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Timmer A, de Sordi D, Kappen S, Kohse KP, Schink T, Perez-Gutthann S, Jacquot E, Deltour N, Pladevall M. Validity of hospital ICD-10-GM codes to identify acute liver injury in Germany. Pharmacoepidemiol Drug Saf 2019; 28:1344-1352. [PMID: 31373108 DOI: 10.1002/pds.4855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 09/28/2018] [Revised: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 01/25/2023]
Abstract
PURPOSE Acute liver injury (ALI) is an important adverse drug reaction. We estimated the positive predictive values (PPVs) of ICD-10-GM codes of ALI used in an international postauthorisation safety study (PASS). METHODS Analyses used routine data (2007 to 2016, adults) from a German academic hospital in a cross-sectional design. Two algorithms from the PASS were applied to extract potential cases from the hospital information system: specific end point (A) (discharge diagnosis of liver disease-specific codes) and less specific end point (B) (discharge and outpatient-specific and nonspecific codes suggestive of liver injury). ALI cases were confirmed on the basis of plasma liver enzyme activity elevation. Secondary analysis was performed following exclusion of cases with known cancer, chronic liver, biliary and pancreatic disease, heart failure, and alcohol-related disorders, as applied in the PASS. RESULTS On the basis of ICD codes: outcome A, 154 cases (143 with case notes and lab data for case verification); outcome B, 485 cases (357 with case notes and lab data). ALI was confirmed in 71 outcome A cases, PPV of 49.7% (95% confidence interval [CI], 41.2%-58.1%), and 100 outcome B cases, PPV of 28.0% (95% CI, 23.4%-33.0%). Applying exclusion criteria increased PPV (95% CI) to 62.7% (50.0%-74.2%) for outcome A and 45.7% (37.2%-54.3%) for outcome B. CONCLUSIONS In safety studies on hepatotoxicity based on routine data using ICD-10-GM discharge codes and when validation of potential cases is not feasible, only the more specific codes should be used to describe ALI, and competing diagnoses for liver injury should be excluded to avoid substantial misclassification.
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Affiliation(s)
- Antje Timmer
- Division of Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Dominik de Sordi
- Division of Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Sanny Kappen
- Division of Epidemiology and Biometry, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Klaus Peter Kohse
- Institute for Laboratory Medicine and Microbiology, Klinikum Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Tania Schink
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | | | | | | | - Manel Pladevall
- Epidemiology, RTI Health Solutions, Barcelona, Spain.,The Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan
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Forns J, Cainzos‐Achirica M, Hellfritzsch M, Morros R, Poblador‐Plou B, Hallas J, Giner‐Soriano M, Prados‐Torres A, Pottegård A, Cortés J, Castellsagué J, Jacquot E, Deltour N, Perez‐Gutthann S, Pladevall M. Validity of ICD-9 and ICD-10 codes used to identify acute liver injury: A study in three European data sources. Pharmacoepidemiol Drug Saf 2019; 28:965-975. [PMID: 31172633 PMCID: PMC6618105 DOI: 10.1002/pds.4803] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 04/04/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
Abstract
Purpose Validating cases of acute liver injury (ALI) in health care data sources is challenging. Previous validation studies reported low positive predictive values (PPVs). Methods Case validation was undertaken in a study conducted from 2009 to 2014 assessing the risk of ALI in antidepressants users in databases in Spain (EpiChron and SIDIAP) and the Danish National Health Registers. Three ALI definitions were evaluated: primary (specific hospital discharge codes), secondary (specific and nonspecific hospital discharge codes), and tertiary (specific and nonspecific hospital and outpatient codes). The validation included review of patient profiles (EpiChron and SIDIAP) and of clinical data from medical records (EpiChron and Denmark). ALI cases were confirmed when liver enzyme values met a definition by an international working group. Results Overall PPVs (95% CIs) for the study ALI definitions were, for the primary ALI definition, 84% (60%‐97%) (EpiChron), 60% (26%‐88%) (SIDIAP), and 74% (60%‐85%) (Denmark); for the secondary ALI definition, 65% (45%‐81%) (EpiChron), 40% (19%‐64%) (SIDIAP), and 70% (64%‐77%) (Denmark); and for the tertiary ALI definition, 25% (18%‐34%) (EpiChron), 8% (7%‐9%) (SIDIAP), and 47% (42%‐52%) (Denmark). The overall PPVs were higher for specific than for nonspecific codes and for hospital discharge than for outpatient codes. The nonspecific code “unspecified jaundice” had high PPVs in Denmark. Conclusions PPVs obtained apply to patients using antidepressants without preexisting liver disease or ALI risk factors. To maximize validity, studies on ALI should prioritize hospital specific discharge codes and should include hospital codes for unspecified jaundice. Case validation is required when ALI outpatient cases are considered.
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Affiliation(s)
- Joan Forns
- EpidemiologyRTI Health SolutionsBarcelonaSpain
| | | | - Maja Hellfritzsch
- Clinical Pharmacology and Pharmacy, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Rosa Morros
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol)BarcelonaSpain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès)BarcelonaSpain
- Institut Català de la SalutBarcelonaSpain
| | - Beatriz Poblador‐Plou
- EpiChron Research Group. Aragon Health Sciences Institute (IACS), IIS Aragón, REDISSEC ISCIIIZaragozaSpain
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Maria Giner‐Soriano
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol)BarcelonaSpain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès)BarcelonaSpain
- Institut Català de la SalutBarcelonaSpain
| | - Alexandra Prados‐Torres
- EpiChron Research Group. Aragon Health Sciences Institute (IACS), IIS Aragón, REDISSEC ISCIIIZaragozaSpain
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Jordi Cortés
- Departament d'Estadística i Investigació OperativaUniversitat Politècnica de CatalunyaBarcelonaSpain
| | | | | | - Nicolas Deltour
- Pharmacoepidemiology DepartmentLes Laboratoires ServierParisFrance
| | | | - Manel Pladevall
- EpidemiologyRTI Health SolutionsBarcelonaSpain
- The Center for Health Policy and Health Services Research, Henry Ford Health SystemDetroitMIUSA
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3
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Forns J, Pottegård A, Reinders T, Poblador-Plou B, Morros R, Brandt L, Cainzos-Achirica M, Hellfritzsch M, Schink T, Prados-Torres A, Giner-Soriano M, Hägg D, Hallas J, Cortés J, Jacquot E, Deltour N, Perez-Gutthann S, Pladevall M, Reutfors J. Antidepressant use in Denmark, Germany, Spain, and Sweden between 2009 and 2014: Incidence and comorbidities of antidepressant initiators. J Affect Disord 2019; 249:242-252. [PMID: 30780117 DOI: 10.1016/j.jad.2019.02.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/18/2019] [Accepted: 02/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND We aimed to describe patterns of use and characteristics of 10 commonly used antidepressants for the period 2009-2014 in Denmark, Germany, Spain, and Sweden. METHODS Adult initiators from 2009 to 2014 of each study antidepressant were identified in four countries using five data sources: the Danish National registers, GePaRD (Germany), EpiChron (Aragon, Spain), SIDIAP (Catalonia, Spain), and the Swedish National Registers. The study included 10 study antidepressants: citalopram, escitalopram, fluoxetine, paroxetine, sertraline, duloxetine, venlafaxine, amitriptyline, mirtazapine, and agomelatine. RESULTS Citalopram was the most prescribed study antidepressant, followed by mirtazapine. Paroxetine and agomelatine were the least prescribed antidepressants. Mirtazapine was widely used among older antidepressant initiators with higher percentages of comorbidities at baseline, and fluoxetine was used among young patients. Citalopram and amitriptyline had the lowest percentage of multiple antidepressant use in the 12 months prior to the current treatment episode, while agomelatine, duloxetine, and venlafaxine had the highest percentage of multiple antidepressant use in the year prior to the current treatment episode. LIMITATIONS The most important limitations are exposure information based on filled prescriptions, focus on antidepressant initiators only, lack of information on the indication, and heterogeneity of the type of data across data sources. CONCLUSIONS Results of this study including 4.8 million study antidepressant initiators of study antidepressants suggest that citalopram and mirtazapine are the most commonly prescribed antidepressants. Agomelatine and paroxetine were the least used antidepressants in the participating populations. Mirtazapine was the antidepressant most commonly prescribed among older antidepressant initiators with high percentage of comorbidities at baseline, whereas fluoxetine was commonly used among young patients.
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Affiliation(s)
- Joan Forns
- Epidemiology, RTI Health Solutions, Barcelona, Spain.
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Tammo Reinders
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Beatriz Poblador-Plou
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragón, REDISSEC ISCIII, Miguel Servet University Hospital, Zaragoza, Spain
| | - Rosa Morros
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; Institut Català de la Salut, Barcelona, Spain
| | - Lena Brandt
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Maja Hellfritzsch
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Alexandra Prados-Torres
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), IIS Aragón, REDISSEC ISCIII, Miguel Servet University Hospital, Zaragoza, Spain
| | - Maria Giner-Soriano
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; Institut Català de la Salut, Barcelona, Spain
| | - David Hägg
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jordi Cortés
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; Institut Català de la Salut, Barcelona, Spain; Universitat Politècnica de Catalunya, Departament d'Estadística i Investigació Operativa, Barcelona, Spain
| | - Emmanuelle Jacquot
- Pharmacoepidemiology Department, Les Laboratoires Servier, Suresnes, France
| | - Nicolas Deltour
- Pharmacoepidemiology Department, Les Laboratoires Servier, Suresnes, France
| | | | | | - Johan Reutfors
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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4
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Pladevall M, Riera-Guardia N, Margulis AV, Varas-Lorenzo C, Calingaert B, Perez-Gutthann S. Cardiovascular risk associated with the use of glitazones, metformin and sufonylureas: meta-analysis of published observational studies. BMC Cardiovasc Disord 2016; 16:14. [PMID: 26769243 PMCID: PMC4714432 DOI: 10.1186/s12872-016-0187-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 09/03/2015] [Accepted: 01/08/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The results of observational studies evaluating and comparing the cardiovascular safety of glitazones, metformin and sufonylureas are inconsistent.To conduct and evaluate heterogeneity in a meta-analysis of observational studies on the risk of acute myocardial infarction (AMI) or stroke in patients with type 2 diabetes using non-insulin blood glucose-lowering drugs (NIBGLD). METHODS We systematically identified and reviewed studies evaluating NIBGLD in patients with type 2 diabetes indexed in Medline, Embase, or the Cochrane Library that met prespecified criteria. The quality of included studies was assessed with the RTI item bank. Results were combined using fixed- and random-effects models, and the Higgins I(2) statistic was used to evaluate heterogeneity. Sensitivity analyses by study quality were conducted. RESULTS The summary relative risk (sRR) (95% CI) of AMI for rosiglitazone versus pioglitazone was 1.13 (1.04-1.24) [I(2) = 55%]. In the sensitivity analysis, heterogeneity was reduced [I(2) = 16%]. The sRR (95% CI) of stroke for rosiglitazone versus pioglitazone was 1.18 (1.02-1.36) [I(2) = 42%]. There was strong evidence of heterogeneity related to study quality in the comparisons of rosiglitazone versus metformin and rosiglitazone versus sulfonylureas (I (2) ≥ 70%). The sRR (95% CI) of AMI for sulfonylurea versus metformin was 1.24 (1.14-1.34) [I(2) = 41%] and for pioglitazone versus metformin was 1.02 (0.75-1.38) [I(2) = 17%]. Sensitivity analyses decreased heterogeneity in most comparisons. CONCLUSION/INTERPRETATION Sulfonylureas increased the risk of AMI by 24% compared with metformin; an imprecise point estimate indicated no difference in risk of AMI when comparing pioglitazone with metformin. The presence of heterogeneity precluded any conclusions on the other comparisons. The quality assessment was valuable in identifying methodological problems in the individual studies and for analysing potential sources of heterogeneity.
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Affiliation(s)
- Manel Pladevall
- RTI Health Solutions, Trav. Gracia 56 Atico 1 08006, Barcelona, Spain. .,The Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA.
| | | | - Andrea V Margulis
- RTI Health Solutions, Trav. Gracia 56 Atico 1 08006, Barcelona, Spain.
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5
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Pladevall M, Divine G, Wells KE, Resnicow K, Williams LK. A randomized controlled trial to provide adherence information and motivational interviewing to improve diabetes and lipid control. Diabetes Educ 2014; 41:136-46. [PMID: 25486932 DOI: 10.1177/0145721714561031] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study was to assess whether providing medication adherence information with or without motivational interviewing improves diabetes and lipid control. METHODS Study participants were adult members of a health system in southeast Michigan, were using both oral diabetes and lipid-lowering medications, and had glycated hemoglobin (A1C) or low-density lipoprotein cholesterol (LDL-C) levels not at goal. Participants were randomly assigned to receive usual care (UC), n = 567; have medication adherence information (AI) provided to their physician, n = 569; or have AI and receive motivational interviewing (MI) though trained staff (AI + MI), n = 556. Primary outcomes were A1C and LDL-C levels at 18 months post randomization. RESULTS Primary outcomes were not significantly different between patients in the AI or AI + MI study arms when compared with UC. Similarly, neither oral diabetes nor lipid-lowering medication adherence was significantly different between groups. Patient participation in the AI + MI arm was low and limit the interpretation of the study results, but post hoc analysis of the AI + MI study arm showed that the number of MI sessions received was positively associated with only oral diabetes medication adherence. CONCLUSION Neither AI nor MI significantly improved diabetes and lipid control when compared with UC. Moreover, patient participation appeared to be a particular barrier for MI.
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Affiliation(s)
- Manel Pladevall
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan (Dr Pladevall, Dr Williams),Research Triangle Institute Health Solutions, Barcelona, Spain (Dr Pladevall)
| | - George Divine
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan (Dr Divine, Ms Wells)
| | - Karen E Wells
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan (Dr Divine, Ms Wells)
| | - Ken Resnicow
- Center for Health Communications Research, University of Michigan, Ann Arbor, Michigan (Dr Resnicow)
| | - L Keoki Williams
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan (Dr Pladevall, Dr Williams),Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan (Dr Williams)
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6
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Margulis AV, Pladevall M, Riera-Guardia N, Varas-Lorenzo C, Hazell L, Berkman ND, Viswanathan M, Perez-Gutthann S. Quality assessment of observational studies in a drug-safety systematic review, comparison of two tools: the Newcastle-Ottawa Scale and the RTI item bank. Clin Epidemiol 2014; 6:359-68. [PMID: 25336990 PMCID: PMC4199858 DOI: 10.2147/clep.s66677] [Citation(s) in RCA: 301] [Impact Index Per Article: 30.1] [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] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The study objective was to compare the Newcastle-Ottawa Scale (NOS) and the RTI item bank (RTI-IB) and estimate interrater agreement using the RTI-IB within a systematic review on the cardiovascular safety of glucose-lowering drugs. METHODS We tailored both tools and added four questions to the RTI-IB. Two reviewers assessed the quality of the 44 included studies with both tools, (independently for the RTI-IB) and agreed on which responses conveyed low, unclear, or high risk of bias. For each question in the RTI-IB (n=31), the observed interrater agreement was calculated as the percentage of studies given the same bias assessment by both reviewers; chance-adjusted interrater agreement was estimated with the first-order agreement coefficient (AC1) statistic. RESULTS The NOS required less tailoring and was easier to use than the RTI-IB, but the RTI-IB produced a more thorough assessment. The RTI-IB includes most of the domains measured in the NOS. Median observed interrater agreement for the RTI-IB was 75% (25th percentile [p25] =61%; p75 =89%); median AC1 statistic was 0.64 (p25 =0.51; p75 =0.86). CONCLUSION The RTI-IB facilitates a more complete quality assessment than the NOS but is more burdensome. The observed agreement and AC1 statistic in this study were higher than those reported by the RTI-IB's developers.
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Affiliation(s)
| | | | | | | | - Lorna Hazell
- Drug Safety Research Unit, Southampton, UK
- Associate Department of the School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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7
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Hayek S, Canepa Escaro F, Sattar A, Gamalski S, Wells KE, Divine G, Ahmedani BK, Lanfear DE, Pladevall M, Williams LK. Effect of ezetimibe on major atherosclerotic disease events and all-cause mortality. Am J Cardiol 2013; 111:532-9. [PMID: 23219178 DOI: 10.1016/j.amjcard.2012.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/01/2012] [Accepted: 11/01/2012] [Indexed: 10/27/2022]
Abstract
Despite ezetimibe's ability to reduce serum cholesterol levels, there are concerns over its vascular effects and whether it prevents or ameliorates atherosclerotic disease (AD). The aims of this study were to estimate the effect of ezetimibe use on major AD events and all-cause mortality and to compare these associations to those observed for hydroxymethylglutaryl coenzyme A reductase inhibitor (statin) use. A total of 367 new ezetimibe users were identified from November 1, 2002, to December 31, 2009. These subjects were aged ≥18 years and had no previous statin use. One to 4 statin user matches were identified for each ezetimibe user, resulting in a total of 1,238 closely matched statin users. Pharmacy data and drug dosage information were used to estimate a moving window of ezetimibe and statin exposure for each day of study follow-up. The primary outcome was a composite of major AD events (coronary heart disease, cerebrovascular disease, and peripheral vascular disease events) and all-cause death. Ezetimibe use (odds ratio 0.33, 95% confidence interval 0.13 to 0.86) and statin use (odds ratio 0.61, 95% confidence interval 0.36 to 1.04) were associated with reductions in the likelihood of the composite outcome. These protective associations were most significant for cerebrovascular disease events and all-cause death. Subgroup analyses by gender, race or ethnicity, history of AD, diabetes status, and estimated renal function showed consistent estimates across strata, with no significant differences between ezetimibe and statin use. In conclusion, ezetimibe appeared to have a protective effect on major AD events and all-cause death that was not significantly different from that observed for statin use.
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8
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Saffar D, Williams K, Lafata JE, Divine G, Pladevall M. Racial disparities in lipid control in patients with diabetes. Am J Manag Care 2012; 18:303-311. [PMID: 22774998 PMCID: PMC3766626] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To describe lipid management over time in a cohort of insured patients with diabetes and evaluate differences between African American and white patients. STUDY DESIGN Automated claims data were used to identify a cohort of 11,411 patients with diabetes in 1997 to 1998. Patients were followed through 2007. METHODS Rates of hypercholesterolemia testing, treatment, and goal attainment were measured annually. Treatment was determined by a claim for lipid-lowering agents, and goal attainment was defined as a low-density lipoprotein cholesterol (LDL-C) level <100 mg/dL. RESULTS During the study period, LDL-C testing increased from 48% to 70% among African American patients and from 61% to 77% among white patients. Treatment with lipid-lowering drugs increased from 23% to 56% among African American patients and 33% to 61% among white patients. The proportion at goal increased from 35% to 76% and from 24% to 59% among white and African American patients, respectively. African American patients were less likely to be tested for LDL-C (odds ratio [OR] 0.79; 95% confidence interval [CI] 0.73-0.86), treated with lipidlowering agents (OR 0.72; 95% CI 0.65-0.80), have their medication dosage altered (OR 0.65; 95% CI 0.59-0.73), or attain LDL-C goal (OR 0.59; 95% CI 0.56-0.63) compared with white patients. CONCLUSIONS Although rates of LDL-C testing, treatment, and goal attainment improved over time, racial disparities in dyslipidemia management continued to exist. Further studies to determine the causes of differences in management by race are warranted.
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Affiliation(s)
- Darcy Saffar
- Institute on Multicultural Health, Henry Ford Health System, Detroit, MI, USA.
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9
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Williams LK, Peterson EL, Wells K, Ahmedani BK, Kumar R, Burchard EG, Chowdhry VK, Favro D, Lanfear DE, Pladevall M. Quantifying the proportion of severe asthma exacerbations attributable to inhaled corticosteroid nonadherence. J Allergy Clin Immunol 2011; 128:1185-1191.e2. [PMID: 22019090 DOI: 10.1016/j.jaci.2011.09.011] [Citation(s) in RCA: 213] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 09/12/2011] [Accepted: 09/16/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND Asthma is an inflammatory condition often punctuated by episodic symptomatic worsening, and accordingly, patients with asthma might have waxing and waning adherence to controller therapy. OBJECTIVE We sought to measure changes in inhaled corticosteroid (ICS) adherence over time and to estimate the effect of this changing pattern of use on asthma exacerbations. METHODS ICS adherence was estimated from electronic prescription and fill information for 298 participants in the Study of Asthma Phenotypes and Pharmacogenomic Interactions by Race-Ethnicity. For each patient, we calculated a moving average of ICS adherence for each day of follow-up. Asthma exacerbations were defined as the need for oral corticosteroids, an asthma-related emergency department visit, or an asthma-related hospitalization. Proportional hazard models were used to assess the relationship between ICS medication adherence and asthma exacerbations. RESULTS Adherence to ICS medications began to increase before the first asthma exacerbation and continued afterward. Adherence was associated with a reduction in exacerbations but was only statistically significant among patients whose adherence was greater than 75% of the prescribed dose (hazard ratio, 0.61; 95% CI, 0.41-0.90) when compared with patients whose adherence was 25% or less. This pattern was largely confined to patients whose asthma was not well controlled initially. An estimated 24% of asthma exacerbations were attributable to ICS medication nonadherence. CONCLUSIONS ICS adherence varies in the time period leading up to and after an asthma exacerbation, and nonadherence likely contributes to a large number of these exacerbations. High levels of adherence are likely required to prevent these events.
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Affiliation(s)
- L Keoki Williams
- Center for Health Services Research, Henry Ford Health System, Detroit, MI 48202, USA.
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10
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Pladevall M, Brotons C, Gabriel R, Arnau A, Suarez C, de la Figuera M, Marquez E, Coca A, Sobrino J, Divine G, Heisler M, Williams LK. Multicenter cluster-randomized trial of a multifactorial intervention to improve antihypertensive medication adherence and blood pressure control among patients at high cardiovascular risk (the COM99 study). Circulation 2010; 122:1183-91. [PMID: 20823391 DOI: 10.1161/circulationaha.109.892778] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [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: 11/16/2022]
Abstract
BACKGROUND Medication nonadherence is common and results in preventable disease complications. This study assessed the effectiveness of a multifactorial intervention to improve both medication adherence and blood pressure control and to reduce cardiovascular events. METHODS AND RESULTS In this multicenter, cluster-randomized trial, physicians from hospital-based hypertension clinics and primary care centers across Spain were randomized to receive and provide the intervention to their high-risk patients. Eligible patients were ≥ 50 years of age, had uncontrolled hypertension, and had an estimated 10-year cardiovascular risk greater than 30%. Physicians randomized to the intervention group counted patients' pills, designated a family member to support adherence behavior, and provided educational information to patients. The primary outcome was blood pressure control at 6 months. Secondary outcomes included both medication adherence and a composite end point of all-cause mortality and cardiovascular-related hospitalizations. Seventy-nine physicians and 877 patients participated in the trial. The mean duration of follow-up was 39 months. Intervention patients were less likely to have an uncontrolled systolic blood pressure (odds ratio 0.62, 95% confidence interval 0.50 to 0.78) and were more likely to be adherent (odds ratio 1.91, 95% confidence interval 1.19 to 3.05) than control group patients at 6 months. After 5 years, 16% of the patients in the intervention group and 19% in the control group met the composite end point (hazard ratio 0.97, 95% confidence interval 0.67 to 1.39). CONCLUSIONS A multifactorial intervention to improve adherence to antihypertensive medication was effective in improving both adherence and blood pressure control, but it did not appear to improve long-term cardiovascular events.
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Affiliation(s)
- Manel Pladevall
- Center for Health Services Research, Henry Ford Hospital, One Ford Place 3A, Detroit, MI, USA.
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Williams LK, Peterson EL, Wells K, Campbell J, Wang M, Chowdhry VK, Walsh M, Enberg R, Lanfear DE, Pladevall M. A cluster-randomized trial to provide clinicians inhaled corticosteroid adherence information for their patients with asthma. J Allergy Clin Immunol 2010; 126:225-31, 231.e1-4. [PMID: 20569973 DOI: 10.1016/j.jaci.2010.03.034] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 03/15/2010] [Accepted: 03/31/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inhaled corticosteroid (ICS) nonadherence is common among patients with asthma; however, interventions to improve adherence have often been complex and not easily applied to large patient populations. OBJECTIVE To assess the effect of supplying patient adherence information to primary care providers. METHODS Patients and providers were members of a health system serving southeast Michigan. Providers (88 intervention; 105 control) and patients (1335 intervention; 1363 control) were randomized together by practice. Patients were age 5 to 56 years, had a diagnosis of asthma, and had existing prescriptions for ICS medication. Adherence was estimated by using prescription and fill data. Unlike clinicians in the control arm, intervention arm providers could view updated ICS adherence information on their patients via electronic prescription software, and further details on patient ICS use could be viewed by selecting that option. The primary outcome was ICS adherence in last 3 months of the study period. RESULTS At the study end for the intention-to-treat analysis, ICS adherence was not different among patients in the intervention arm compared with those in the control arm (21.3% vs 23.3%, respectively; P = .553). However, adherence was significantly higher among patients whose clinician elected to view their detailed adherence information (35.7%) compared with both control arm patients (P = .026) and intervention arm patients whose provider did not view adherence data (P = .002). CONCLUSIONS Overall, providing adherence information to clinicians did not improve ICS use among patients with asthma. However, patient use may improve when clinicians are sufficiently interested in adherence to view the details of this medication use.
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Affiliation(s)
- L Keoki Williams
- Center for Health Services Research, Henry Ford Health System, Detroit, MI 48202, USA.
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Habib ZA, Havstad SL, Wells K, Divine G, Pladevall M, Williams LK. Thiazolidinedione use and the longitudinal risk of fractures in patients with type 2 diabetes mellitus. J Clin Endocrinol Metab 2010; 95:592-600. [PMID: 20061432 PMCID: PMC2840855 DOI: 10.1210/jc.2009-1385] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [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: 06/30/2009] [Accepted: 11/25/2009] [Indexed: 12/13/2022]
Abstract
CONTEXT Thiazolidinedione (TZD) use has recently been associated with an increased risk of fractures. OBJECTIVE The aim of this study was to determine the time-dependent relationship between TZD use and fracture risk. DESIGN We conducted a retrospective cohort study in a large health system in southeast Michigan. PATIENTS PATIENTS who received care from the health system were included if they were at least 18 yr of age, had a diagnosis of diabetes, and had at least one prescription for an oral diabetes medication. These criteria identified 19,070 individuals (9,620 women and 9,450 men). INTERVENTION This study compared patients treated with TZDs to patients without TZD treatment. Cox proportional hazard models were used to assess the relationship between exposure and outcomes. MAIN OUTCOME MEASURES The primary outcome was the time to fracture. Secondary analyses examined the risk of fractures in subgroups defined by sex and age. RESULTS TZD use was associated with an increased risk of fracture in the cohort overall [adjusted hazard ratio (aHR), 1.35; 95% confidence interval (CI), 1.05-1.71] and in women (aHR, 1.57; 95% CI, 1.16-2.14), but not in men (aHR, 1.05; 95% CI, 0.70-1.58). Women more than 65 yr of age appeared to be at greatest risk for fracture (aHR, 1.72; 95% CI, 1.17-2.52). Among women, the increased fracture risk was not apparent until after 1 yr of TZD treatment. CONCLUSIONS TZD use was associated with an increased risk for fractures in women, particularly at ages above 65 yr. Clinicians should be aware of this association when considering TZD therapy so as to appropriately manage and counsel their patients.
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Affiliation(s)
- Zeina A Habib
- Center for Health Services Research, Henry Ford Health System, 1 Ford Place, 3A Center for Health Services Research, Detroit, Michigan 48202, USA
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Cerghet M, Dobie E, Lafata JE, Schultz L, Elias S, Pladevall M, Reuther J. Adherence to Disease-Modifying Agents and Association with Quality of Life Among Patients with Relapsing-Remitting Multiple Sclerosis. Int J MS Care 2010. [DOI: 10.7224/1537-2073-12.2.51] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study was conducted to evaluate the association of adherence to disease-modifying agents (DMAs) and outcomes among multiple sclerosis (MS) patients in a practice setting. The study had a cross-sectional design. A survey was administered to 214 patients with relapsing-remitting multiple sclerosis (RRMS) to measure quality of life, health status, disability, and employment. Measures of health-care costs and adherence to DMAs were constructed using claims data. The relationship between DMA adherence and outcomes was evaluated using generalized estimating equation methods, adjusting for patient sociodemographic characteristics, comorbidities, medication on hand at the time of the survey, insurance status, prescription copay, and duration of disease. A total of 163 patients (76%) responded to the survey, of whom 111 had been dispensed a DMA. Mean adherence in the 12-month period preceding the survey was 78.1%. Patients with higher adherence had better mental health and pain interference scores. Increasing adherence was also associated with a greater likelihood of employment and lower Expanded Disability Status Scale score. These findings illustrate the potential for improved outcomes among RRMS patients who adhere to DMA regimens and highlight the importance of considering medication adherence when evaluating DMA use and outcomes in practice.
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Habib ZA, Tzogias L, Havstad SL, Wells K, Divine G, Lanfear DE, Tang J, Krajenta R, Pladevall M, Williams LK. Relationship between thiazolidinedione use and cardiovascular outcomes and all-cause mortality among patients with diabetes: a time-updated propensity analysis. Pharmacoepidemiol Drug Saf 2009; 18:437-47. [PMID: 19235778 DOI: 10.1002/pds.1722] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE To investigate the association of the thiazolidinediones (TZDs), rosiglitazone, and pioglitazone, together and individually on the risk of cardiovascular outcomes and all-cause mortality, using time-updated propensity score adjusted analysis. METHODS We conducted a retrospective cohort study in a large vertically integrated health system in southeast Michigan. Cohort inclusion criteria included adult patients with diabetes treated with oral medications and followed longitudinally within the health system between 1 January 2000 and 1 December 2006. The primary outcome was fatal and non-fatal acute myocardial infarction (AMI). Secondary outcomes included hospitalizations for congestive heart failure (CHF), fatal, and non-fatal cerebrovascular accidents (CVA) and transient ischemic attacks (TIA), combined coronary heart disease (CHD) events, and all-cause mortality. RESULTS 19,171 patients were included in this study. Use of TZDs (adjusted hazard ratio (aHR) with propensity adjustment (PA), 0.92; 95% confidence interval (CI) 0.73-1.17), rosiglitazone (aHR with PA, 1.06; 95%CI 0.66-1.70), and pioglitazone (aHR with PA, 0.91; 95%CI 0.69-1.21) was not associated with a higher risk of AMI. However, pioglitazone use was associated with a reduction in all-cause mortality (aHR with PA, 0.60; 95%CI 0.42-0.96). Compared with rosiglitazone, pioglitazone use was associated with a lower risk of all outcomes assessed, particularly CHF (p = 0.013) and combined CHD events (p = 0.048). CONCLUSIONS Our findings suggest that pioglitazone may have a more favorable risk profile when compared to rosiglitazone, arguing against a singular effect for TZDs on cardiovascular outcomes.
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Affiliation(s)
- Zeina A Habib
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
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Williams GC, Patrick H, Niemiec CP, Williams LK, Divine G, Lafata JE, Heisler M, Tunceli K, Pladevall M. Reducing the health risks of diabetes: how self-determination theory may help improve medication adherence and quality of life. Diabetes Educ 2009; 35:484-92. [PMID: 19325022 DOI: 10.1177/0145721709333856] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study is to apply the self-determination theory (SDT) model of health behavior to predict medication adherence, quality of life, and physiological outcomes among patients with diabetes. METHODS Patients with diabetes (N = 2973) receiving care from an integrated health care delivery system in 2003 and 2004 were identified from automated databases and invited to participate in this study. In 2005, patients responded to a mixed telephone-and-mail survey assessing perceived autonomy support from health care providers, autonomous self-regulation for medication use, perceived competence for diabetes self-management, medication adherence, and quality of life. In 2006, pharmacy claims data were used to indicate medication adherence, and patients' non-high-density lipoprotein (HDL) cholesterol, A1C, and glucose levels were assessed. RESULTS The SDT model of health behavior provided adequate fit to the data. As hypothesized, perceived autonomy support from health care providers related positively to autonomous self-regulation for medication use, which in turn related positively to perceived competence for diabetes self-management. Perceived competence then related positively to quality of life and medication adherence, and the latter construct related negatively to non-HDL cholesterol, A1C, and glucose levels. CONCLUSIONS Health care providers' support for patients' autonomy and competence around medication use and diabetes self-management related positively to medication adherence, quality of life, and physiological outcomes among patients with diabetes.
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Affiliation(s)
- Geoffrey C Williams
- The University of Rochester, Rochester, New York (Dr G. C. Williams, Dr Patrick, Mr Niemiec)
| | - Heather Patrick
- The University of Rochester, Rochester, New York (Dr G. C. Williams, Dr Patrick, Mr Niemiec)
| | - Christopher P Niemiec
- The University of Rochester, Rochester, New York (Dr G. C. Williams, Dr Patrick, Mr Niemiec)
| | - L Keoki Williams
- Henry Ford Hospital, Detroit, Michigan (Dr L. K. Williams, Dr Divine, Dr Lafata, Dr Tunceli, Dr Pladevall)
| | - George Divine
- Henry Ford Hospital, Detroit, Michigan (Dr L. K. Williams, Dr Divine, Dr Lafata, Dr Tunceli, Dr Pladevall)
| | - Jennifer Elston Lafata
- Henry Ford Hospital, Detroit, Michigan (Dr L. K. Williams, Dr Divine, Dr Lafata, Dr Tunceli, Dr Pladevall)
| | - Michele Heisler
- Veterans Affairs Center for Clinical Practice Management Research, Ann Arbor Health System, Ann Arbor, Michigan (Dr Heisler)
- Department of Internal Medicine, University of Michigan, Ann Arbor (Dr Heisler)
- Diabetes Research and Training Center, Ann Arbor, Michigan (Dr Heisler)
| | - Kaan Tunceli
- Henry Ford Hospital, Detroit, Michigan (Dr L. K. Williams, Dr Divine, Dr Lafata, Dr Tunceli, Dr Pladevall)
| | - Manel Pladevall
- Henry Ford Hospital, Detroit, Michigan (Dr L. K. Williams, Dr Divine, Dr Lafata, Dr Tunceli, Dr Pladevall)
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Wells K, Pladevall M, Peterson E, et al.. Race-Ethnic Differences in Factors Associated with Inhaled Steroid Adherence Among Adults with Asthma. J Asthma 2009. [DOI: 10.1080/02770900902720825] [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: 10/20/2022]
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Wells K, Pladevall M, Peterson EL, Campbell J, Wang M, Lanfear DE, Williams LK. Race-ethnic differences in factors associated with inhaled steroid adherence among adults with asthma. Am J Respir Crit Care Med 2008; 178:1194-201. [PMID: 18849496 DOI: 10.1164/rccm.200808-1233oc] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Adherence to inhaled corticosteroid (ICS) medication is known to be low overall, but tends to be lower among African-American patients when compared with white patients. OBJECTIVES To understand the factors that contribute to ICS adherence among African-American and white adults with asthma. METHODS Eligible individuals had a prior diagnosis of asthma, one or more ICS prescriptions, and were members of a large health maintenance organization in southeast Michigan. Individuals were sent a survey that included questions about internal factors (e.g., patient beliefs, knowledge, and motivation) and external factors (e.g., socioeconomic status, barriers to care, social support, and stressors) potentially related to ICS adherence. Adherence was calculated using electronic prescription and fill data. Stepwise regression was used to identify factors associated with adherence before and after stratifying by race-ethnicity. MEASUREMENTS AND MAIN RESULTS Surveys were returned by 1,006 (56.3%) of 1,787 eligible patients. Adjusting for internal factors, but not external factors, diminished the relationship between race-ethnicity and ICS adherence. Among African-American patients, readiness to take ICS medication was the only internal or external factor significantly associated with ICS adherence; it explained 5.6% of the variance in adherence. Among white patients, perceived ICS necessity, ICS knowledge, doctors being perceived as the source of asthma control, and readiness to take medication were the internal factors associated with ICS adherence; these accounted for 19.8% of the variance in adherence. CONCLUSIONS Factors associated with ICS adherence appear to differ between African-American and white patients, suggesting that group-specific approaches are needed to improve adherence.
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Affiliation(s)
- Karen Wells
- Department of Biostatistics and Research Epidemiology, Henry Ford Hospital, Detroit, MI 48202, USA
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Simpkins J, Divine G, Wang M, Holmboe E, Pladevall M, Williams LK. Improving asthma care through recertification: a cluster randomized trial. ACTA ACUST UNITED AC 2007; 167:2240-8. [PMID: 17998498 DOI: 10.1001/archinte.167.20.2240] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND As part of recertification, the American Board of Internal Medicine requires its diplomats to complete at least 1 practice improvement module (PIM). We assessed whether completing an asthma-specific PIM resulted in improved patient outcomes. METHODS Practices were the unit of randomization in this cluster randomized trial. Physicians in the intervention group were asked to complete the PIM through its planning phase. The primary outcome was the dispensing of an inhaled corticosteroid (ICS) after a postintervention visit for asthma. Secondary outcomes included patient reported processes of care, asthma-related heath care use, and asthma severity. Analyses were adjusted for baseline rates at the cluster-level as well as for individual sociodemographic characteristics. RESULTS Eight practices (19 internists) were randomized to the intervention group and 8 practices (21 internists) to the control group. For the primary outcome, ICS fill rates, patients seen by intervention group physicians were not more likely to fill an ICS prescription in the postintervention period than patients seen by control group physicians (adjusted odd ratio [AOR], 1.00; 95% confidence interval [CI], 0.64-1.56). Patients seen for asthma by intervention group physicians were less likely to receive a written action plan than patients seen by control group physicians (AOR, 0.67; 95% CI, 0.48-0.93); however, they were more likely to discuss potential asthma triggers (AOR, 1.62; 95% CI, 1.08-2.42) and had lower self-reported asthma severity measures (unadjusted P = .03). Per-protocol analysis supported the latter 2 associations. CONCLUSION A PIM designed to improve asthma care did not improve filling of ICS prescriptions but may have lessened asthma severity through an increased discussion of asthma triggers.
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Affiliation(s)
- Jan Simpkins
- Center for Health Services Research, Henry Ford Hospital, One Ford Place, Detroit, MI 48202, USA
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Williams LK, Joseph CL, Peterson EL, Wells K, Wang M, Chowdhry VK, Walsh M, Campbell J, Rand CS, Apter AJ, Lanfear DE, Tunceli K, Pladevall M. Patients with asthma who do not fill their inhaled corticosteroids: a study of primary nonadherence. J Allergy Clin Immunol 2007; 120:1153-1159. [PMID: 17936894 DOI: 10.1378/chest.130.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 08/08/2007] [Accepted: 08/10/2007] [Indexed: 05/22/2023]
Abstract
BACKGROUND Adherence to inhaled corticosteroids (ICSs) is known to be poor among patients with asthma; however, little is known about patients who do not fill their ICS prescriptions (ie, primary nonadherence). OBJECTIVE To estimate rates of primary nonadherence and to explore associated factors. METHODS The study population was members of a large health maintenance organization in southeast Michigan who met the following criteria: age 5 to 56 years; previous diagnosis of asthma; at least 1 electronic prescription for an ICS between February 17, 2005, and June 1, 2006; and at least 3 months follow-up after the ICS prescription. Adherence was estimated by using electronic prescription information and pharmacy claims data. Multivariable stepwise analysis was used to identify factors associated with primary nonadherence compared with adherent patients. RESULTS One thousand sixty-four patients met the study criteria and had calculable adherence. Of these patients, 82 (8%) never filled their ICS prescription. Stepwise regression identified the following factors to be associated with an increased likelihood of primary nonadherence: younger age, female sex, African American race-ethnicity, and lower rescue medication use. Factors associated with primary nonadherence differed between race-ethnic groups. CONCLUSION Primary nonadherence was associated with lower baseline rescue medication use, which may reflect lower perceived need for ICS therapy in patients with milder asthma. Rates of primary nonadherence and the factors which influenced this outcome differed by race-ethnicity. CLINICAL IMPLICATIONS Understanding patient characteristics associated with primary nonadherence may be important for disease management, because many patients with asthma do not fill their ICS prescriptions.
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Affiliation(s)
- L Keoki Williams
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA.
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Williams LK, Joseph CL, Peterson EL, Wells K, Wang M, Chowdhry VK, Walsh M, Campbell J, Rand CS, Apter AJ, Lanfear DE, Tunceli K, Pladevall M. Patients with asthma who do not fill their inhaled corticosteroids: a study of primary nonadherence. J Allergy Clin Immunol 2007; 120:1153-9. [PMID: 17936894 DOI: 10.1016/j.jaci.2007.08.020] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 08/08/2007] [Accepted: 08/10/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adherence to inhaled corticosteroids (ICSs) is known to be poor among patients with asthma; however, little is known about patients who do not fill their ICS prescriptions (ie, primary nonadherence). OBJECTIVE To estimate rates of primary nonadherence and to explore associated factors. METHODS The study population was members of a large health maintenance organization in southeast Michigan who met the following criteria: age 5 to 56 years; previous diagnosis of asthma; at least 1 electronic prescription for an ICS between February 17, 2005, and June 1, 2006; and at least 3 months follow-up after the ICS prescription. Adherence was estimated by using electronic prescription information and pharmacy claims data. Multivariable stepwise analysis was used to identify factors associated with primary nonadherence compared with adherent patients. RESULTS One thousand sixty-four patients met the study criteria and had calculable adherence. Of these patients, 82 (8%) never filled their ICS prescription. Stepwise regression identified the following factors to be associated with an increased likelihood of primary nonadherence: younger age, female sex, African American race-ethnicity, and lower rescue medication use. Factors associated with primary nonadherence differed between race-ethnic groups. CONCLUSION Primary nonadherence was associated with lower baseline rescue medication use, which may reflect lower perceived need for ICS therapy in patients with milder asthma. Rates of primary nonadherence and the factors which influenced this outcome differed by race-ethnicity. CLINICAL IMPLICATIONS Understanding patient characteristics associated with primary nonadherence may be important for disease management, because many patients with asthma do not fill their ICS prescriptions.
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Affiliation(s)
- L Keoki Williams
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA.
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Nau DP, Steinke DT, Williams LK, Austin R, Lafata JE, Divine G, Pladevall M. Adherence analysis using visual analog scale versus claims-based estimation. Ann Pharmacother 2007; 41:1792-7. [PMID: 17925497 DOI: 10.1345/aph.1k264] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Although visual analog scales (VAS) have been used frequently in outcomes research, there is little evidence regarding the validity of this scale for measuring medication adherence. OBJECTIVE To determine whether a VAS self-report measure of medication adherence is concordant with claims-based measurement of adherence. METHODS A mail survey was conducted in 2005 of persons with diabetes. Prescription claims were obtained for the 1985 survey respondents who used oral diabetes medications and lipid-modifying drugs. The self-reported measure of adherence was a VAS scored 0-100%, and the claims-based measure was the continuous measure of medication gaps (CMG), reverse-coded to yield a score of 0-100%. Dichotomous measures (highly adherent vs poorly adherent) were also created from the VAS and CMG using a cutoff value of 80%. For diabetes and lipid-modifying drugs, the scores on the VAS and CMG (continuous versions) were compared using a Pearson correlation coefficient, while the concordance of the dichotomous versions of the measures was compared using the kappa coefficient. RESULTS The mean +/- SD for the VAS and CMG for oral diabetes drugs were 95.9 +/- 9.2 and 84.1 +/- 19.2, respectively, and for lipid-modifying drugs, 95.2 +/- 11.2 and 85.3 +/- 20.0, respectively. The VAS-diabetes and CMG-diabetes scales were moderately correlated (r = 0.22), as were the VAS-lipid and CMG-lipid (r = 0.26). The majority (69.0%) of subjects had consistent adherence classifications across the dichotomous versions of VAS-diabetes and CMG-diabetes (kappa = 0.13), while 73.1% of subjects had consistent classifications for the dichotomous VAS-lipid and CMG-lipid (kappa = 0.19). CONCLUSIONS The VAS self-reports of adherence to medications had moderate concordance with estimates derived from drug benefit claims. Although the majority of subjects were consistently classified by the VAS and claims, the concordance may not be sufficient for direct comparisons of studies using VAS data with studies using claims-based estimates.
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Affiliation(s)
- David P Nau
- College of Pharmacy, University of Kentucky, Lexington, KY 40536, USA.
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Affiliation(s)
- Kaan Tunceli
- Center for Health Services Research, Henry Ford Health System, Detroit, Michigan, USA.
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Williams LK, Joseph CL, Peterson EL, Moon C, Xi H, Krajenta R, Johnson R, Wells K, Booza JC, Tunceli K, Lafata JE, Johnson CC, Ownby DR, Enberg R, Pladevall M. Race-ethnicity, crime, and other factors associated with adherence to inhaled corticosteroids. J Allergy Clin Immunol 2007; 119:168-75. [PMID: 17208598 DOI: 10.1016/j.jaci.2006.09.029] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [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] [Received: 07/17/2006] [Revised: 09/05/2006] [Accepted: 09/21/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Previous studies have shown differences in adherence to inhaled corticosteroids (ICSs) by race-ethnicity, yet little is known about factors that contribute to adherence within these groups. Environmental stressors, such as crime exposure, which has been associated with asthma morbidity, might also predict ICS adherence. OBJECTIVE We sought to identify factors associated with ICS adherence among patients with asthma and among African American patients and white patients separately. METHODS Study patients with asthma were aged 18 to 50 years and were enrolled in a large southeast Michigan health maintenance organization between January 1, 1999, and December 31, 2001. The primary outcome, ICS adherence, was calculated by linking prescription-fill data with dosage information. Predictor variables included age, sex, race-ethnicity, measures of socioeconomic status (SES), average ICS copay, existing comorbidities, and crime rate in area of residence. RESULTS Adherence information was available for 176 patients. ICS adherence was lower among African American patients (n = 75) when compared with white patients (n = 94; 40% vs 58%, respectively; P = .002). Among white patients, adherence was significantly lower for women when compared with men. Among African American patients, age and residential crime rates were positively and negatively associated with ICS adherence, respectively. Area crime remained a predictor of adherence in African American patients, even after adjusting for multiple measures of SES. CONCLUSIONS This study suggests that an environmental stressor, area crime, provides additional predictive insight into ICS-adherent behavior beyond typical SES factors. CLINICAL IMPLICATIONS Better understanding of environmental factors that influence ICS adherence might aid in efforts to improve it.
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Affiliation(s)
- L Keoki Williams
- Department of Internal Medicine, Henry Ford Health System, Detroit, MI 48202, USA.
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Abstract
OBJECTIVE This study describes the clinical management of type 2 diabetes among a cohort of patients receiving oral antidiabetic monotherapy. STUDY DESIGN AND SETTING A retrospective study was conducted within an integrated Midwestern health system that included all individuals receiving oral antidiabetic monotherapy during the period June 1, 1999 to November 30, 2002 (n = 9335). Among patients with elevated hemoglobin A(1c) (HbA(1c)) test result(s), Kaplan-Meier estimates of median time until pharmacotherapy change were calculated. RESULTS Among the 8068 patients who had > or = 1 HbA(1c) measurement during the study period, 21.4% were at goal (i.e. HbA(1c) < 7%). Among patients with at least one elevated test result (> or = 7%), the median time to pharmacotherapy change following an HbA(1c) test result of between 7-10% was just over 1 year (372 days, 95% confidence interval [CI] 358-393 days) and 160 days for patients with HbA(1c) > 10%. Among patients with at least two elevated tests, the median time to pharmacotherapy change was 275 days from the second test result of between 7-10%, and 70 days among patients with a second HbA(1c) > 10%. The median time between HbA(1c) testing was 166 days overall, and 154 days among patients with at least one elevated result. CONCLUSION Despite the known benefits of glycemic control among patients with diabetes, the time between elevated HbA(1c) results and pharmacotherapy change exceeds 12 months for those with HbA(1c) test results between 7-10% and 9 months for those with results over 10%.
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Tunceli K, Pladevall M, Williams LK, Divine GW, Simpkins JC, Nag SS, Sajjan SG, Kamal-Bahl SJ, Alexander CM, Lafata JE. Trends in Lipid Management Among Patients with Diabetes. Endocr Pract 2006; 12:380-7. [PMID: 16901793 DOI: 10.4158/ep.12.4.380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To examine trends in lipid management (cholesterol testing, treatment, and goal attainment) among patients with diabetes and to analyze the factors associated with initiation of lipid-lowering therapy. METHODS We conducted a longitudinal, retrospective study of patients with diabetes identified during a 24-month baseline period (January 1, 1995, to December 31, 1996) and for whom follow-up was continued for 5 years (1997 to 2001). Generalized estimating equations were used to test for time trend effects in lipid management. We modeled the days from baseline to the first lipid-lowering prescription fill date with a multivariate Cox proportional hazards regression model. RESULTS Rates of lipid testing, treatment, and goal attainment significantly improved (P<0.001) during the 5-year study period: from 37% to 67% for lipid testing; from 19% to 41% for treatment with a lipid-lowering agent; from 22% to 37% for achievement of low-density lipoprotein cholesterol (LDL-C) levels < 100 mg/dL; and from 54% to 75% for achievement of LDL-C levels < 130 mg/dL. The relative likelihood (hazard rate) of treatment with lipid-lowering agents was greater for patients with LDL-C levels > or = 100 mg/dL relative to patients with LDL-C concentrations < 100 mg/dL. Treatment with lipid-lowering agents of patients with a cardiovascular event during follow-up was approximately 3 times more likely relative to those without such an event. CONCLUSION We found that rates of lipid testing, treatment, and goal attainment improved significantly between 1997 and 2001. Nevertheless, ample room for improvement of these rates continues to exist. Particular attention may be warranted to ensure that patients with diabetes receive lipid-lowering agents not only after a cardiovascular event but also before such an event occurs.
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Affiliation(s)
- Kaan Tunceli
- Center for Health Services Research, Henry Ford Health System, Detroit, Michigan 48202, USA
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Pladevall M, Lafata J, Williams K, Kolk D, Wang M, Austin R. Predictive and Convergent Validity of Claims-Based Measures of Adherence to Medications. Am J Epidemiol 2006. [DOI: 10.1093/aje/163.suppl_11.s185-a] [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: 11/14/2022] Open
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Pladevall M, Singal B, Williams LK, Brotons C, Guyer H, Sadurni J, Falces C, Serrano-Rios M, Gabriel R, Shaw JE, Zimmet PZ, Haffner S. A single factor underlies the metabolic syndrome: a confirmatory factor analysis. Diabetes Care 2006; 29:113-22. [PMID: 16373906 DOI: 10.2337/diacare.29.1.113] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Confirmatory factor analysis (CFA) was used to test the hypothesis that the components of the metabolic syndrome are manifestations of a single common factor. RESEARCH DESIGN AND METHODS Three different datasets were used to test and validate the model. The Spanish and Mauritian studies included 207 men and 203 women and 1,411 men and 1,650 women, respectively. A third analytical dataset including 847 men was obtained from a previously published CFA of a U.S. population. The one-factor model included the metabolic syndrome core components (central obesity, insulin resistance, blood pressure, and lipid measurements). We also tested an expanded one-factor model that included uric acid and leptin levels. Finally, we used CFA to compare the goodness of fit of one-factor models with the fit of two previously published four-factor models. RESULTS The simplest one-factor model showed the best goodness-of-fit indexes (comparative fit index 1, root mean-square error of approximation 0.00). Comparisons of one-factor with four-factor models in the three datasets favored the one-factor model structure. The selection of variables to represent the different metabolic syndrome components and model specification explained why previous exploratory and confirmatory factor analysis, respectively, failed to identify a single factor for the metabolic syndrome. CONCLUSIONS These analyses support the current clinical definition of the metabolic syndrome, as well as the existence of a single factor that links all of the core components.
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Affiliation(s)
- Manel Pladevall
- Henry Ford Health System, Center for Health Services Research, One Ford Place, Suite 3A, Detroit, Michigan 48202, USA.
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Abstract
OBJECTIVE The purpose of this study was to longitudinally examine the effect of diabetes on labor market outcomes. RESEARCH DESIGN AND METHODS Using secondary data from the first two waves (1992 and 1994) of the Health and Retirement Study, we identified 7,055 employed respondents (51-61 years of age), 490 of whom reported having diabetes in wave 1. We estimated the effect of diabetes in wave 1 on the probability of working in wave 2 using probit regression. For those working in wave 2, we modeled the relationships between diabetic status in wave 1 and the change in hours worked and work-loss days using ordinary least-squares regressions and modeled the presence of health-related work limitations using probit regression. All models control for health status and job characteristics and are estimated separately by sex. RESULTS Among individuals with diabetes, the absolute probability of working was 4.4 percentage points less for women and 7.1 percentage points less for men relative to that of their counterparts without diabetes. Change in weekly hours worked was not statistically significantly associated with diabetes. Women with diabetes had 2 more work-loss days per year compared with women without diabetes. Compared with individuals without diabetes, men and women with diabetes were 5.4 and 6 percentage points (absolute increase), respectively, more likely to have work limitations. CONCLUSIONS This article provides evidence that diabetes affects patients, employers, and society not only by reducing employment but also by contributing to work loss and health-related work limitations for those who remain employed.
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Affiliation(s)
- Kaan Tunceli
- Center for Health Services Research, Henry Ford Health System, Detroit, MI 48202, USA.
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Williams LK, Peterson EL, Pladevall M, Tunceli K, Ownby DR, Johnson CC. Timing and intensity of early fevers and the development of allergies and asthma. J Allergy Clin Immunol 2005; 116:102-8. [PMID: 15990781 DOI: 10.1016/j.jaci.2005.04.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Early childhood fevers appear to protect against later allergies and asthma. What is not known is the time in which fevers exert this effect and whether the degree of temperature increase is important. OBJECTIVE We sought to examine the relationship between the time and degree of early fevers and later allergies and asthma. METHODS Eight hundred thirty-five children from southeast Michigan were enrolled at birth. Clinic records from their first 2 years were abstracted for episodes of fever. At age 6 to 7 years, children underwent allergy testing. We examined fevers occurring within 6-month intervals in the first 2 years of life and outcomes at age 6 to 7 years. The primary outcome measures were allergic sensitization, asthma, asthma with allergic sensitization, and asthma without allergic sensitization. RESULTS In the unadjusted analysis each episode of fever between 7 and 12 months of age was associated with a lower odds of allergic sensitization (odds ratio [OR], 0.71; 95% CI, 0.54-0.93) and asthma with allergic sensitization (OR, 0.43; 95% CI, 0.21-0.90) at age 6 to 7 years. Likewise, every 1 degrees C increase in the maximum temperature between 7 and 12 months was associated with a lower odds of allergic sensitization (OR, 0.77; 95% CI, 0.61-0.96) and asthma with allergic sensitization (OR, 0.62; 95% CI, 0.40-0.94). After adjusting for potential confounders, each episode of fever between 7 and 12 months was associated with a lower likelihood of asthma with allergic sensitization (adjusted OR, 0.33; 95% CI, 0.11-0.94) at age 6 to 7 years. CONCLUSIONS Both the timing and intensity of childhood fevers appear to be important factors in the development of allergies and asthma.
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Affiliation(s)
- L Keoki Williams
- Department of Internal Medicine,Center for Health Services Research, Henry Ford Health System, Detroit, MI 48202, USA.
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Richter A, Pladevall M, Manjunath R, Lafata JE, Xi H, Simpkins J, Brar I, Markowitz N, Iloeje UH, Irish W. Patient characteristics and costs associated with dyslipidaemia and related conditions in HIV-infected patients: a retrospective cohort study. HIV Med 2005; 6:79-90. [PMID: 15807713 DOI: 10.1111/j.1468-1293.2005.00269.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Metabolic abnormalities are common in HIV-infected individuals and, although multifactorial in origin, have been strongly associated with antiretroviral therapy. METHODS Using automated claims and clinical databases, combined with medical record data, we evaluated the burden of dyslipidaemia (DYS) and associated metabolic abnormalities among a cohort of 900 HIV-infected patients aged 18 years and older who received their care from a large multispecialty medical group between 1 January 1996 and 30 June 2002. A Cox proportional hazards model for DYS was developed. Resource use was compiled and subsequently costed with stratification to account for variable length of follow-up. RESULTS Mean follow-up time was 3.3 years. DYS was present in 54% of the cohort and 3.4% experienced a cardiovascular (CV) event. Both unadjusted and adjusted results found patients with dyslipidaemia and cardiovascular events significantly more likely to have received protease inhibitor (PI) treatment for longer periods of time. In the Cox proportional hazards model the following factors were significantly associated with an increased risk for DYS: older age, white race, PI use and male sex. Diagnoses of hypertension, hepatitis C virus infection, depression or opportunistic infections were all negatively associated with a DYS diagnosis. When controlled for length of follow up, patients with DYS (and no CV-related events) incurred greater median and mean total average costs than patients without DYS or CV-related events. For patients with more than 2 years of follow up, these total cost differences were statistically significant (P<0.05). CONCLUSIONS These findings indicate that DYS is common among patients with HIV infection and is associated with increased use of medical resources.
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Affiliation(s)
- A Richter
- Defences Resources Management Institute, Naval Postgraduate School, Monterey, CA 93943, USA.
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Pladevall M, Lafata JE, Tunceli K, Divine G, Simpkins J, Williams LK. 364: Racial Disparities in Lipid Management in Patients with Diabetes. Am J Epidemiol 2005. [DOI: 10.1093/aje/161.supplement_1.s91c] [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: 11/13/2022] Open
Affiliation(s)
- M Pladevall
- Center for Health Services Research, Detroit, MI 48202
| | | | - K Tunceli
- Center for Health Services Research, Detroit, MI 48202
| | - G Divine
- Center for Health Services Research, Detroit, MI 48202
| | - J Simpkins
- Center for Health Services Research, Detroit, MI 48202
| | - L K Williams
- Center for Health Services Research, Detroit, MI 48202
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Pladevall M, Brotons C, Gabriel R, Sobrino J, Leiva A, Soler J, Cirujano FJ, Canal V, Alvarez E, De la Iglesia N, Luis Alvarez I, Deig E, Novella B. 023: The COM99 Study Results: A Cluster-Randomized Trial of an Intervention to Improve Adherence to Antihypertensive Drugs Among Patients at High Cardiovascular Risk. Am J Epidemiol 2005. [DOI: 10.1093/aje/161.supplement_1.s6b] [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: 11/14/2022] Open
Affiliation(s)
- M Pladevall
- Center for Health Services Research, Detroit, MI 48202
| | - C Brotons
- Center for Health Services Research, Detroit, MI 48202
| | - R Gabriel
- Center for Health Services Research, Detroit, MI 48202
| | - J Sobrino
- Center for Health Services Research, Detroit, MI 48202
| | - A Leiva
- Center for Health Services Research, Detroit, MI 48202
| | - J Soler
- Center for Health Services Research, Detroit, MI 48202
| | - F J Cirujano
- Center for Health Services Research, Detroit, MI 48202
| | - V Canal
- Center for Health Services Research, Detroit, MI 48202
| | - E Alvarez
- Center for Health Services Research, Detroit, MI 48202
| | | | | | - E Deig
- Center for Health Services Research, Detroit, MI 48202
| | - B Novella
- Center for Health Services Research, Detroit, MI 48202
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Williams L, Pladevall M, Xi H, Peterson E, Joseph C, Elston Lafata J, Ownby D, Johnson C. Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol 2005. [DOI: 10.1016/j.jaci.2004.12.1102] [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: 10/25/2022]
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Williams LK, Pladevall M, Xi H, Peterson EL, Joseph C, Lafata JE, Ownby DR, Johnson CC. Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol 2005; 114:1288-93. [PMID: 15577825 DOI: 10.1016/j.jaci.2004.09.028] [Citation(s) in RCA: 366] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Regular use of inhaled corticosteroids (ICSs) can improve asthma symptoms and prevent exacerbations. However, overall adherence is poor among patients with asthma. Objective To estimate the proportion of poor asthma-related outcomes attributable to ICS nonadherence. METHODS We retrospectively identified 405 adults age 18 to 50 years who had asthma and were members of a large health maintenance organization in southeast Michigan between January 1, 1999, and December 31, 2001. Adherence indices were calculated by using medical records and pharmacy claims. The main outcomes were the number of asthma-related outpatient visits, emergency department visits, and hospitalizations, as well as the frequency of oral steroid use. RESULTS Overall adherence to ICS was approximately 50%. Adherence to ICS was significantly and negatively correlated with the number of emergency department visits (correlation coefficient [ R ] = -0.159), the number of fills of an oral steroid ( R = -0.179), and the total days' supply of oral steroid ( R = -0.154). After adjusting for potential confounders, including the prescribed amount of ICS, each 25% increase in the proportion of time without ICS medication resulted in a doubling of the rate of asthma-related hospitalization (relative rate, 2.01; 95% CI, 1.06-3.79). During the study period, there were 80 asthma-related hospitalizations; an estimated 32 hospitalizations would have occurred were there no gaps in medication use (60% reduction). CONCLUSIONS Adherence to ICS is poor among adult patients with asthma and is correlated with several poor asthma-related outcomes. Less than perfect adherence to ICS appears to account for the majority of asthma-related hospitalizations.
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Affiliation(s)
- L Keoki Williams
- Department of Internal Medicine, Henry Ford Health System, Detoit, MI 48202, USA.
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Abstract
OBJECTIVE Although poor medication adherence may contribute to inadequate diabetes control, ways to feasibly measure adherence in routine clinical practice have yet to be established. The present study was conducted to determine whether pharmacy claims-based measures of medication adherence are associated with clinical outcomes in patients with diabetes. RESEARCH DESIGN AND METHODS The study setting was a large, integrated delivery and financial system serving the residents of southeastern Michigan. The study population consisted of 677 randomly selected patients aged > or =18 years with a diagnosis of diabetes, hypercholesterolemia, and hypertension and who filled at least one prescription for either an antidiabetic, lipid-lowering, or antihypertensive drug in each of the 3 study years (1999-2001). The main outcome measures were HbA1c, LDL cholesterol levels, and blood pressure. RESULTS Nonadherent patients had both statistically and clinically worse outcomes than adherent patients. Even after adjusting for demographic and clinical characteristics, nonadherence was significantly associated with HbA1c and LDL cholesterol levels. A 10% increase in nonadherence to metformin and statins was associated with an increase of 0.14% in HbA1c and an increase of 4.9 mg/dl in LDL cholesterol levels. Nonadherence to ACE inhibitors was not significantly associated with blood pressure. CONCLUSIONS Claims-based measures of medication adherence are associated with clinical outcomes in patients with diabetes and may therefore prove to be useful in clinical practice. More research is needed on methods to introduce claims-based adherence measurements into routine clinical practice and how to use these measurements to effectively improve adherence and health outcomes in chronic care management.
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Affiliation(s)
- Manel Pladevall
- Center for Health Services Research, Henry Ford Health System, One Ford Place, Suite 3A, Detroit, Michigan 48202, USA.
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Lafata JE, Pladevall M, Divine G, Ayoub M, Philbin EF. Are there race/ethnicity differences in outpatient congestive heart failure management, hospital use, and mortality among an insured population? Med Care 2004; 42:680-9. [PMID: 15213493 DOI: 10.1097/01.mlr.0000129903.12843.fc] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to assess the quality of outpatient care received by patients with congestive heart failure (CHF) and whether differences in care and outcomes exist by race/ethnicity. BACKGROUND Appropriate outpatient CHF management can improve patient well-being and reduce the need for costly inpatient care. Yet, little is known regarding outpatient CHF management or whether differences in this care exist by race/ethnicity. METHODS Using automated data sources, we identified a cohort of insured patients seen in an outpatient setting for CHF between September 1992 and August 1993. Medical record abstraction was used to confirm diagnosis of CHF. Patients (N = 566) were followed until September 1998. Race/ethnicity differences in outpatient management and medical care utilization were assessed using generalized estimating equations. Differences in mortality and hospitalization for CHF, controlling for patient characteristics and outpatient management, were assessed using Cox and Andersen-Gill models, respectively. RESULTS With the exception of beta blocker use and primary care visit frequency, few differences by race/ethnicity in patient characteristics and CHF management were found. However, older black patients had more hospital use both at baseline and during follow up. These differences persisted after adjusting for patient characteristics and clinical management. No race/ethnicity differences were found in mortality. CONCLUSIONS In an insured population, older black patients with CHF have substantially more hospital use than older white patients. This increased use was not explained by differences in CHF outpatient management. Further research is needed to understand why race/ethnicity differences in hospital use are observed among older patients with CHF.
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Affiliation(s)
- Jennifer Elston Lafata
- Department of Biostatistics & Research Epidemiology, Henry Ford Health System, Detroit, Michigan 48202, USA.
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Williams LK, Pladevall M, Fendrick AM, Lafata JE, McMahon LF. Differences in the Reporting of Care-Related Patient Injuries to Existing Reporting Systems. ACTA ACUST UNITED AC 2003; 29:460-7. [PMID: 14513669 DOI: 10.1016/s1549-3741(03)29055-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study compared the number of care-related injuries reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) with the number reported to 15 mandatory-reporting states. METHODS The primary outcome measure was the number of patient injuries reported to each in 1999. RESULTS In all categories examined, the number of reports submitted by accredited hospitals to states equaled or exceeded the number reported to JCAHO. DISCUSSION State-reporting systems identified a greater number of care-related injuries than did the JCAHO system. Although JCAHO received fewer reports from accredited hospitals, its process requires an analysis of the event and a prevention plan, and it disseminates the lessons learned from reported events. For adverse event reporting to improve patient safety, there must be assurances that lessons are learned from these events, preventive measures are taken, and information is shared so others may benefit without having to experience the same adverse event. CONCLUSION This study represents an early attempt to understand the system characteristics that influence hospital reporting of care-related patient injuries. As reporting systems become more prevalent and standardized, the influence of factors such as legal protections, confidentiality, and technology on reporting should be better understood.
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Affiliation(s)
- L Keoki Williams
- Department of Internal Medicine, Division of General Medicine, Henry Ford Hospital, Detroit, USA.
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Pladevall M, Williams K, Guyer H, Sadurní J, Falces C, Ribes A, Paré C, Brotons C, Gabriel R, Serrano-Ríos M, Haffner S. The association between leptin and left ventricular hypertrophy: a population-based cross-sectional study. J Hypertens 2003; 21:1467-73. [PMID: 12872039 DOI: 10.1097/00004872-200308000-00009] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Plasma leptin levels have been shown to be an independent risk factor for cardiovascular disease. Leptin has been shown to have sympathetic and vascular effects, and may increase cardiovascular risk through increased blood pressure, left ventricular hypertrophy, or atherosclerotic mechanisms. This study examines whether leptin levels, independent of body mass and insulin resistance, are a risk factor for hypertension and left ventricular hypertrophy. METHODS AND PARTICIPANTS A population-based, cross-sectional sample of 410 adults from rural Spain was studied. The correlations between plasma leptin levels and left ventricular mass index, sum of wall thicknesses, and blood pressure were calculated. Multiple linear regression analysis was used to adjust for other cardiovascular risk factors. RESULTS After adjusting for age, body mass index, systolic blood pressure, sex, and insulin resistance, leptin was inversely associated with left ventricular mass index (beta = -0.20, P < 0.01). Leptin was also inversely related to the sum of wall thicknesses; however, this association did not reach statistical significance (beta = -0.12, P = 0.063). Leptin was not statistically associated with blood pressure after adjusting for body mass index. CONCLUSIONS The results do not support the hypothesis that leptin increases cardiovascular risk by increasing left ventricular mass index or blood pressure. Other mechanisms, related to atherosclerosis, could explain the increased risk of cardiovascular diseases observed with high leptin levels.
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Affiliation(s)
- Manel Pladevall
- Center for Health Services Research, Henry Ford Health System, Detroit, Michigan, USA [corrected]
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Abstract
BACKGROUND Strategies for reducing breast cancer mortality in western countries have focused on screening, at least for women aged 50 to 69 years. One of the requirements of any community screening program is to achieve a high participation rate, which is related to methods of invitation. Therefore, it was decided to systematically review the scientific evidence on the different strategies aimed at improving women's participation in breast cancer screening programs and activities. OBJECTIVES To assess the effectiveness of different strategies for increasing the participation rate of women invited to community (population-based) breast cancer screening activities or mammography programs. SEARCH STRATEGY MEDLINE (1966-2000), CENTRAL (2000), and EMBASE (1998-1999) searches for 1966 to 1999 were supplemented by reports and letters to the European Screening Breast Cancer Programs (Euref Network). SELECTION CRITERIA Both published and unpublished trials were eligible for inclusion, provided the women had been invited to a community breast screening activity or program and had been randomised to an intervention group or a control group with no active intervention. DATA COLLECTION AND ANALYSIS We identified 151 articles, which were reviewed independently by two people. The discrepancies were resolved by a third reviewer in order to reach consensus. Thirty-four studies were excluded because they lacked a control group; 58 of the other 117 articles were considered as opportunistic and not community-based; 59 articles, which reported 70 community-based randomised controlled trials or clinical controlled trials, were accepted. In 24 of these, the control group had not been exposed to any active intervention, but 8 of the 24 had to be excluded because the denominator for estimating attendance was unknown. At the end, 16 studies constituted the material for this review, although two studies were further excluded because their groups were not comparable at baseline. Data from all but one study were based on or converted to an intention-to-treat analysis. Attendance in response to the mammogram invitation was the main outcome measure. MAIN RESULTS The evidence favoured five active strategies for inviting women into community breast cancer screening services: letter of invitation (OR 1.66, 95% CI 1.43 to 1.92), mailed educational material (OR 2.81, 95% CI 1.96 to 4.02), letter of invitation plus phone call (OR 2.53, 95% CI 2.02 to 3.18), phone call (OR 1.94, 95% CI 1.70 to 2.23), and training activities plus direct reminders for the women (OR 2.46, 95% CI 1.72 to 3.50). Home visits did not prove to be effective (OR 1.06, 95 % CI 0.80 to 1.40) and letters of invitation to multiple examinations plus educational material favoured the control group (OR 0.62, 95 % CI 0.32 to 1.20). REVIEWER'S CONCLUSIONS Most active recruitment strategies for breast cancer screening programs examined in this review were more effective than no intervention. Combinations of effective interventions can have an important effect. Some costly strategies, as a home visit and a letter of invitation to multiple screening examinations plus educational material, were not effective. Further reviews comparing the effective interventions and studies that include cost-effectiveness, women's satisfaction and equity issues are needed.
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Affiliation(s)
- X Bonfill
- Centro Cochrane Iberoamericano., Hospital de la Santa Creu i Sant Pau, Casa de Convalescència, Sant Antoni M. Claret 171, Barcelona, Catalonia, Spain, 08041.
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Espaulella J, Guyer H, Diaz-Escriu F, Mellado-Navas JA, Castells M, Pladevall M. Nutritional supplementation of elderly hip fracture patients. A randomized, double-blind, placebo-controlled trial. Age Ageing 2000; 29:425-31. [PMID: 11108415 DOI: 10.1093/ageing/29.5.425] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND undernourishment is common in elderly hip fracture patients and has been linked to poorer recovery and increased post-operative complications. OBJECTIVE to determine whether a nutritional supplement may (i) help elderly patients return to pre-fracture functional levels 6 months post-fracture and (ii) decrease fracture-related complications and mortality. DESIGN a double-blind, randomized, placebo-controlled clinical trial. SETTING a county hospital near Barcelona. SUBJECTS 171 patients, aged 70 and older, hospitalized for hip fracture between July 1994 and July 1996. METHODS we randomized patients to intervention (n = 85) or control (n = 86) group. Patients received a nutritional supplement containing 20 g of protein and 800 mg of calcium or placebo for 60 days. We determined functional levels by the Barthel index, the mobility index and by the use of walking aids. We performed assessments during hospitalization and at 2 and 6 months post-fracture. FINDINGS the two groups were comparable at study entry. We observed no differences in return to functional status 6 months post-fracture (61% intervention group vs 55% in control group) nor in fracture-related mortality (13% in intervention group vs 10% in control group). The intervention group suffered fewer in-hospital [odds ratio 1.88 (95% CI 1.01 - 3.53), P = 0.05] and total complications [odds ratio 1.94 (95% CI 1.02-3.7), P = 0.04] than the control group. CONCLUSION based on our results, we cannot recommend routine nutritional supplementation of all elderly hip fracture patients. While nutritional supplementation may be useful in decreasing complications, this reduction does not result in improvement in functional recovery and nor does it decrease fracture-related mortality. Selected patients may, however, benefit from nutritional supplementation.
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Affiliation(s)
- J Espaulella
- Department of Geriatrics, Hospital de la Santa Creu de Vic, Barcelona, Spain
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Bonfill X, Etcheverry C, Martí J, Glutting JP, Urrutia G, Pladevall M. [The development of the Spanish Cochrane Collaboration]. Med Clin (Barc) 2000; 112 Suppl 1:17-20. [PMID: 10618795] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Affiliation(s)
- X Bonfill
- Centro Cochrane Español, Fundació Parc Taulí, Sabadell, Barcelona.
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Kanterewicz E, Iruela A, Pladevall M, Serrarols M, Pañella D, Brugués J, Díez A. [Calcitonin prescriptions: an estimate of the expenditure due to inadequate prescription]. Med Clin (Barc) 1998; 110:411-5. [PMID: 9608496] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of calcitonin is very common in patients diagnosed with osteoporosis. The objective of this study was to determine the percentage of adequate prescriptions of calcitonin for patients with osteoporosis and to estimate the costs due to inadequate prescription. PATIENTS AND METHODS Observational study. Four pharmacies in Osona County (Barcelona) were randomly selected. During two time periods, July-September and November-December of 1994, all women filling prescriptions for calcitonin in any of the eight pharmacies were invited to participate in the study. Adequate and inadequate prescription of calcitonin was determined based on the patient's clinical record. Justifiable and non-justifiable prescriptions were then determined after implementing a protocol and reviewing X-rays of the spine. RESULTS Forty-eight women agreed to participate (participation rate: 68%). In the first analysis, 58.3% (95% CI: 43-72) of prescriptions were determined to be inadequate whereas in the second analysis 29.2% (95% CI: 17-44) were considered non-justifiable. Chronic back pain was associated with non-justifiable prescription of calcitonin (odds ratio: 5.2; 95% CI: 1.3-33.4). In the best of situations, the excess in annual spending due to inadequate prescription was estimated at 13 million pesetas for Osona County, 1,300 million for Catalonia, and 4,300 million for Spain. CONCLUSIONS Between one-third and one-half of patients prescribed calcitonin in the study area apparently do not need it. Many cases of chronic back pain are being treated as osteoporosis without being properly studied. The costs derived from this incorrect practice are important. This study highlights the need for better practices in the diagnosis of osteoporosis.
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Affiliation(s)
- E Kanterewicz
- Unitat de Reumatologia, Hospital General de Vic, Barcelona
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Pladevall M, Goff DC, Nichaman MZ, Chan F, Ramsey D, Ortíz C, Labarthe DR. An assessment of the validity of ICD Code 410 to identify hospital admissions for myocardial infarction: The Corpus Christi Heart Project. Int J Epidemiol 1996; 25:948-52. [PMID: 8921479 DOI: 10.1093/ije/25.5.948] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The identification of myocardial infarction (MI) is typically based on finding events designated by a nosologist with the appropriate International Classification of Diseases (ICD) code, currently code 410. These codes are applied based on review of medical records or death certificates. However, other factors, including reimbursement considerations, may influence the coding process, especially for hospitalizations. Thus, the validity of using ICD code 410 to identify MI must be assessed. METHODS The Corpus Christi Heart Project (CCHP) is a population-based surveillance programme for hospitalized MI. Patients were identified using concurrent ascertainment in coronary care units and retrospective review of medical records. Events were validated as definite or possible MI using data regarding chest pain, electrocardiographic changes and cardiac enzymes. The validity of using ICD code 410 to identify cases of MI was assessed by calculating the sensitivity, specificity, predictive values and efficiency of ICD code 410 versus the CCHP 'gold standard'. RESULTS Use of ICD code 410 identified 80.9% (401/496) of definite MI, but only 19.0% (243/1280) of possible MI. Only 12.3% (90/734) of discharges with an ICD 410 code received a 'no MI' designation based on the 'gold standard'. The efficiency of ICD code 410 for identifying MI was 92.0% for definite MI and 77.1% for definite and possible MI. CONCLUSIONS The use of ICD code 410 to identify hospitalized cases of MI results in a modestly biased overestimate of the number of definite MI hospitalizations; however, this approach warrants consideration due to the expense of validation procedures.
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Affiliation(s)
- M Pladevall
- University of Texas-Houston School of Public Health 77225, USA
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Sanmarti R, Kanterewicz E, Pladevall M, Pañella D, Tarradellas JB, Gomez JM. Analysis of the association between chondrocalcinosis and osteoarthritis: a community based study. Ann Rheum Dis 1996; 55:30-3. [PMID: 8572730 PMCID: PMC1010078 DOI: 10.1136/ard.55.1.30] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To analyse the association between chondrocalcinosis and osteoarthritis (OA) of the hands and knees in an unselected elderly rural population. METHODS A community based cross sectional study was performed in individuals randomly selected from a previous epidemiological survey on the prevalence of chondrocalcinosis in people older than 60 years from Osona county, Catalonia, northeastern Spain. Radiological OA (grade 2 or more of Kellgren's classification) was evaluated in 26 individuals with chondrocalcinosis and in 104 controls. A total of 18 articular areas of both knees (medial and lateral tibiofemoral compartments) and hands (first, second and third metacarpophalangeal (MCP), first carpometacarpal, trapezium-scaphoid, radiocarpal and distal radioulnar joints) were studied. RESULTS Radiological changes of OA in the knees were more common in subjects with chondrocalcinosis than in those without it, with an odds ratio adjusted for age and gender (aOR) of 4.3 (95% confidence interval (CI) 1.6 to 11.8, p = 0.005). OA was also more frequent in almost all areas of the hands in individuals with chondrocalcinosis, though the difference reached statistical significance only in the MCP joints (aOR 3.1; 95% CI 1.1 to 8.8; p = 0.033). However, taking into account the side and the different joint compartments analysed, the association between chondrocalcinosis and OA was significant only in the lateral tibiofemoral compartment and the left MCP joints. CONCLUSIONS In an elderly population unselected for their rheumatic complaints, there was a real association between OA and chondrocalcinosis. This association was particularly relevant in the lateral tibiofemoral compartment of the knee and in the first three left MCP joints.
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Affiliation(s)
- R Sanmarti
- Hospital Clínic i Provincial de Barcelona, Servei de Reumatologia, Spain
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