 DOI: 10.1016/j.euros.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 11/22/2022] Open
Abstract
Background One out of five patients with muscle-invasive bladder cancer undergo radical cystectomy—a guideline-recommended treatment. Previous studies have primarily evaluated patient characteristics associated with the use of radical cystectomy, ignoring potential nesting of data. Objective To determine the impact of patient, diagnosing urologist, and hospital characteristics on the variation in the use of radical cystectomy. Design, setting, and participants This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results Registry (SEER)-Medicare linked database. Outcome measurements and statistical analysis A total of 7097 muscle-invasive bladder cancer patients and 4601 diagnosing urologists affiliated to 822 hospitals from January 1, 2002 to December 31, 2012 were analyzed. Multilevel logistic regression analyses were used to determine variation and factors associated with the use of radical cystectomy. Results and limitations Of the 7097 patients, only 27% underwent radical cystectomy. The intraclass correlation coefficient for variation in the use of radical cystectomy attributed to the hospital level was 4.3%. Higher radical cystectomy volume by diagnosing urologists (more than five vs zero to one surgery: odds ratio [OR], 1.27; 95% confidence interval [CI], 1.00–1.62) and hospitals (more than five vs zero to four surgeries: OR,1.48; 95% CI, 1.14–1.93) was associated with increased use of radical cystectomy. Patients diagnosed by female rather than male urologists were more likely to undergo radical cystectomy (OR, 1.32; 95% CI, 1.07–1.62). Conclusions We found that 4.3% variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. We identified significantly increased use among higher-volume and female diagnosing urologists. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy. Patient summary In this large population-based study, we found that 4.3% of variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. Higher radical cystectomy volume of diagnosing urologists and female urologists were independently associated with increased use of radical cystectomy. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy.
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Affiliation(s)
- Vishnukamal Golla
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Yong Shan
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hemalkumar B. Mehta
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Douglas S. Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Ashish M. Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - John L. Gore
- Department of Urology, The University of Washington, Seattle, WA, USA
| | - Karim Chamie
- Department of Urology, University of California, Los Angeles, CA, USA
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, USA
| | - Stephen B. Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
- Corresponding author. Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA. Tel.: +1-409-747-7333; Fax: +1-409-772-0088.
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Abstract
OBJECTIVES The coronavirus disease 2019 (COVID-19) pandemic has prompted many initiatives to identify safe and efficacious treatments, yet little is known regarding where early efforts have focused. We aimed to characterise registered clinical trials assessing drugs or plasma treatments for COVID-19. DESIGN, SETTING AND PARTICIPANTS Cross-sectional analysis of clinical trials for the treatment of COVID-19 that were registered in the USA or in countries contributing to the WHO's International Clinical Trials Registry Platform. Relevant trial entries of drugs or plasma were downloaded on 26 March 2020, deduplicated, verified with reviews of major medical journals and WHO websites and independently analysed by two reviewers. MAIN OUTCOMES Trial intervention, sponsorship, critical design elements and specified outcomes RESULTS: Overall, 201 clinical trials were registered for testing the therapeutic benefits of 92 drugs or plasma, including 64 in monotherapy and 28 different combinations. Only eight (8.7%) products or combinations involved new molecular entities. The other test therapies had a wide range of prior medical uses, including as antivirals, antimalarials, immunosuppressants and oncology treatments. In 152 trials (75.7%), patients were randomised to treatment or comparator, including 55 trials with some form of blinding and 97 open-label studies. The 49 (24.4%) of trials without a randomised design included 29 single armed studies and 20 trials with some comparison group. Most trial designs featured multiple endpoints. Clinical endpoints were identified in 134 (66.7%) of trials and included COVID-19 symptoms, death, recovery, required intensive care and hospital discharge. Clinical scales were being used in 33 (16.4%) trials, most often measures of oxygenation and critical illness. Surrogate endpoints or biomarkers were studied in 88 (42.3%) of trials, primarily assays of viral load. Although the trials were initiated in more than 17 countries or regions, 100 (49.8%) were registered in China and 78 (37.8%) in the USA. Registered trials increased rapidly, with the number of registered trials doubling from 1 March to 26 March 2020. CONCLUSIONS While accelerating morbidity and mortality from the COVID-19 pandemic has been paralleled by early and rapid clinical investigation, many trials lack features to optimise their scientific value. Global coordination and increased funding of high-quality research may help to maximise scientific progress in rapidly discovering safe and effective treatments.
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Affiliation(s)
- Hemalkumar B Mehta
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stephan Ehrhardt
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Thomas J Moore
- Institute for Safe Medication Practices, Alexandria, Virginia, USA
| | - Jodi B Segal
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public health, Baltimore, Maryland, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Williams SB, Shan Y, Jazzar U, Kerr P, Okereke I, Klimberg VS, Tyler DS, Putluri N, Lopez DS, Prochaska JD, Elferink C, Baillargeon JG, Kuo YF, Mehta HB. Proximity to oil refineries and risk of cancer: A population-based analysis. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e13586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e13586 Background: Proximity to oil refineries and cancer incidence is largely unknown. We sought to compare the incidence of cancer (bladder, breast, colon, lung, lymphoma, and prostate) according to proximity to an oil refinery in the State of Texas. Methods: A total of 6,302,265 persons aged ≥20 years from January 1, 2001 through December 31, 2014 were identified. We used zero-inflated Poisson regression models to examine the association of proximity to an oil refinery with cancer incidence. Results: We observed that proximity to an oil refinery was associated with a significantly increased risk of incident cancer diagnosis across all cancer types. For example, persons residing within 0-10 (Risk Ratio (RR) 1.16, 95% Confidence Interval (CI) 1.13-1.19) and 11-20 (RR 1.08, 95% CI 1.05-1.11) miles were significantly more likely to be diagnosed with lymphoma than individuals who lived within 21-30 miles from an oil refinery. We also observed differences in stage of cancer at diagnosis according to proximity to an oil refinery. We also found persons residing within 0-10 miles were more likely to be diagnosed with distant metastasis and/or systemic disease than people residing 21-30 miles from an oil refinery. The greatest risk of distant disease was observed in patients diagnosed with bladder cancer living within 0-10 vs. 21-30 miles (RR 1.33, 95% CI 1.06-1.68), respectively. Conclusions: Proximity to an oil refinery was associated with an increased risk of multiple cancer types. We also observed significantly increased risk of regional and distant/metastatic disease according to proximity to an oil refinery.
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Affiliation(s)
| | - Yong Shan
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Usama Jazzar
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Preston Kerr
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Ikenna Okereke
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Douglas S. Tyler
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - David S Lopez
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - John D Prochaska
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | | | - Yong-Fang Kuo
- University of Texas Medical Branch at Galveston, Galveston, TX
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Li CY, Karmarkar A, Kuo YF, Mehta HB, Mallinson T, Haas A, Kumar A, Ottenbacher KJ. A comparison of three methods in categorizing functional status to predict hospital readmission across post-acute care. PLoS One 2020; 15:e0232017. [PMID: 32379765 PMCID: PMC7205206 DOI: 10.1371/journal.pone.0232017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 04/06/2020] [Indexed: 11/20/2022] Open
Abstract
Background Methods used to categorize functional status to predict health outcomes across post-acute care settings vary significantly. Objectives We compared three methods that categorize functional status to predict 30-day and 90-day hospital readmission across inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF) and home health agencies (HHA). Research design Retrospective analysis of 2013–2014 Medicare claims data (N = 740,530). Data were randomly split into two subsets using a 1:1 ratio. We used half of the cohort (development subset) to develop functional status categories for three methods, and then used the rest (testing subset) to compare outcome prediction. Three methods to generate functional categories were labeled as: Method I, percentile based on proportional distribution; Method II, percentile based on change score distribution; and Method III, functional staging categories based on Rasch person strata. We used six differentiation and classification statistics to determine the optimal method of generating functional categories. Setting IRF, SNF and HHA. Subjects We included 130,670 (17.7%) Medicare beneficiaries with stroke, 498,576 (67.3%) with lower extremity joint replacement and 111,284 (15.0%) with hip and femur fracture. Measures Unplanned 30-day and 90-day hospital readmission. Results For all impairment conditions, Method III best predicted 30-day and 90-day hospital readmission. However, we observed overlapping confidence intervals among some comparisons of three methods. The bootstrapping of 30-day and 90-day hospital readmission predictive models showed the area under curve for Method III was statistically significantly higher than both Method I and Method II (all paired-comparisons, p<.001), using the testing sample. Conclusions Overall, functional staging was the optimal method to generate functional status categories to predict 30-day and 90-day hospital readmission. To facilitate clinical and scientific use, we suggest the most appropriate method to categorize functional status should be based on the strengths and weaknesses of each method.
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Affiliation(s)
- Chih-Ying Li
- Department of Occupational Therapy, University of Texas Medical Branch, Galveston, Texas, United States of America
- * E-mail:
| | - Amol Karmarkar
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Yong-Fang Kuo
- Department of Preventive Medicine & Community Health, University of Texas Medical Branch, Galveston, Texas, United States of America
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Hemalkumar B. Mehta
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Trudy Mallinson
- Department of Clinical Research and Leadership, The George Washington University, Washington, DC, United States of America
| | - Allen Haas
- Department of Preventive Medicine & Community Health, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Amit Kumar
- Department of Physical Therapy, Northern Arizona University, Phoenix, Arizona, United States of America
| | - Kenneth J. Ottenbacher
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas, United States of America
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, United States of America
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Jazzar U, Shan Y, Klaassen Z, Freedland SJ, Kamat AM, Raji MA, Masel T, Tyler DS, Baillargeon J, Kuo YF, Mehta HB, Bergerot CD, Williams SB. Impact of Alzheimer's disease and related dementia diagnosis following treatment for bladder cancer. J Geriatr Oncol 2020; 11:1118-1124. [PMID: 32354675 DOI: 10.1016/j.jgo.2020.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Our objective was to assess the incidence of Alzheimer's Disease and related dementia diagnosis following treatment for muscle-invasive bladder cancer and impact on survival outcomes. MATERIALS AND METHODS A total of 4814 patients diagnosed with clinical stage T2-T4a, N0, M0 bladder cancer between January 1, 2002 to December 31, 2011 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database were identified. Alzheimer's disease and related dementia diagnosis was identified using International Statistical Classification of Disease-Ninth Edition outpatient and inpatient codes. Incidence of dementia following treatment were calculated and reported as dementia cases per 10,000 person-years. Cox proportional hazards models were used to assess the impact of dementia on survival outcomes. RESULTS Of the 4814 patients, 2403 (49.9%) underwent radical cystectomy (RC) and 2411 (50.1%) underwent radiotherapy (RTX) and/or chemotherapy (CTX). Overall, 837 (17.4%) patients developed Alzheimer's disease and related dementia following bladder cancer treatment. There was no significant difference in the incidence of Alzheimer's disease and related dementia following either treatment. Patients diagnosed with Alzheimer's disease and related dementia had worse overall (Hazard Ratio (HR), 2.64; 95% Confidence Interval (CI), 2.41-2.89) and cancer-specific (HR, 2.45; 95% CI, 2.18-2.76) survival than those without a dementia diagnosis following treatment. CONCLUSION While we observed no difference in new-onset Alzheimer's disease and related dementia diagnosis following RC or RTX and/or CTX, patients with a Alzheimer's and related dementia diagnosis was associated with worse overall and cancer-specific survival. These findings have important implications for screening and the development of targeted interventions for improving outcomes in older adults following complex cancer treatments, as observed in this bladder cancer population.
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Affiliation(s)
- Usama Jazzar
- Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Yong Shan
- Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Georgia Regents University, Augusta, GA, United States of America
| | - Stephen J Freedland
- Department of Urology, Cedars Sinai Medical Center, Los Angeles, CA, United States of America
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Mukaila A Raji
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Todd Masel
- Department of Neurology, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Jacques Baillargeon
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, Sealy Center of Aging, The University of Texas Medical Branch, Galveston, TX, United States of America
| | - Hemalkumar B Mehta
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Cristiane D Bergerot
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA, United States of America
| | - Stephen B Williams
- Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, United States of America.
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Mehta HB, Kuo YF, Westra J, Raji M, Goodwin JS. TRENDS IN OPIOID USE IN LONG-TERM CARE NURSING HOME RESIDENTS WITH DEMENTIA. Innov Aging 2019. [PMCID: PMC6841614 DOI: 10.1093/geroni/igz038.2605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We examined opioid use in long-term care nursing home residents with dementia. This retrospective cohort study used Minimum Data Set linked Medicare data, 2011-2016, and included long-term care episodes for residents 65+ years who survived 100+ days each year (592,211 episodes for 256,207 residents). Cognitive status at first annual assessment was classified as none/mild, moderate and severe impairment. Overall opioid use, prolonged opioid use (prescription supply 90+ days) and long-acting opioid use were identified from Medicare part D. Descriptive statistics were used to describe opioid use by cognitive impairment. Cochrane Armitage trends test was used to determine trends in opioid use. 114,622 (19%) patients had severe and 129,257 (22%) had moderate dementia. Overall opioid (none/mild=15.4%, moderate=13.9%, severe=9%), prolonged opioid (none/mild=5.2%, moderate=4.5%, severe=3.2%) and long-acting opioid use (none/mild=1.1%, moderate=0.9%, severe=0.3% ) were lower in patients with advanced dementia. Opioid use was significantly higher in females and Whites and varied by states. Substantial increase was found in overall opioid and prolonged opioid use from 2011 to 2016, with greater increase in none/mild and moderate dementia patients. For example, prolonged opioid use increased by 69% in none/mild and 71% in moderate dementia patients compared to 52% in severe dementia patients (p<0.0001). Long-acting opioid use decreased, with a greater decline in none/mild (69%) and moderate (71%) dementia patients compared to severe dementia patients (58%) (p<0.0001). Contrary to decreasing opioid use in community setting, overall and prolonged opioid use increased in nursing home residents. Future studies should identify the reasons behind increased use.
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Affiliation(s)
| | - Yong-Fang Kuo
- The University of Texas Medical Branch, Galveston, Texas, United States
| | - Jordan Westra
- The University of Texas Medical Branch, Galveston, Texas, United States
| | - Mukaila Raji
- The University of Texas Medical Branch, Galveston, Texas, United States
| | - James S Goodwin
- The University of Texas Medical Branch, Galveston, Texas, United States
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Williams SB, Shan Y, Jazzar U, Mehta HB, Baillargeon JG, Huo J, Senagore AJ, Orihuela E, Tyler DS, Swanson TA, Kamat AM. Comparing Survival Outcomes and Costs Associated With Radical Cystectomy and Trimodal Therapy for Older Adults With Muscle-Invasive Bladder Cancer. JAMA Surg 2019; 153:881-889. [PMID: 29955780 DOI: 10.1001/jamasurg.2018.1680] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Radical cystectomy is the guidelines-recommended treatment of muscle-invasive bladder cancer, but a resurgence of trimodal therapy has occurred. Limited comparative data are available on outcomes and costs attributable to these 2 treatments. Objective To compare the survival outcomes and costs between trimodal therapy and radical cystectomy in older adults with muscle-invasive bladder cancer. Design, Setting, and Participants This population-based cohort study used data from the Surveillance, Epidemiology, and End Results-Medicare linked database. A total of 3200 older adults (aged ≥66 years) with clinical stage T2 to T4a bladder cancer diagnosed from January 1, 2002, to December 31, 2011, and with claims data available through December 31, 2013, were included in the analysis. Patients who received radical cystectomy underwent either only surgery or surgery in combination with radiotherapy or chemotherapy. Patients who received trimodal therapy underwent transurethral resection of the bladder followed by radiotherapy and chemotherapy. Propensity score matching by sociodemographic and clinical characteristics was used. Data analysis was performed from August 1, 2017, to March 11, 2018. Main Outcomes and Measures Overall survival and cancer-specific survival were evaluated using the Cox proportional hazards regression model and the Fine and Gray competing risk model. All Medicare health care costs for inpatient, outpatient, and physician services within 30, 90, and 180 days of treatment were compared. The total amount spent nationwide was estimated, using 180-day medical costs between treatments, by the total number of new cases of muscle-invasive bladder cancer in the United States in 2011. Results Of the 3200 patients who met the inclusion criteria, 2048 (64.0%) were men and 1152 (36.0%) were women, with a mean (SD) age of 75.8 (6.0) years. After propensity score matching, 687 patients (21.5%) underwent trimodal therapy and 687 patients (21.5%) underwent radical cystectomy. Patients who underwent trimodal therapy had significantly decreased overall survival (hazard ratio [HR], 1.49; 95% CI, 1.31-1.69) and cancer-specific survival (HR, 1.55; 95% CI, 1.32-1.83). No differences in costs at 30 days were observed between trimodal therapy ($15 233 in 2002 vs $18 743 in 2011) and radical cystectomy ($17 990 in 2002 vs $21 738 in 2011). However, median total costs were significantly higher with trimodal therapy than with radical cystectomy at 90 days ($80 174 vs $69 181; median difference, $8964; Hodges-Lehmann 95% CI, $3848-$14 079) and at 180 days ($179 891 vs $107 017; median difference, $63 771; Hodges-Lehmann 95% CI, $55 512-$72 029). Extrapolating these figures to the total US population revealed $335 million in excess spending for trimodal therapy compared with the less costly radical cystectomy ($492 million) for patients who received a muscle-invasive bladder cancer diagnosis in 2011. Conclusions and Relevance Trimodal therapy was associated with significantly decreased overall survival and cancer-specific survival as well as $335 million in excess spending in 2011. These findings have important health policy implications regarding the appropriate use of high value-based care among older adults with invasive bladder cancer who are candidates for either radical cystectomy or trimodal therapy.
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Affiliation(s)
- Stephen B Williams
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Yong Shan
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Usama Jazzar
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Hemalkumar B Mehta
- Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Jacques G Baillargeon
- Sealy Center on Aging, Division of Epidemiology, Department of Medicine, The University of Texas Medical Branch, Galveston
| | - Jinhai Huo
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville
| | - Anthony J Senagore
- Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Eduardo Orihuela
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch, Galveston
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston
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Mehta HB, Yong S, Sura SD, Hughes BD, Kuo YF, Williams SB, Tyler DS, Riall TS, Goodwin JS. Development of comorbidity score for patients undergoing major surgery. Health Serv Res 2019; 54:1223-1232. [PMID: 31576566 DOI: 10.1111/1475-6773.13209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To develop and validate a claims-based comorbidity score for patients undergoing major surgery, and compare its performance with established comorbidity scores. DATA SOURCE Five percent Medicare data from 2007 to 2014. STUDY DESIGN Retrospective cohort study of patients aged ≥65 years undergoing six major operations (N = 99 250). DATA COLLECTION One-year mortality was the primary outcome. Secondary outcomes were hospital mortality, 30-day mortality, 30-day readmission, and length of stay. The comorbidity score was developed in the derivation cohort (70 percent sample) using logistic regression model. The comorbidity score was calibrated and validated in the validation cohort (30 percent sample), and compared against the Charlson, Elixhauser, and Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) comorbidity scores using c-statistic, net reclassification improvement, and integrated discrimination improvement. PRINCIPAL FINDINGS In the validation cohort, the surgery-specific comorbidity score was well calibrated and performed better than the Charlson, Elixhauser, and CMS-HCC comorbidity scores for all outcomes; the performance was comparable to the CMS-HCC for 30-day readmission. For example, the surgery-specific comorbidity score (c-statistic = 0.792; 95% CI, 0.785-0.799) had greater discrimination than the Charlson (c-statistic = 0.747; 95% CI, 0.739-0.755), Elixhauser (c-statistic = 0.747; 95% CI, 0.735-0.755), or CMS-HCC (c-statistic = 0.755; 95% CI, 0.747-0.763) scores in predicting 1-year mortality. The net reclassification improvement and integrated discrimination improvement were greater for surgery-specific comorbidity score compared to the Charlson, Elixhauser, and CMS-HCC scores. CONCLUSIONS Compared to commonly used comorbidity measures, a surgery-specific comorbidity score better predicted outcomes in the surgical population.
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Affiliation(s)
- Hemalkumar B Mehta
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Shan Yong
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Sneha D Sura
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas
| | - Byron D Hughes
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas
| | - Stephen B Williams
- Division of Urology, Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
| | - Taylor S Riall
- Department of Surgery, The University of Arizona, Tucson, Arizona
| | - James S Goodwin
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, Texas
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Kerr PS, Dafashy TJ, Phillips DL, Kuo YF, Mehta HB, Williams SB. Proximity to Oil Refineries and Risk of Bladder Cancer: A Population-Based Analysis. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Williams SB, Shan Y, Ray-Zack MD, Hudgins HK, Jazzar U, Tyler DS, Freedland SJ, Swanson TA, Baillargeon JG, Hu JC, Kaul S, Kamat AM, Gore JL, Mehta HB. Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer. JAMA Surg 2019; 154:e191629. [PMID: 31166593 DOI: 10.1001/jamasurg.2019.1629] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.
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Affiliation(s)
- Stephen B Williams
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Yong Shan
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Mohamed D Ray-Zack
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Hogan K Hudgins
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Usama Jazzar
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
| | | | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas Medical Branch at Galveston, Galveston
| | - Jacques G Baillargeon
- Sealy Center on Aging, Division of Epidemiology, Department of Medicine, The University of Texas Medical Branch at Galveston, Galveston
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York, New York
| | - Sapna Kaul
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch at Galveston, Galveston
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston
| | - John L Gore
- Department of Urology, University of Washington, Seattle
| | - Hemalkumar B Mehta
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston
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Mehta HB, Kuo YF, Westra J, Goodwin JS, Raji M. P4-634: ASSOCIATION OF DEMENTIA SEVERITY AND OPIOID USE IN LONG-TERM CARE NURSING HOME RESIDENTS WITH DEMENTIA. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.08.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | - Yong-Fang Kuo
- University of Texas Medical Branch; Galveston TX USA
| | - Jordan Westra
- University of Texas Medical Branch; Galveston TX USA
| | | | - Mukaila Raji
- University of Texas Medical Branch; Galveston TX USA
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Hughes BD, Hancock KJ, Shan Y, Thakker RA, Maharsi S, Tyler DS, Mehta HB, Senagore AJ. Cost of benign versus oncologic colon resection among fee-for-service Medicare enrollees. J Surg Oncol 2019; 120:280-286. [PMID: 31134661 DOI: 10.1002/jso.25511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/04/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Reimbursement for colonic pathology by the Centers for Medicare and Medicaid Services (CMS) are grouped in the Medicare Severity-Diagnosis Related Groups (MS-DRG). With limited available data, we sought to compare the relative impact of malignant vs benign colonic pathology on reimbursement under the MS-DRG system. METHODS We used 5% national Medicare data from 2011 to 2014. Patients were classified as having benign disease or malignancy. Descriptive statistics and multivariate regression analysis were used to evaluate the surgical approach and health resource utilization. RESULTS Of 10 928 patients, most were Non-Hispanic White women. The majority underwent open colectomy in both cohorts (P < .001). Colectomy for benign disease was associated with higher total charges (P < .001) and a longer length of stay (P = .0002). Despite higher charges, payments were not significantly different between the cohorts (P = .434). Both inpatient mortality and discharge to a rehab facility were higher in the oncologic group (P < .001). CONCLUSION Payment methodology for colectomy under the CMS MS-DRG system does not appear to accurately reflect the episode cost of care. The data suggest that inpatient costs are not fully compensated. A transition to value-based payments with expanded episode duration will require a better understanding of unique costs before adoption.
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Affiliation(s)
- Byron D Hughes
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Kevin J Hancock
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Yong Shan
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Ravi A Thakker
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Safa Maharsi
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Hemalkumar B Mehta
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Anthony J Senagore
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine Kalamazoo, Michigan
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Dafashy T, Phillips D, Ray-Zack MD, Kerr P, Shan Y, Baillargeon JG, Kuo YF, Mehta HB, Williams SB. Proximity to oil refineries and risk of bladder cancer: A population-based analysis. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.4538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4538 Background: Exposure to aromatic amines is a risk factor for bladder cancer. Incidence rates according to proximity to oil refineries are largely unknown. We sought to determine proximity of oil refineries and bladder cancer incidence in the State of Texas which is home to the largest number of oil refineries in the United States. Methods: We used the Texas Cancer Registry database to identify patients diagnosed with bladder cancer from January 1, 2001 to December 31, 2014. The U.S. census data from 2010 was used to ascertain overall population size, age and sex distributions. Heat maps of the 28 active oil refineries in Texas were developed. Incidence of bladder cancer were compared according to proximity ( < 10 vs. ≥ 10 miles) to an oil refinery. Risk ratios were adjusted using a Poisson regression model. Results: A total of 45,517 incident bladder cancer cases were identified of which 5,501 cases were within 10 miles of an oil refinery. In adjusted analyses, bladder cancer risk was significantly greater among males vs. females (Relative Risk (RR) 3.41, 95% Confidence Interval (CI), 3.33-3.50), and greater among people living within 10 miles from an oil refinery than those living outside a 10-mile radius from an oil refinery (RR 1.19, 95% CI, 1.08-1.31). Conclusions: People living within 10 miles from oil refineries were at greater risk for bladder cancer. Further research into exposure to oil refineries and bladder cancer incidence is warranted.
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Affiliation(s)
- Tamer Dafashy
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | | | - Preston Kerr
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Yong Shan
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Yong-Fang Kuo
- University of Texas Medical Branch at Galveston, Galveston, TX
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Dafashy T, Phillips D, Shan Y, Hudgins HK, Jazzar U, Ray-Zack MD, Kaul S, Kerr P, Kamat AM, Tyler DS, Freedland SJ, Swanson TA, Mehta HB, Williams SB. Population-based outcomes comparing radical cystectomy with trimodal therapy for patients diagnosed with localized muscle-invasive bladder cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e16029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16029 Background: Radical cystectomy is the guideline-recommended treatment for muscle-invasive bladder cancer; however, use of trimodal therapy, which utilizes a combination of surgery, radiation, and chemotherapy, has increased in recent years with conflicting survival outcomes. Methods: Utilizing data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, a total of 2,963 patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002 to December 31, 2011 were analyzed. Conventional regression, propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to compare radical cystectomy and trimodal therapy for overall and cancer-specific survival, and cost. Results: Patients who underwent TMT had significantly decreased overall (conventional regression: Hazard Ratio (HR) 1.54, 95% Confidence Interval (CI), 1.39-1.71; PSM: HR 1.49, 95% CI 1.31-1.69; IPTW: HR 1.54, 95% CI 1.39-1.71) and cancer-specific (conventional regression: HR 1.51, 95% CI 1.40-1.63; PSM: HR 1.55, 95% CI 1.32-1.83; IPTW: HR 1.51, 95% CI 1.40-1.63) survival. Median total costs were significantly higher with trimodal therapy than with radical cystectomy at 6-month ($171,401 vs. $99,890, p < 0.001). Conclusions: Using population-based data and different analytic methods to control for imbalance between study groups, we found that trimodal therapy was associated with decreased overall and cancer-specific survival at increased costs compared to radical cystectomy.
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Affiliation(s)
- Tamer Dafashy
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Yong Shan
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Hogan K Hudgins
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Usama Jazzar
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Sapna Kaul
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Preston Kerr
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Ashish M. Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Douglas S. Tyler
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Todd A. Swanson
- The University of Texas Medical Branch at Galveston, Galveston, TX
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Mehta HB, Golla V, Ray-Zack MD, Shan Y, Kuo YF, Chamie K, Williams SB. Association of diagnosing physician and hospital characteristics with the use of radical cystectomy among patients with muscle-invasive bladder cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6576 Background: Only one out of five muscle-invasive bladder cancer patients receive radical cystectomy, a guideline-recommended treatment. Prior studies evaluated patient characteristics associated with radical cystectomy use. We aimed to determine bladder cancer diagnosing physician and hospital characteristics associated with the use of radical cystectomy. Methods: This cohort study used linked SEER-Medicare Data from 2002 to 2011. We included older adults (age>65 years) diagnosed with muscle-invasive bladder cancer. For each patient, a urologist who performed transurethral resection of bladder tumor was assigned as a diagnosing physician. The diagnosing physician was assigned to one hospital based on where he/she performed more than half of all urologic surgeries. Two-level hierarchical model (patients nested within hospitals) were constructed to determine the association of patient, physician and hospital characteristics with radical cystectomy use. Results: A total of 7,097 patients were diagnosed by 4601 physicians who were affiliated with 822 hospitals. Overall, the radical cystectomy utilization rate was 26.5%. Only 4.8% of the variation in radical cystectomy was attributed to the hospital level. In the two-level hierarchical model, patients diagnosed by female physicians were more likely to undergo radical cystectomy (32.8% vs. 25.8%; OR=1.63, 95% CI=1.31-2.02). Higher radical cystectomy volume by diagnosing physicians and hospitals increased the radical cystectomy use (Table). Diagnosing physician characteristics (age, years in practice, employment status), and hospital characteristics (teaching states, location, type of hospital) were not associated with radical cystectomy use. Patient characteristics such as age, male, higher comorbidity burden were associated with lower likelihood of radical cystectomy use. Conclusions: Physician and hospital factors do not largely contribute to the receipt of radical cystectomy. Radical cystectomy volume by diagnosing physicians and hospital drives radical cystectomy use.[Table: see text]
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Affiliation(s)
| | | | | | - Yong Shan
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Yong-Fang Kuo
- University of Texas Medical Branch at Galveston, Galveston, TX
| | - Karim Chamie
- Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Phillips D, Dafashy T, Shan Y, Ray-Zack MD, Hudgins HK, Jazzar U, Tyler DS, Freedland SJ, Swanson TA, Baillargeon JG, Hu JC, Kaul S, Kamat AM, Gore JL, Mehta HB, Williams SB. Comparing costs of radical cystectomy versus trimodal therapy for patients diagnosed with localized muscle-invasive bladder cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e16021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16021 Background: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. The objective of this study is to compare the one-year costs associated with trimodal therapy versus radical cystectomy, accounting for survival and intensity effects on total costs. Methods: This cohort study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Data analysis was performed from March 5, 2018 through December 4, 2018. A total of 2,963 patients aged 66-85 years diagnosed with clinical stage T2-4a muscle-invasive bladder cancer from January 1, 2002 through December 31, 2011. Total Medicare costs within one year of diagnosis following radical cystectomy versus trimodal therapy were compared using inverse probability of treatment-weighted (IPTW) propensity score models, which included a two-part estimator to account for intrinsic selection bias. Results: Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83,754 vs. $68,692; median difference $11,805, 95% CI $7,745 to $15,864), 180 days ($187,162 vs. $109,078; median difference $62,370, 95% CI $55,581 to $69,160), and 365 days ($289,142 vs. $148,757; median difference $109,027, 95% CI $98,692 to $119,363), respectively. Outpatient care, radiology, medication expenses and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On IPTW-adjusted analyses, patients undergoing trimodal therapy had $129,854 (95% CI $115,793-$145,299) higher costs compared with radical cystectomy one year after diagnosis. Conclusions: Compared to radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. Extrapolating cost figures resulted in nationwide excess spending of $444 million for trimodal therapy compared with radical cystectomy for patients diagnosed in 2017.
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Affiliation(s)
| | - Tamer Dafashy
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Yong Shan
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Hogan K Hudgins
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Usama Jazzar
- University of Texas Medical Branch, Galveston, TX
| | - Douglas S. Tyler
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Todd A. Swanson
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Jim C. Hu
- Weill Cornell Medicine, New York, NY
| | - Sapna Kaul
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Ashish M. Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John L. Gore
- University of Washington Medical Center, Seattle, WA
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Mehta HB, Mehta V, Goodwin JS. Association of Hypoglycemia With Subsequent Dementia in Older Patients With Type 2 Diabetes Mellitus. J Gerontol A Biol Sci Med Sci 2019; 74:750. [PMID: 30947336 DOI: 10.1093/gerona/glz053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - James S Goodwin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston
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Ray-Zack MD, Shan Y, Kerr P, Kosarek CD, Hudgins HK, Jazzar U, Tyler DS, Freedland SJ, Swanson TA, Baillargeon JG, Hu JC, Kaul S, Kamat AM, Gore JL, Mehta HB, Williams SB. Comparing costs of radical cystectomy versus trimodal therapy for patients diagnosed with localized muscle-invasive bladder cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
372 Background: Studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. This study aimed to compare the one-year costs of trimodal therapy versus radical cystectomy, accounting for survival and intensity effects on total costs. Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, we included a total of 2,963 patients aged ≥66 years diagnosed with clinical stage T2-4a bladder cancer between 2002 and 2011. We compared total Medicare costs within one year of diagnosis among patients following radical cystectomy or trimodal therapy using inverse probability of treatment weighted (IPTW) propensity score models, which included a two-part estimator to account for intrinsic selection bias. Results: Median total costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83,754 vs. $68,692; median difference $11,805, 95% CI $7,745 to $15,864), 180 days ($187,162 vs. $109,078; median difference $62,370, 95% CI $55,581 to $69,160), and 365 days ($289,142 vs. $148,757; median difference $109,027, 95% CI $98,692 to $119,363), respectively. Outpatient, radiology, pharmacy and pathology/laboratory costs contributed largely to the significantly higher costs associated with trimodal therapy. On IPTW-adjusted analyses, patients undergoing trimodal therapy had $142,337 (95% CI $117,423-$175,300) higher costs compared with radical cystectomy one year after treatment (Table). Conclusions: Compared to radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. Extrapolating cost figures to the total US population resulted in excess spending of $853 million for trimodal therapy compared with radical cystectomy for patients diagnosed in 2018. [Table: see text]
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Affiliation(s)
| | - Yong Shan
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Preston Kerr
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Hogan K Hudgins
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Usama Jazzar
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Douglas S. Tyler
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Todd A. Swanson
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Jim C. Hu
- Weill Cornell Medicine, New York, NY
| | - Sapna Kaul
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Ashish M. Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John L. Gore
- University of Washington Medical Center, Seattle, WA
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Abstract
Diagnosis-related group (DRG) migration is defined as the reassignment of colectomy patients from DRG 331 to 330 based exclusively on postoperative complications. Strategic and comparative application of this metric has the potential to demonstrate baseline and excessive rates of complications related directly to patient care differences across institutions. The aim of this study was to report the variability of DRG migration across United States hospitals and its impact on overall cost and length of stay (LOS). This study investigated the variability of DRG migration rates across United States hospitals polling 5 per cent of the national Medicare data. The study end-points were total cost, LOS, and DRG migration rate. Hospitals were classified into tertiles for low (0.1–16.6%), moderate (16.7–23.0%), and high (23.1–83.3%) DRG migration rates. The study included 5120 patients from 615 hospitals. DRG migration rates for hospitals ranged from 0.1 per cent to 83.3 per cent, with 157 in the low, 183 in the moderate, and 364 in the high tertile. DRG migration resulted in a progressively increased LOS and hospital costs from the lowest to highest tertile. Several diagnoses were identified which are suggestive of failure to integrate evidence-based processes of care across the tertiles. The data confirm a wide variation in DRG migration rates from DRG 331 to 330 based only on postoperative complications. These ranges allow for the potential definition of both best practice, and opportunities for quality improvement with respect to postoperative complications, identification of hospital outliers, and the economics of care as part of a value-based care program.
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Affiliation(s)
- Byron D. Hughes
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Samantha A. Moore
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | | | - Yong Shan
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
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Ray-Zack MD, Shan Y, Kerr P, Kosarek CD, Hudgins HK, Jazzar U, Kaul S, Kamat AM, Tyler DS, Swanson TA, Mehta HB, Williams SB. Comparing radical cystectomy with trimodal therapy for patients diagnosed with bladder cancer: Critical assessment of statistical methodology and interpretation of observational data. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
373 Background: Treatment guidelines for muscle-invasive bladder cancer recommend radical cystectomy. However, use of trimodal therapy has increased in recent years with conflicting survival outcomes. The aim of this study was to compare radical cystectomy and trimodal therapy in terms of survival outcomes and cost of treatment according to varying statistical methodology in order to interpret findings using observational data. Methods: Patients aged 66 years or older diagnosed with clinical stage T2-4a bladder cancer from January 1, 2002-December 31, 2011 were included from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Outcomes included cancer-specific survival, overall survival, and 6-month costs. Cox proportional hazards regression, propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to control for baseline differences between patients undergoing radical cystectomy vs. trimodal therapy, and to determine predictors for overall and cancer-specific survival. Results: A total of 2,963 patients were included: 728 (24.6%) who underwent trimodal therapy were compared to 2,235 (75.4%) who underwent radical cystectomy. In all adjusted analyses, patients who underwent trimodal therapy had significantly decreased cancer-specific survival (Cox regression: Hazard Ratio (HR) 1.51, 95% Confidence Interval (CI) 1.40-1.63; PSM: HR 1.55, 95% CI 1.32-1.83; IPTW: HR 1.51, 95% CI 1.40-1.63) and overall survival (Cox regression: HR 1.54, 95% CI 1.39-1.71; PSM: HR 1.49, 95% CI 1.31-1.69; IPTW: HR 1.54, 95% CI 1.39-1.71). However, median total costs over six months were significantly higher with trimodal therapy than radical cystectomy ($171,401 vs. $99,890, p<0.001). Conclusions: Trimodal therapy was associated with decreased cancer-specific and overall survival at increased costs compared to radical cystectomy. In the absence of data from randomized controlled trials, this observational study provides further evidence to suggest the superiority of radical cystectomy over trimodal therapy in patients with muscle-invasive bladder cancer.
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Affiliation(s)
| | - Yong Shan
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Preston Kerr
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | | | - Hogan K Hudgins
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Usama Jazzar
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Sapna Kaul
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Ashish M. Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Douglas S. Tyler
- The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Todd A. Swanson
- The University of Texas Medical Branch at Galveston, Galveston, TX
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