Estimating the economic burden of osteoporotic fractures in a multinational study: a real-world data perspective

Fracture-related costs vary by country. A standardized methodology and presentations were proposed to fairly assess the economic burden of osteoporotic fracture. Results indicated substantial costs of osteoporotic fractures for pharmacy, hospitalization, emergency care, and outpatient visits in women aged ≥ 50 years in Australia, Germany, South Korea, Spain, and the USA.

PURPOSE

The objective of this multinational, retrospective matched cohort study was to use a standardized methodology across different healthcare systems to estimate the burden of osteoporotic fracture (OF) in women aged ≥ 50 years in Australia, Germany, South Korea, Spain, and the USA.

METHODS

Within each country, healthcare resource utilization and direct costs of care were compared between patients with newly identified OF and a propensity score-matched cohort without OF during follow-up periods of up to 5 years.

RESULTS

Across all five countries, the OF cohort had significantly higher rates and length of inpatient admissions compared with the non-OF cohort. In each country, the adjusted total costs of care ratio between OF and non-OF cohorts were significant. The adjusted cost ratios for pharmacy, inpatient care, emergency care, and outpatient visits were similarly higher in the OF cohort across countries.

CONCLUSION

The current study demonstrates the substantial economic burden of OF across different countries when compared with matched non-OF patients. The findings would assist stakeholders and policymakers in developing appropriate health policies.

A roadmap for early psychosocial support in palliative care for people impacted by ALS-reducing suffering, building resiliency, and setting the stage for delivering timely transdiagnostic psychosocial care

This commentary describes the current state of psychosocial care for people with amyotrophic lateral sclerosis and their caregivers. We provide recommendations for developing a roadmap for future research based on existing literature and our group's clinical and research experience to inform next steps to expand evidence-based psychosocial care for people with amyotrophic lateral sclerosis and their caregivers, with potential implications for a range of advanced illnesses.

Italian cross-cultural adaptation of the Quality of Communication questionnaire and the 4-item advance care planning engagement questionnaire

BACKGROUND

Advance care planning (ACP) is influenced by several factors (e.g., patient's readiness to engage, clinician's skills, and the cultural environment). Availability of reliable and valid self-reported measures of the ACP domains is crucial, including cross-cultural equivalence.

AIM

To culturally adapt into Italian the 19-item Quality of Communication (QOC) and the 4-item ACP Engagement (4-item ACP-E) questionnaires.

METHODS

We translated and culturally adapted the two questionnaires and produced a significant other (SO) version of the QOC (QOC-SO). Each questionnaire was field tested via cognitive interviews with users: nine patients (QOC, 4-item ACP-E) and three SOs (QOC-SO) enrolled at three palliative care services.

RESULTS

We made minor changes to 5/19 QOC items, to improve clarity and internal consistency; we changed the response option 'didn't do' into 'not applicable'. Finally, we slightly revised the QOC to adapt it to the paper/electronic format. QOC debriefing revealed that the section on end of life was emotionally challenging for both patients and SOs. We simplified the 4-item ACP-E layout, added a sentence in the introduction, and revised the wording of one item, to improve coherence with the Italian ACP legislation. ACP-E debriefing did not reveal any major issue.

CONCLUSIONS

Results were satisfactory in terms of semantic, conceptual and normative equivalence of both questionnaires. Acceptability was satisfactory for the 4-item ACP-E, while findings of the QOC cognitive debriefing informed a major amendment of a pilot trial protocol on ACP in multiple sclerosis (ConCure-SM): use of the interviewer version only, in an adaptive form. Psychometric testing of both questionnaires on a large, independent sample will follow.

Advance Care Planning Documentation and Intensity of Care at the End of Life for Adults With Congestive Heart Failure, Chronic Kidney Disease, and Both Illnesses

CONTEXT

Heart failure (HF) and chronic kidney disease (CKD) are associated with high morbidity and mortality, especially in combination, yet little is known about the impact of these conditions together on end-of-life care.

OBJECTIVES

Compare end-of-life care and advance care planning (ACP) documentation among patients with both HF and CKD to those with either condition.

METHODS

We conducted a retrospective analysis of deceased patients (2010-2017) with HF and CKD (n = 1673), HF without CKD (n = 2671), and CKD without HF (n = 1706), excluding patients with cancer or dementia. We compared hospitalizations and intensive care unit (ICU) admissions in the last 30 days of life, hospital deaths, and ACP documentation >30 days before death.

RESULTS

39% of patients with HF and CKD were hospitalized and 33% were admitted to the ICU in the last 30 days vs. 30% and 28%, respectively, for HF, and 26% and 23% for CKD. Compared to patients with both conditions, those with only 1 were less likely to be admitted to the hospital [HF: adjusted odds ratio (aOR) 0.72, 95%CI 0.63-0.83; CKD: aOR 0.63, 95%CI 0.53-0.75] and ICU (HF: aOR 0.83, 95%CI 0.71-0.94; CKD: aOR 0.68, 95%CI 0.56-0.80) and less likely to have ACP documentation (aOR 0.53, 95%CI 0.47-0.61 and aOR 0.70, 95%CI 0.60-0.81).

CONCLUSIONS

Decedents with both HF and CKD had more ACP documentation and received more intensive end-of-life care than those with only 1 condition. These findings suggest that patients with co-existing HF and CKD may benefit from interventions to ensure care received aligns with their goals.

Validation of an algorithm to identify incident interstitial lung disease in patients with rheumatoid arthritis

Background/purpose

Interstitial lung disease (ILD) is an important problem for patients with rheumatoid arthritis (RA). However, current approaches to ILD case finding in real-world data have been evaluated only in limited settings and identify only prevalent ILD and not new-onset disease. Our objective was to develop, refine, and validate a claims-based algorithm to identify both prevalent and incident ILD in RA patients compared to the gold standard of medical record review.

Methods

We used administrative claims data 2006–2015 from Medicare to derive a cohort of RA patients. We then identified suspected ILD using variations of ILD algorithms to classify both prevalent and incident ILD based on features of the data that included hospitalization vs. outpatient setting, physician specialty, pulmonary-related diagnosis codes, and exclusions for potentially mimicking pulmonary conditions. Positive predictive values (PPV) of several ILD algorithm variants for both prevalent and incident ILD were evaluated.

Results

We identified 234 linkable RA patients with sufficient data to evaluate for ILD. Overall, 108 (46.2%) of suspected cases were confirmed as ILD. Most cases (64%) were diagnosed in the outpatient setting. The best performing algorithm for prevalent ILD had a PPV of 77% (95% CI 67–84%) and for incident ILD was 96% (95% CI 85–100%).

Conclusion

Case finding in administrative data for both prevalent and incident interstitial lung disease in RA patients is feasible and has reasonable accuracy to support population-based research and real-world evidence generation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02655-z.

Comparative safety of flavocoxid vs prescription NSAIDs among osteoarthritis patients

OBJECTIVE

Flavocoxid is a prescription medical food used to manage osteoarthritis (OA) symptoms. Safety concerns based on case reports raised an association with acute liver injury and hypersensitivity pneumonitis. We determined incidence rates (IR) of these safety events in a cohort of new users of flavocoxid and prescription non-steroidal anti-inflammatory drugs (NSAIDs).

METHOD

MarketScan® claims data (2006-2017) was used to identify patients initiating flavocoxid or NSAIDs. Propensity score matching (1:2 ratio) was used to balance patient characteristics. Outcomes included hospitalization for hypersensitivity pneumonitis, liver injury, gastrointestinal bleeding, myocardial infarction, and acute kidney injury. Poisson regression was used to calculate IRs and Cox regression for calculating adjusted hazard ratios (aHR).

RESULTS

3,337 flavocoxid and 6,674 NSAID users met eligibility criteria. Before matching, flavocoxid users were older (mean 57 vs 51 years), had more polypharmacy (68% vs 29% taking ≥11 medications). After matching, characteristics were well balanced. The rate of hypersensitivity pneumonitis was 1.1 (95% CI 0.0-5.9) per 1,000 PY for flavocoxid and 0.0 (95% CI 0.0-2.2) for NSAIDs. For hospitalized liver injury, it was 3.2 (95% CI 0.7-9.3) for flavocoxid and 2.4 (95% CI 0.7-6.1) for NSAIDs, aHR = 1.16, 95% CI 0.23-6.01. A lower rate of GI bleed was observed, IR: 5.3 (1.7-12.3) for flavocoxid and 10.2 (5.9-16.3) for NSAIDs, aHR 0.49 (0.18-1.68). There were no significant differences for MI or AKI.

CONCLUSION

The rate of hypersensitivity pneumonitis and liver injury associated with flavocoxid was low and minimally elevated compared to NSAIDs. Flavocoxid users had a significantly lower risk for hospitalized GI bleeding. The risk-benefit profile of flavocoxid may warrant reevaluation in light of these findings.

Osteoporotic fracture trends in a population of US managed care enrollees from 2007 to 2017

This study expands on previous findings that hip fracture rates may no longer be declining. We found that age- and sex-adjusted fracture rates in the US plateaued or increased through mid-2017 in a population of commercially insured and Medicare Advantage health plan enrollees, in contrast to a decline from 2007 to 2013.

INTRODUCTION

The purpose of this study was to evaluate fracture trends in US commercial and Medicare Advantage health plan members aged ≥ 50 years between 2007 and 2017.

METHODS

Retrospective analysis of the Optum Research Database from January 1, 2007, to May 31, 2017.

RESULTS

Of 1,841,263 patients identified with an index fracture, 930,690 were case-qualifying and included in this analysis. The overall age- and sex-adjusted fracture rate decreased from 14.67/1000 person-years (py) in 2007 to 11.79/1000 py in 2013, followed by a plateau for the next 3 years and then an increase to 12.50/1000 py in mid-2017. In females aged ≥ 65 years, fracture rates declined from 27.49/1000 py in 2007 to 22.08/1000 py in 2013, then increased to 24.92/1000 py in mid-2017. Likewise, fracture rates in males aged ≥ 65 years declined from 2007 (12.00/1000 py) to 2013 (10.72/1000 py), then increased to 12.04/1000 py in mid-2017. The age- and sex-adjusted fracture rates for most fracture sites declined from 2007 to 2013 by 3.7% per year (P = 0.310).

CONCLUSIONS

Following a consistent decline in fracture rate from 2007 to 2013, trends from 2014 to 2017 indicate fracture rates are no longer declining and, for some fracture types, rates are rising.

Factors associated with the contemplative stage of readiness to initiate osteoporosis treatment

We investigated the factors associated with readiness for initiating osteoporosis treatment in women at high risk of fracture. We found that women in the contemplative stage were more likely to report previously being told having osteoporosis or osteopenia, acknowledge concern about osteoporosis, and disclose prior osteoporosis treatment.

INTRODUCTION

Understanding factors associated with reaching the contemplative stage of readiness to initiate osteoporosis treatment may inform the design of behavioral interventions to improve osteoporosis treatment uptake in women at high risk for fracture.

METHODS

We measured readiness to initiate osteoporosis treatment using a modified form of the Weinstein Precaution Adoption Process Model (PAPM) among 2684 women at high risk of fracture from the Activating Patients at Risk for OsteoPOroSis (APROPOS) clinical trial. Pre-contemplative participants were those who self-classified in the unaware and unengaged stages of PAPM (stages 1 and 2). Contemplative participants were those in the undecided, decided not to act, or decided to act stages of PAPM (stages 3, 4, and 5). Using multivariable logistic regression, we evaluated participant characteristics associated with levels of readiness to initiate osteoporosis treatment.

RESULTS

Overall, 24% (N = 412) self-classified in the contemplative stage of readiness to initiate osteoporosis treatment. After adjusting for age, race, education, health literacy, and major osteoporotic fracture in the past 12 months, contemplative women were more likely to report previously being told they had osteoporosis or osteopenia (adjusted odds ratio [aOR] (95% CI) 11.8 (7.8-17.9) and 3.8 (2.5-5.6), respectively), acknowledge concern about osteoporosis (aOR 3.5 (2.5-4.9)), and disclose prior osteoporosis treatment (aOR 4.5 (3.3-6.3)) than women who self-classified as pre-contemplative.

CONCLUSIONS

For women at high risk for future fractures, ensuring women's recognition of their diagnosis of osteoporosis/osteopenia and addressing their concerns about osteoporosis are critical components to consider when attempting to influence stage of behavior transitions in osteoporosis treatment.

Physician attitudes about non-medical switching to biosimilars: results from an online physician survey in the United States

OBJECTIVE

This study was designed to understand the level of familiarity of US rheumatologists, gastroenterologists and dermatologists with biosimilar therapies, their experience with non-medical switching (switching medications for reasons unrelated to patient health) of patients between biologics and their attitudes towards switching from a biologic to a biosimilar.

METHODS

A total of 297 US physicians who currently prescribe biologics for their patients completed a 15-minute online survey. Rheumatologists, dermatologists and gastroenterologists were included.

RESULTS

The majority of physicians (84%) did not want stable patients undergoing a non-medical switch to a biosimilar. While 60% of physicians believed non-medical switching to biosimilars may have a positive impact on healthcare system costs, multiple negative impacts were also expected. A majority of physicians anticipated a negative impact on patient mental health (59%), treatment efficacy (57%), patient safety (53%) and physician office management (60%).

CONCLUSIONS

The majority of physicians had concerns regarding non-medical switching to biosimilars and the impact such switching would have on patient care and physician practice.

Patient attitudes about non-medical switching to biosimilars: results from an online patient survey in the United States

OBJECTIVE

To evaluate patient attitudes regarding non-medical switching (NMS) to biosimilars among patients with autoimmune disease currently receiving a biologic.

METHODS

An online survey was conducted among patients meeting the following criteria: ≥18 years of age; residing in the US; diagnosis of rheumatoid arthritis, Crohn's disease, ulcerative colitis, psoriasis or psoriatic arthritis; currently taking a biologic; and consenting to participate. Patients answered questions about their attitudes and experiences related to NMS. Descriptive statistics were used to summarize responses.

RESULTS

A total of 1696 patients completed the 20-min survey. Eighty-five per cent of patients were concerned that biosimilars wouldn't treat their disease as well; 85% didn't want to switch to a biosimilar if their current biologic was helping their disease; and 83% were concerned that switching may cause more side-effects. Twenty per cent of patients had previously received notification about a potential NMS to another biologic (that was not a biosimilar) from their insurance company. Of these, 79% took at least one action to avoid the NMS and 45% ultimately switched. Of these patients (n = 150), 67% indicated that their previous biologic worked well for them and 70% didn't want to switch to another biologic. Most patients who switched (67%) did so to avoid paying a higher cost. More than half (56%) went without therapy for administrative reasons during the period of transition from the old biologic to the other treatment.

CONCLUSIONS

Patients reported multiple concerns about NMS that might impact treatment outcomes, and many of the patients who non-medically switched in this survey missed treatments. Future studies should be conducted on patient expectations and experiences with NMS to understand the impact on healthcare delivery, treatment persistency, and patient outcomes. The patient perspective and experience should be considered by decision-makers when developing coverage policies for biosimilar medications and associated communication strategies.

Risk of subsequent fracture after prior fracture among older women

Among 377,561 female Medicare beneficiaries who sustained a fracture, 10% had another fracture within 1 year, 18% within 2 years, and 31% within 5 years. Timely management to reduce risk of subsequent fracture is warranted following all nontraumatic fractures, including nonhip nonvertebral fractures, in older women.

INTRODUCTION

Prior fracture is a strong predictor of subsequent fracture; however, postfracture treatment rates are low. Quantifying imminent (12-24 month) risk of subsequent fracture in older women may clarify the need for early postfracture management.

METHODS

This retrospective cohort study used Medicare administrative claims data. Women ≥ 65 years who sustained a clinical fracture (clinical vertebral and nonvertebral fracture; index date) and were continuously enrolled for 1-year pre-index and ≥ 1-year (≥  2 or ≥ 5 years for outcomes at those time points) post-index were included. Cumulative incidence of subsequent fracture was calculated from 30 days post-index to 1, 2, and 5 years post-index. For appendicular fractures, only those requiring hospitalization or surgical repair were counted. Death was considered a competing risk.

RESULTS

Among 377,561 women (210,621 and 10,969 for 2- and 5-year outcomes), cumulative risk of subsequent fracture was 10%, 18%, and 31% at 1, 2, and 5 years post-index, respectively. Among women age 65-74 years with initial clinical vertebral, hip, pelvis, femur, or clavicle fractures and all women ≥ 75 years regardless of initial fracture site (except ankle and tibia/fibula), 7-14% fractured again within 1 year depending on initial fracture site; risk rose to 15-26% within 2 years and 28-42% within 5 years. Risk of subsequent hip fracture exceeded 3% within 5 years in all women studied, except those < 75 years with an initial tibia/fibula or ankle fracture.

CONCLUSIONS

We observed a high and early risk of subsequent fracture following a broad array of initial fractures. Timely management with consideration of pharmacotherapy is warranted in older women following all fracture types evaluated.

Correction to: Hip fracture trends in the United States, 2002 to 2015

The name of the first author, E.M. Lewiecki, was rendered incorrectly in the original publication. The publisher regrets any inconvenience and is pleased to correct the error here.

Combining online and in-person methods to evaluate the content validity of PROMIS fatigue short forms in rheumatoid arthritis

PURPOSE

Fatigue is frequent and often severe and disabling in RA, and there is no consensus on how to measure it. We used online surveys and in-person interviews to evaluate PROMIS Fatigue 7a and 8a short forms (SFs) in people with RA.

METHODS

We recruited people with RA from an online patient community (n = 200) and three academic medical centers (n = 84) in the US. Participants completed both SFs then rated the comprehensiveness and comprehensibility of the items to their fatigue experience. Cognitive debriefing of items was conducted in a subset of 32 clinic patients. Descriptive statistics were calculated, and associations were evaluated using Pearson and Spearman correlation coefficients.

RESULTS

Mean SF scores were similar (p ≥ .61) among clinic patients reflecting mild fatigue (i.e., 54.5-55.9), but were significantly higher (p < .001) in online participants. SF Fatigue scores correlated highly (r ≥ 0.82; p < .000) and moderately with patient assessments of disease activity (r ≥ 0.62; p = .000). Most (70-92%) reported that the items "completely" or "mostly" reflected their experience. Almost all (≥ 94%) could distinguish general fatigue from RA fatigue. Most (≥ 85%) rated individual items questions as "somewhat" or "very relevant" to their fatigue experience, averaged their fatigue over the past 7 days (58%), and rated fatigue impact versus severity (72 vs. 19%). 99% rated fatigue as an important symptom they considered when deciding how well their current treatment was controlling their RA.

CONCLUSIONS

Results suggest that items in the single-score PROMIS Fatigue SFs demonstrate content validity and can adequately capture the wide range of fatigue experiences of people with RA.

Dose Finding Study of a Low Molecular Weight Heparin, Innohep, in Haemodialysis

A pilot investigation was performed with Innohep, a low molecular weight (LMWH) preparation (peak maximum molecular mass 3,000-6,000), to determine possible dose regimens for patients undergoing regular maintenance haemodialysis for chronic renal failure. Results from this study suggested that suppression of macroscopic clot formation and fibrinopeptide A (FPA), a marker of fibrin formation, could be achieved following bolus injections rather than bolus injections and an infusion. On the basis of these preliminary findings, a randomised crossover study was performed in eight patients undergoing regular maintenance haemodialysis for 5-7 h to determine the effective antithrombotic dose of this LMWH. Single i.v. bolus doses of 1,250 AFXa u, 2,500 AFXa u and 5,000 AFXa u (n = 7-8) were compared to an UFH regime of 5,000 iu + 1,500 iu/h. Excessive clot formation in the dialyser bubble trap, necessitating additional UFH to enable completion of a prolonged (up to 7 h) dialysis, was observed in all patients on the 1,250 AFXa u dose (mean duration of dialysis prior to UFH, 3 h) but in a single patient only receiving the other LMWH doses. A dose-related response in the AFXa activity, measured by chromogenic substrate (CS) assay was seen in the three LMWH groups, with levels declining significantly (p <0.05) from 1-7 h. This contrasted with the constant levels maintained during dialysis with UFH. FPA levels were significantly elevated after 2 h following the 1,250 AFXa u bolus and after 4 h following the 2,500 AFXa u bolus. There was no significant difference in FPA levels between the 5,000 AFXa u bolus and UFH. β-thromboglobulin (pTG) levels rose significantly towards the end of dialysis in all LMWH groups and, at 5 h, were significantly increased following the 5,000 AFXa u and 2,500 AFXa u doses when compared to the UFH regime. AFXa levels correlated negatively with FPA levels (r = -0.62; p <0.01). In conclusion, for administration of Innohep, a bolus dose of 2,500 AFXa u would appear to be sufficient for dialyses of short duration (up to 4 h), whilst a 5,000 AFXa u bolus is as effective as UFH for a 6 h dialysis. AFXa activity measured by CS assay is related to inhibition of fibrin formation and can be used for monitoring purposes.

The Anticoagulant Effect of Heparinoid Org 10172 During Haemodialysis: An Objective Assessment

The heparinoid of natural origin Org 10172 has anti-factor Xa activity but minimal anti-thrombin activity, and little effect upon broad spectrum assays such as the KCCT in vitro. Its anticoagulant effects have been compared to those of commercial heparin in 7 patients undergoing haemodialysis for chronic renal failure. Commercial heparin was administered in a dose (5,000 iu bolus + 1,500 iu/hour continuous iv infusion) previously shown to inhibit fibrin formation during haemodialysis. This produced mean anti-factor Xa levels in plasma between 0.7-1.0 iu/ml and largely suppressed fibrin formation for 5 h dialysis measured as mean FPA levels in plasma. Administration of Org 10172 as a bolus of 1,350 anti-factor Xa u or 2,000-2,400 anti-factor Xa u produced plasma anti-factor Xa levels of less than 0.5 u/ml and allowed fibrin clot and FPA generation during dialysis. Org 10172 administered as a bolus dose of 4,000-4,800 anti-factor Xa u produced mean anti-factor Xa levels of greater than 0.5 u/ml, allowed dialysis of 6 patients for 5 h and appreciably suppressed FPA generation during dialysis, with little effect on the KCCT.

It is concluded that the anti-factor Xa activity of Org 10172 may reflect its ability to inhibit fibrin during dialysis and that single bolus injection of Org 10172 may be a useful alternative method of achieving anticoagulation.

Antithrombotic Properties of Dermatan Sulphate (MF 701) in Haemodialysis for Chronic Renal Failure

The therapeutic potential of the glycosaminoglycan (GAG), dermatan sulphate (DS), as an antithrombotic agent in humans has yet to be established. We have performed dose ranging studies of DS to determine its effectiveness as an antithrombotic agent in patients (n = 6–8) undergoing haemodialysis for chronic renal failure. In an initial study, Study 1, i.v. bolus doses of 2–4 mg/kg and 5–6 mg/kg DS were given to patients dialysing with polyacrylonitrile hollow fibre (PAN HF) membranes. In a second crossover study, Study 2, performed using cuprophane hollow fibre (CHF) membranes, i. v. bolus doses of 3 mg/kg and 6 mg/kg DS were compared to a standard unfractionated heparin (UFH) regime that has been shown previously to inhibit fibrin formation. Further infusion studies, Study 3 and Study 4 evaluated the antithrombotic efficacy of an i. v. DS bolus of 3 mg/kg plus an i. v. infusion of DS 0.6 mg kg-1 h-1 and a DS bolus of 5 mg/ kg plus an infusion of 1 mg kg-1 h-1 over 5 h, respectively. These studies were compared to standard UFH regimes in a randomised crossover design. Plasma levels of fibrinopeptide A (FPA) and thrombin-antithrombin (TAT) were used as markers of fibrin formation and thrombin generation during dialysis using both membranes.

The changes in DS concentration following administration of the different doses were similar in Studies 1 and 2. However, the effectiveness of DS as an anticoagulant appeared to depend markedly on the different dialyser types used in the two studies. In Study 1, 13/14 dialyses required additional UFH to complete a normal ~6 h session and DS was unable to prevent thrombin and fibrin formation, as determined by measurement of plasma FPA and TAT. However, some dose related effects were observed in the levels of these markers. Furthermore, DS levels correlated with those of FPA and TAT. In Study 2, increasing doses of DS (3 mg/kg and 6 mg/kg), allowed longer dialysis sessions (mean 4.57 h c.f. 5.25 h), approaching that obtained with UFH regime (5.86 h). FPA and TAT generation were incompletely suppressed by both doses of DS; FPA rose significantly compared to that observed with the UFH regime, while TAT did not. While no significant differences in the activation markers were observed between the two DS doses, DS levels, taken as a whole, showed significant negative correlations with those of FPA and TAT Little effect on the KCCT was seen.

In Study 3, 3/6 patients required additional UFH (mean dialysis duration with DS 4.33 h c. f. 5.67 h with UFH). Mean DS levels were maintained between 35–40 µg/ml. Mean plasma FPA levels were maintained at constant levels throughout dialysis following DS administration but were higher than those observed following the UFH regime. In Study 4 mean DS levels were

Low Molecular Weight Heparin in Haemodialysis for Chronic Renal Failure: Dose Finding Study of CY222

A dose finding study of the very low molecular weight heparin CY222 (MW 2500) in patients (n = 8) with chronic renal failure undergoing dialysis has been carried out to (i) establish an effective dose and (ii) determine the relationship between ex vivo anti-factor Xa levels in plasma and the anticoagulant effect (in vivo suppression of FPA levels). Doses of CY222 were compared to a dose (5000 iu bolus + 1500 iu/hr) of unfractionated heparin (UFH) that has been shown to suppress FPA levels during prolonged (>5 hr) dialysis (Ireland et ah, J Lab Clin Med 103, 643, 1984). CY222 given iv in increasing doses produced a dose related increase in anti-factor Xa levels (measured as Institute Choay u/ml, with CY222 itself as standard) and suppression of FPA levels. When given in its highest dose, 20,000 Institute Choay u bolus + 1500 Institute Choay u/hr, there was little effect upon KCCT, FPA levels were statistically indistinguishable from those of the UFH regime (indicating comparable anticoagulant effect), but anti-factor Xa levels (expressed in Institute Choay u/ ml) were 2-3 times those of UFH (expressed in iu/ml). All samples were also assayed for anti-factor Xa level against the proposed low MW Heparin Standard. Plasma levels of CY222 were then found to be 2.78 times lower, so that the anti-factor Xa levels of CY222 required to produce comparable anticoagulant effect were then indistinguishable from those of UFH. Clinically, doses of CY222 exceeding 10,000 Institute Choay u bolus were effective, although increasing amounts of fibrin were visible in the drip chamber of the dialyser circuit with decreasing dose. These results indicate that CY222 is an effective anticoagulant for haemodialysis that can be monitored by its anti-factor Xa level in plasma (in conjunction with the appropriate standard). For prolonged dialysis a dose of 20,000 Institute Choay u bolus + 1500 Institute Choay u/hr is effective at suppressing fibrin formation, while the maintenance infusion may be unnecessary for short frequent dialyses.

Hip fracture trends in the United States, 2002 to 2015

An analysis of United States (US) Medicare claims data from 2002 to 2015 for women aged ≥ 65 years found that age-adjusted hip fracture rates for 2013, 2014, and 2015 were higher than projected, resulting in an estimated increase of more than 11,000 hip fractures.

INTRODUCTION

Hip fractures are a major public health concern due to high morbidity, mortality, and healthcare expenses. Previous studies have reported a decrease in the annual incidence of hip fractures in the US beginning in 1995, coincident with the introduction of modern diagnostic tools and therapeutic agents for osteoporosis. In recent years, there has been less bone density testing and fewer prescriptions for osteoporosis treatments. The large osteoporosis treatment gap raises concern of possible adverse effects on hip fracture rates.

METHODS

We assessed hip fracture incidence in the US to determine if the previous decline in hip fracture incidence continued. Using 2002 to 2015 Medicare Part A and Part B claims for women ≥ 65 years old, we calculated age-adjusted hip fracture rates, weighting to the 2014 population.

RESULTS

We found that hip fracture rates declined each year from 2002 to 2012 and then plateaued at levels higher than projected for years 2013, 2014, and 2015.

CONCLUSIONS

The plateau in age-adjusted hip fracture incidence rate resulted in more than 11,000 additional estimated hip fractures over the time periods 2013, 2014, and 2015. We recommend further study to assess all factors contributing to this remarkable change in hip fracture rate and to develop strategies to reduce the osteoporosis treatment gap.

Recovery after critical illness: putting the puzzle together-a consensus of 29

In this review, we seek to highlight how critical illness and critical care affect longer-term outcomes, to underline the contribution of ICU delirium to cognitive dysfunction several months after ICU discharge, to give new insights into ICU acquired weakness, to emphasize the importance of value-based healthcare, and to delineate the elements of family-centered care. This consensus of 29 also provides a perspective and a research agenda about post-ICU recovery.

The cost of a patient activation intervention for achieving successful outcomes: results from the PAADRN randomized controlled trial

In a large, pragmatic clinical trial, we calculated the costs of achieving four successful patient-centered outcomes using a tailored patient activation DXA result letter accompanied by a bone health brochure. The cost to achieve one successful outcome (e.g., a 0.5 standard deviation improvement in care satisfaction) ranged from $127.41 to $222.75.

INTRODUCTION

Pragmatic randomized controlled trials (RCTs) should focus on patient-centered outcomes and report the costs for achieving those outcomes. We calculated per person incremental intervention costs, the number-needed-to-treat (NNT), and incremental per patient costs (cost per NNT) for four patient-centered outcomes in a direct-to-patient bone healthcare intervention.

METHODS

The Patient Activation after DXA Result Notification (PAADRN) pragmatic RCT enrolled 7749 patients presenting for DXA at three health centers between February 2012 and August 2014. Interviews occurred at baseline and 52 weeks post-DXA. Intervention subjects received an individually tailored DXA result letter accompanied by an educational bone health brochure 4 weeks post-DXA, while the usual care subjects did not. Outcomes focused on patients (a) correctly identifying their results, (b) contacting their providers, (c) discussing their results with their providers, and (d) satisfaction with their bone healthcare. NNTs were determined using intention-to-treat linear probability models, per person incremental intervention costs were calculated, and costs per NNT were computed.

RESULTS

Mean age was 66.6 years old, 83.8% were women, and 75.3% were non-Hispanic whites. The incremental per patient cost (costs per NNT) to increase the ability of a patient to (a) correctly identify their DXA result was $171.07; (b) contact their provider about their DXA result was $222.75; (c) discuss their DXA result with their provider was $193.55; and (d) achieve a 0.5 SD improvement in satisfaction with their bone healthcare was $127.41.

CONCLUSION

An individually tailored DXA result letter accompanied by an educational brochure can improve four patient-centered outcomes at a modest cost.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT01507662.

Assessing the feasibility of the Effectiveness of Discontinuing Bisphosphonates trial: a pilot study

The Effectiveness of Discontinuing Bisphosphonates (EDGE) study is a planned pragmatic clinical trial to guide "drug holiday" clinical decision making. This pilot study assessed work flow and feasibility of such a study. While participant recruitment and treatment adherence were suboptimal, administrative procedures were generally feasible and minimally disrupted clinic flow.

INTRODUCTION

The comparative effectiveness of continuing or discontinuing long-term alendronate (ALN) on fractures is unknown. A large pragmatic ALN discontinuation study has potential to answer this question.

METHODS

We conducted a 6-month pilot study of the planned the EDGE study among current long-term ALN users (women aged ≥65 with ≥3 years of ALN use) to determine study work flow and feasibility including evaluating the administrative aspects of trial conduct (e.g., time to contract, institutional review board (IRB) approval), assessing rates of site and participant recruitment, and evaluating post-randomization outcomes, including adherence, bisphosphonate-associated adverse events, and participant and site satisfaction. We assessed outcomes 1 and 6 months after randomization.

RESULTS

Nine sites participated, including seven community-based medical practices and two academic medical centers. On average (SD), contract execution took 3.4 (2.3) months and IRB approval took 13.9 (4.1) days. Sites recruited 27 participants (13 to continue ALN and 14 to discontinue ALN). Over follow-up, 22% of participants did not adhere to their randomization assignment: 30.8% in the continuation arm and 14.3% in the discontinuation arm. No fractures or adverse events were reported. Sites reported no issues regarding work flow, and participants were highly satisfied with the study.

CONCLUSIONS

Administrative procedures of the EDGE study were generally feasible, with minimal disruption to clinic flow. In this convenience sample, participant recruitment was suboptimal across most practice sites. Accounting for low treatment arm adherence, a comprehensive recruitment approach will be needed to effectively achieve the scientific goals of the EDGE study.

Impact of neighbourhood-level inequity on paediatric diabetes care

AIMS

To evaluate the association between neighbourhood-level inequity and glycaemic control in paediatric participants with Type 1 diabetes using the Neighbourhood Equity Index (NEI).

METHODS

The NEI was linked to the clinical data of 519 children with diabetes followed at the Hospital for Sick Children (Toronto, Canada). The NEI is a composite measure of inequity developed using the World Health Organization's Urban Health Equity Assessment and Response Tool (HEART), which encompasses 15 weighted indicators evaluating economic, social, environmental and lifestyle factors. The geographic distribution of participants was determined using postal codes, and the relationship between HbA_1c and NEI was evaluated using regression and spatial analysis techniques.

RESULTS

Participants' mean HbA_1c was significantly correlated with NEI (R = -0.24, P < 0.0001). Regression analysis demonstrated that NEI was a strong predictor of mean HbA_1c (P < 0.0001), accounting for differences in HbA_1c as large as 1.0% (11 mmol/mol) when controlled for age, sex, diabetes duration, insulin pump therapy and number of annual clinic visits. Geo-mapping using spatial scan testing revealed the presence of two clusters of low-equity neighbourhoods containing 3.22 (P = 0.001) and 2.83 (P = 0.02) times more participants with HbA_1c ≥ 9.5% (80 mmol/mol) than expected.

CONCLUSIONS

Our findings demonstrated that NEI was a significant predictor of HbA_1c in our clinic population and a useful tool for investigating spatial trends related to inequities in health, providing evidence that a composite, area-based measure of overall inequity is well suited to the study of glycaemic control in urban paediatric Type 1 diabetes populations.

Abstract 191: Identification of Adults With Congenital Heart Disease From Administrative Data

Introduction: With improved management, there are now more adults with congenital heart disease (ACHD) than children. However, long-term survival with moderate or severe ACHD remains limited, and there is relatively sparse literature on the intensity or quality of end-of-life care for these patients. The goal of this analysis is to examine the accuracy of administrative data for identifying patients who died with ACHD to facilitate study of care provided near the end of life.

Methods: We created a list of ICD-9 and ICD-10 codes representing ACHD of moderate or great complexity. We performed a search for these codes in the electronic health record (EHR) of adults who received care 2010-2016 within our healthcare system. We used state death records to identify which of these patients died during the same timeframe. Manual EHR review was completed to evaluate performance of this search strategy. Identified patients were also compared to a list of patients seen in our ACHD clinic and known to have died during 2010-2016.

Results: Using ICD data, 121 patients were identified, of which 66 actually had the moderate or greater complexity ACHD conditions by EHR review (positive predictive value, 0.55; 95% confidence interval 0.45, 0.63). EHR review confirmed 12 patients with Eisenmenger Syndrome, for which there is no specific ICD code. “Cyanosis+other” did not identify any of these, “VSD+other” (ventricular septal defect) identified 6, and there were 6 whose only ACHD code was VSD. Of the remaining 55 patients, 24 had ACHD not on the targeted list, largely due to coding error. In addition, despite being coded as having ACHD, 31 patients had no identified ACHD on EHR review. These misidentifications were attributed to coding error for 15 patients. Another 11 patients (35%) had acquired VSD due to myocardial infarction or endocarditis, for which there is no separate ICD code. Codes with the highest degree of error, incorrect more than 50% of the time, were those for congenitally corrected transposition, endocardial cushion defect, and hypoplastic left heart syndrome. The list of known deceased clinic patients included 21 with ACHD of interest. Only 1 of these was not identified by the ICD search, yielding a sensitivity for our list of ICD codes in this small sample of 0.95 (0.77,0.99).

Conclusion: Use of administrative data to identify patients with ACHD of moderate or great complexity who have died had good sensitivity but suboptimal positive predictive value. Strategies to improve accuracy can be employed. Excluding patients who have codes for myocardial infarction or endocarditis in addition to VSD and using “VSD+other” as an additional proxy for Eisenmenger Syndrome are two examples. Administrative data is not ideal for identification of patients with ACHD of moderate or great complexity who have died, and manual EHR review is necessary to confirm these diagnoses.

Glucocorticoid exposure and fracture risk in patients with new-onset rheumatoid arthritis

Retrospective claims analysis indicated that high levels of daily and cumulative doses of systemic glucocorticoids were associated with elevated fracture risk in a large cohort of new RA patients under age 65. Heightened risk began to decline within months of discontinuation. Findings were similar among patients age <50 years.

INTRODUCTION

We evaluated the impact of systemic glucocorticoid exposure on fracture risk among relatively young patients with new-onset rheumatoid arthritis (RA).

METHODS

Using administrative data, we identified 42,127 RA patients diagnosed January 1, 2005-December 31, 2012, age 18-64 years, with benefits coverage for ≥12 months before RA diagnosis. Follow-up extended to clinical fracture, cancer diagnosis, or December 31, 2012. Glucocorticoid users were new to therapy. Fracture incidence rates (IR) were stratified by glucocorticoid exposure expressed as prednisone equivalent doses. Cox's proportional hazards models estimated fracture risk adjusted for demographics and baseline clinical characteristics to assess dose-response relationships with current (daily) and prior (cumulative) dose, and by time since discontinuation.

RESULTS

Most patients (85 %) had glucocorticoid exposure. Exposed and unexposed patients were demographically similar (74 % female; mean age 49.7 and 48.8 years); 1 % had prior fracture. Fracture IRs (95 % confidence intervals) were 5 to 9 per 1000 person-years at doses <15 mg/day, 16.0 (11.0, 22.6) at doses ≥15 mg/day, and 13.4 (10.7, 16.7) at cumulative doses ≥5400 mg. Adjusted fracture risk was approximately 2-fold higher at highest dose levels compared with 0 mg/day current daily dose and <675 mg cumulative dose, respectively. Fracture risk was 29 % lower at 60-182 days post-discontinuation compared with ongoing use and was similar to unexposed patients by 12 months. Findings were similar among patients age <50 years.

CONCLUSIONS

Among younger, new-onset RA patients, fracture risk was significantly elevated at high levels of daily and cumulative dose, and was similar to unexposed patients by 12 months post-discontinuation.

Patient's experience with subcutaneous and oral methotrexate for the treatment of rheumatoid arthritis

Background

Despite the prominent position of methotrexate (MTX) in Rheumatoid Arthiris (RA) therapeutics, its real-world effectiveness may be influenced by a relative lack of tolerability or other side effects that physicians may not be aware of but that are bothersome to patients.

The aim of this study is to identify suboptimal patient experience with MTX and to raise awareness for clinicians to identify opportunities to mitigate bothersome symptoms and side effects and optimize response to MTX.

Methods

We conducted a prospective, cross-sectional, online survey among RA patients who were members of Creakyjoints, a large arthritis patient community. Eligible participants must have recently initiated a new biologic, subcutaneous (SQ) MTX, or oral MTX in the last 12 months and were uniquely assigned to one of these 3 groups. Descriptive statistics were used to compare patient-reported side effects and tolerability related to MTX use in the 3 medication groups (SQ MTX, oral MTX, and biologic).

Results

A total of 382 (85 %) of 448 eligible patients completed the survey and were grouped as: biologic (n = 218), SQ MTX (n = 49), and oral MTX (n = 115). Demographics were mean standard deviation (SD) age 48 (10) years, 92 % white, 91 % women. Symptoms significantly more prevalent in the SQ and oral MTX groups included diarrhea, fatigue, malaise, and hair loss. Injection related pain was lower with SQ MTX compared to SQ biologics. Out of a total of 8 potential symptoms and side effects examined, higher dose MTX (> = 20 mg/week) was associated with a 2.26 (1.25–4.09) greater likelihood of more side effects referent to < =10 mg/week.

Conclusion

Results from this real-world RA patient cohort suggest that MTX is accompanied by many patient-reported side effects and tolerability problems that may be under-recognized by physicians. These may impact both treatment satisfaction and medication adherence.

Determining the Minimally Important Difference in the Clinical Disease Activity Index for Improvement and Worsening in Early Rheumatoid Arthritis Patients

OBJECTIVE

Simplified measures to quantify rheumatoid arthritis (RA) disease activity are increasingly used. The minimum clinically important differences (MCID) for some measures, such as the Clinical Disease Activity Index (CDAI), have not been well-defined in real-world clinic settings, especially for early RA patients with low/moderate disease activity.

METHODS

Data from Canadian Early Arthritis Cohort patients were used to examine absolute change in CDAI in the first year after enrollment, stratified by disease activity. MCID cut points were derived to optimize the sum of sensitivity and specificity versus the gold standard of patient self-reported improvement or worsening. Sensitivity, specificity, positive predictive values, and negative predictive values were calculated against patient self-reported improvement (gold standard) and for change in pain, Health Assessment Questionnaire (HAQ), and Disease Activity Score in 28 joints (DAS28) improvement. Discrimination was examined using the area under receiver operator curves. Similar methods were used to evaluate MCIDs for worsening for patients who achieved low disease activity.

RESULTS

A total of 578 patients (mean ± SD age 54.1 ± 15.3 years, 75% women, median [interquartile range] disease duration 5.3 [3.3, 8.0] months) contributed 1,169 visit pairs to the improvement analysis. The MCID cut points for improvement were 12 (patients starting in high disease activity: CDAI >22), 6 (moderate: CDAI 10-22), and 1 (low disease activity: CDAI <10). Performance characteristics were acceptable using these cut points for pain, HAQ, and DAS28. The MCID for CDAI worsening among patients who achieved low disease activity was 2 units.

CONCLUSION

These minimum important absolute differences in CDAI can be used to evaluate improvement and worsening and increase the utility of CDAI in clinical practice.

Development of END-of-Life ScorING-System to identify critically ill patients after initial critical care who are highly likely to die: a pilot study

BACKGROUND

High quality palliative care should be provided for the dying patients in the intensive care unit (ICU). The aim of this pilot study is to develop a scoring system, the "END-of-Life ScorING-System" (ENDING-S), that may help to identify ICU patients at very high risk of dying after initial response to the intensive treatments and which could be used to facilitate palliative care.

METHODS

The characteristics of longer-term ICU patients (>4 days) who are at very high risk of dying were identified through an analysis of the literature and developed in a retrospective cohort of patients. ENDING-S Score was developed through a multivariate analysis. Model accuracy was tested through ROC and Hosmer-Lemeshow analysis for model discrimination and calibration respectively. Cross validation was used to provide internal model validation.

RESULTS

Potential predictors of death were identified and applied to 80 ICU patients. Significant variables in the multivariate analysis were the ratio of the ICU days in which the patient needs mechanical ventilation or vasoactive drugs divided by the total ICU days, the total ICU length of stay, and current sepsis. Analysis of accuracy showed a ROC-AUC equals to 0.98 (95% CI, 0.97 to 1), and agreement between the predicted probability and the observed frequency of death in the ICU was observed (P>0.05 at Hosmer-Lemeshow test). The internal validation confirms these results.

CONCLUSION

In these preliminary results, ENDING-s shows acceptable calibration and discrimination properties. ENDING-S may raise awareness among ICU physicians about the importance of integrating palliative care into ICU daily practice.

Analysis of osteoporosis treatment patterns with bisphosphonates and outcomes among postmenopausal veterans

PURPOSE

Adherence and persistence with bisphosphonates are frequently poor, and stopping, restarting, or switching bisphosphonates is common. We evaluated bisphosphonate change behaviors (switching, discontinuing, or reinitiating) over time, as well as fractures and costs, among a large, national cohort of postmenopausal veterans.

METHODS

Female veterans aged 50+ treated with bisphosphonates during 2003-2011 were identified in Veterans Health Administration (VHA) datasets. Bisphosphonate change behaviors were characterized using pharmacy refill records. Patients' baseline disease severity was characterized based on age, T-score, and prior fracture. Cox Proportional Hazard analysis was used to evaluate characteristics associated with discontinuation and the relationship between change behaviors and fracture outcomes. Generalized estimating equations were used to evaluate the relationship between change behaviors and cost outcomes.

RESULTS

A total of 35,650 patients met eligibility criteria. Over 6800 patients (19.1%) were non-switchers. The remaining patients were in the change cohort; at least half displayed more than one change behavior over time. A strong, significant predictor of discontinuation was ≥5 healthcare visits in the prior year (11-23% more likely to discontinue), and discontinuation risk decreased with increasing age. No change behaviors were associated with increased fracture risk. Total costs were significantly higher in patients with change behaviors (4.7-19.7% higher). Change-behavior patients mostly had significantly lower osteoporosis-related costs than non-switchers (22%-118% lower).

CONCLUSIONS

Most bisphosphonate patients discontinue treatment at some point, which did not significantly increase the risk of fracture in this majority non-high risk population. Bisphosphonate change behaviors were associated with significantly lower osteoporosis costs, but significantly higher total costs.

Disease activity in rheumatoid arthritis and the risk of cardiovascular events

OBJECTIVE

Use of several immunomodulatory agents has been associated with reduced numbers of cardiovascular (CV) events in epidemiologic studies of rheumatoid arthritis (RA). However, it is unknown whether time-averaged disease activity in RA correlates with CV events.

METHODS

We studied patients with RA whose cases were followed in a longitudinal US-based registry. Time-averaged disease activity was assessed during followup using the area under the curve of the Clinical Disease Activity Index (CDAI), a validated measure of RA disease activity. Age, sex, presence of diabetes mellitus, hypertension, or hyperlipidemia, body mass index, family history of myocardial infarction (MI), use of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), presence of CV disease, and baseline use of an immunomodulator were assessed at baseline. Cox proportional hazards regression models were examined to determine the risk of a composite CV end point that included MI, stroke, and death from CV causes.

RESULTS

A total of 24,989 patients who had been followed up for a median of 2.7 years were included in these analyses. During followup, we observed 534 confirmed CV end points, for an incidence rate of 7.8 per 1,000 person-years (95% confidence interval [95% CI] 6.7-8.9). In models adjusted for variables noted above, a 10-point reduction in the time-averaged CDAI was associated with a 21% reduction in CV risk (95% CI 13-29). These results were robust in subgroup analyses stratified by the presence of CV disease, use of corticosteroids, use of NSAIDs or selective cyclooxygenase 2 inhibitors, and change in RA treatment, as well as when restricted to events adjudicated as definite or probable.

CONCLUSION

Our findings showed that reduced time-averaged disease activity in RA is associated with fewer CV events.

Families' experiences of intensive care unit quality of care: Development and validation of a European questionnaire (euroQ2)

PURPOSE

The purpose of the study is to adapt and provide preliminary validation for questionnaires evaluating families' experiences of quality of care for critically ill patients in the intensive care unit (ICU).

MATERIALS AND METHODS

This study took place in 2 European ICUs. Based on literature and qualitative interviews, we adapted 2 previously validated North American questionnaires: "Family Satisfaction with the ICU" and "Quality of Dying and Death." Family members were asked to assess relevance and understandability of each question. Validation also included test-retest reliability and construct validity.

RESULTS

A total of 110 family members participated. Response rate was 87%. For all questions, a median of 97% (94%-99%) was assessed as relevant, and a median of 98% (97%-100%), as understandable. Median ceiling effect was 41% (30%-47%). There was a median of 0% missing data (0%-1%). Test-retest reliability showed a median weighted κ of 0.69 (0.53-0.83). Validation showed significant correlation between total scores and key questions.

CONCLUSIONS

The questions were assessed as relevant and understandable, providing high face and content validity. Ceiling effects were comparable to similar instruments; missing data, low; and test-retest reliability, acceptable. These measures are promising for use in research, but further validation is needed before they can be recommended for routine clinical use.

An evaluation of clinical risk factors for estimating fracture risk in postmenopausal osteoporosis using an electronic medical record database

SUMMARY

Many of the clinical risk factors used in fracture risk assessment (FRAX) calculator are available in electronic medical record (EMR) databases and are good sources of osteoporosis risk factor information. The EPIC EMR database showed a lower prevalence of FRAX risk factors and, consequently, proportion of patients who would be deemed "high risk."

INTRODUCTION

The FRAX tool is underutilized for osteoporosis screening. Many of the clinical risk factors for FRAX may be available in EMR databases and may enable health systems to perform fracture risk assessments. We intended to identify variables in an EMR database for calculating FRAX score in a cohort of postmenopausal women, to estimate absolute fracture risk, and to determine the proportions of women whose absolute fracture risks exceed the National Osteoporosis Foundation (NOF) thresholds.

METHODS

Our cohort was selected using an EMR database with demographic, inpatient, outpatient, and clinical information for female patients age≥50 in a family practice, internal medicine, or obstetrics/gynecology clinic in 2007-2008. The latest physician encounter was the index date. Variables, problem and medication lists, diagnosis codes, and histories from the EMR were used to populate the 11 clinical risk factor variables used in the FRAX. These risk factor prevalence and treatment-eligible proportions were compared to those of published epidemiology studies.

RESULTS

The study included 345 patients. Mean (SD) 10-year risk for any major fracture was 11.1% (6.8) when bone mineral density (BMD) was used and 11.2% (6.5) when BMI was used. About 10.1% of the cohort exceeded the NOF's 20% major fracture risk threshold and 32.5% exceeded the NOF's 3% hip fracture risk threshold when BMD was used. Overall, the number of treatment-eligible patients was slightly lower when FRAX was calculated using BMD versus BMI (13.6 and 36.8%).

CONCLUSION

Our cohort using EMR data most likely underestimated the mean 10-year probability of any major fracture compared to other cohorts in published literature. The difference may be in the nature of EMRs for supporting only passive data collection of risk factor information.

Risk of hospitalized bacterial infections associated with biologic treatment among US veterans with rheumatoid arthritis

OBJECTIVE

The comparative risk of infection associated with non-anti-tumor necrosis factor (anti-TNF) biologic agents is not well established. Our objective was to compare risk for hospitalized infections between anti-TNF and non-anti-TNF biologic agents in US veterans with rheumatoid arthritis (RA).

METHODS

Using 1998-2011 data from the US Veterans Health Administration, we studied RA patients initiating rituximab, abatacept, or anti-TNF therapy. Exposure was based upon days supplied (injections) or usual dosing intervals (infusions). Treatment episodes were defined as new biologic agent use. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for hospitalization for a bacterial infection were estimated from Cox proportional hazards models, adjusting for potential confounders.

RESULTS

Among 3,152 unique RA patients contributing 4,158 biologic treatment episodes to rituximab (n = 596), abatacept (n = 451), and anti-TNF agents (n = 3,111), the patient mean age was 60 years and 87% were male. The most common infections were pneumonia (37%), skin/soft tissue (22%), urinary tract (9%), and bacteremia/sepsis (7%). Hospitalized infection rates per 100 person-years were 4.4 (95% CI 3.1-6.4) for rituximab, 2.8 (95% CI 1.7-4.7) for abatacept, and 3.0 (95% CI 2.5-3.5) for anti-TNF. Compared to etanercept, the adjusted rate of hospitalized infection was not different for adalimumab (HR 1.4, 95% CI 0.9-2.2), abatacept (HR 1.1, 95% CI 0.6-2.1), or rituximab (HR 1.4, 0.8-2.6), although it was increased for infliximab (HR 2.3, 95% CI 1.3-4.0). Infection risk was greater for those taking prednisone >7.5 mg/day (HR 1.8, 95% CI 1.3-2.7) and in the highest quartile of C-reactive protein (HR 2.3, 95% CI 1.4-3.8) and erythrocyte sedimentation rate (HR 4.1, 95% CI 2.3-7.2) compared to the lowest quartile.

CONCLUSION

In older, predominantly male US veterans with RA, the risk of hospitalized bacterial infections associated with rituximab or abatacept was similar to etanercept.

Use of pharmacologic agents for the primary prevention of osteoporosis among older women with low bone mass

We examined the use of pharmacologic agents for the primary prevention of osteoporosis among older women with osteopenia. We found that these individuals were not managed in concordance with the National Osteoporosis Foundation (NOF) guidelines and that self-perceived osteoporosis risk and lower bone density were strongly associated with receipt of treatment.

INTRODUCTION

Although osteoporosis medications are used for the primary prevention of osteoporosis among persons with low bone mass (osteopenia), their use may be discordant with clinical practice guidelines.

METHODS

We studied women 55 years and older participating in the Global Longitudinal Study of Osteoporosis in Women (GLOW). Eligible participants had a dual energy x-ray absorptiometry (DXA) test performed at the University of Alabama at Birmingham hospital and had an osteopenia diagnosis based on their DXA test results. Participants' demographics, fracture risk factors, and exposure to osteoporosis medications were determined from the GLOW survey. We examined the proportions of women managed in concordance with the National Osteoporosis Foundation 2008 guidelines, and we assessed factors independently associated with osteoporosis treatment decisions. Women with a prior spine or hip fracture were excluded.

RESULTS

Among 597 eligible women from GLOW, the mean age ± standard deviation (SD) was 70 ± 7 years. Among all subjects, 309 (52%) were treated in concordance with the NOF 2008 guidelines. Greater self-perceived osteoporosis risk and lower bone mineral density were significantly and consistently associated with receipt of osteoporosis treatment, both for those considered appropriate and for those considered inappropriate for treatment based on the NOF guidelines.

CONCLUSIONS

We found significant discordance between NOF 2008 guidelines and pharmacologic management of women with osteopenia. A person's self-perceived osteoporosis risk and bone mineral density were most strongly associated with receipt of osteoporosis medication use among women with low bone mass.

Initiation of TNF inhibitor therapy and change in physiologic measures in psoriasis

BACKGROUND

Psoriasis may predispose to cardiovascular disease and diabetes. However, the role of tumor necrosis factor (TNF) inhibitor in mediating this risk is controversial.

OBJECTIVE

To assess this relationship, we estimated change in metabolic physiologic measures before and after initiation of TNF inhibitor therapy compared with methotrexate (MTX) therapy among psoriasis patients.

METHODS

We conducted a retrospective cohort study, 2007-2012, using computerized clinical data for 1274 new users of TNF inhibitor and 979 new users of MTX therapy to compare change in blood pressure, lipids, triglycerides, fasting plasma glucose and body mass index (BMI) before and after start of TNF inhibitors or MTX. The study was restricted to new users. We computed within-person change in each measure, so that each patient served as their own control. In addition, we compared TNF inhibitor patients to MTX patients, by computing the adjusted difference in their group means. In secondary analyses, we examined phototherapy as a comparator.

RESULTS

Among starters of TNF inhibitor and MTX therapy, within-person change in physiologic measures at 6 months did not differ significantly. We observed no important or significant changes in any of the physiologic measures with initiation of TNF inhibitor compared with MTX. The same results were found in subgroup analyses focused on men, and on those with hypertension, diabetes mellitus, or obesity. The same results were observed with phototherapy, except that diastolic blood pressure declined by 0.6 mmHg within person during the 6 months after starting phototherapy (P < 0.05).

CONCLUSIONS

The study provides no evidence for improvement of physiologic measures associated with the metabolic syndrome resulting from TNF inhibitor use for psoriasis.

Performance of FRAX in a cohort of community-dwelling, ambulatory older men: the Osteoporotic Fractures in Men (MrOS) study

We evaluated performance of FRAX in older men who participated in the Osteoporotic Fractures in Men (MrOS) study.

INTRODUCTION

FRAX has been extensively studied in women, but there are few studies of its performance in men.

METHODS

FRAX estimates for 10-year hip fracture and major osteoporotic fracture (MOF; either hip, clinical spine, forearm, or shoulder) were calculated from data obtained from MrOS participants and compared to observed 10-year fracture cumulative incidence calculated using product limit estimate methods, accounting for competing mortality risk.

RESULTS

Five thousand eight hundred ninety-one men were followed for an average of 8.4 years. Without bone mineral density (BMD) in the FRAX model, the mean 10-year predicted fracture probabilities for hip and MOF were 3.5% and 8.9%, respectively; addition of BMD to the calculations reduced these estimates to 2.3% and 7.6%. Using FRAX without BMD, predicted quintile probabilities closely estimated cumulative incidence of hip fracture (range of observed to predicted ratios 0.9-1.1). However, with BMD in the FRAX calculation, observed to predicted hip fracture probabilities were not close to unity and varied markedly across quintiles of predicted probability. For MOF, FRAX without BMD overestimated observed cumulative incidence (range of observed to predicted ratios 0.7-0.9) and addition of BMD did not improve this discrepancy (range of observed to predicted ratios 0.7-1.1). Addition of BMD to the calculation had mixed effects on the discriminatory performance of FRAX, depending on the analysis tool applied.

CONCLUSION

Among this cohort of community-dwelling older men, the FRAX risk calculator without BMD was well calibrated to hip fracture but less well to MOF.

Magnitude and consequences of misclassification of incident hip fractures in large cohort studies: the Study of Osteoporotic Fractures and Medicare claims data

In the Study of Osteoporotic Fractures (SOF), 18.5 % of incident hip fractures identified in Medicare Fee-for-Service claims data were not reported to or confirmed by the cohort. Cognitive impairment was a modest risk factor for false-negative hip fracture ascertainment via self-report.

INTRODUCTION

Prospective cohort studies of fractures that rely on participant self-report to be the initial signal of an incident fracture could be prone to bias if a significant proportion of fractures are not self-reported.

METHODS

We used data from the SOF merged with Medicare Fee-for-Service claims data to estimate the proportion of participants who had an incident hip fracture identified in Medicare claims that was either not self-reported or confirmed (by review of radiographic reports) in SOF.

RESULTS

Between 1/1/1991 and 12/31/2007, 647 SOF participants had a hip fracture identified in Medicare claims, but 120 (18.5 %) were either not reported to or confirmed by the cohort. False-negative hip fracture ascertainment was associated with a reduced modified Mini-Mental State Exam (MMSE) score (odds ratio 1.31 per SD decrease, 95 % C.I. 1.06-1.63). Point estimates of associations of predictors of incident hip fracture were changed minimally when the misclassification of incident hip fracture status was corrected with use of claims data.

CONCLUSIONS

A substantial minority of incident hip fractures were not reported to or confirmed in the SOF. Cognitive impairment was modestly associated with false-negative hip fracture ascertainment. While there was no evidence to suggest that misclassification of incident hip fracture status resulted in biased associations of potential predictors with hip fracture in this study, false-negative incident fracture ascertainment in smaller cohort studies with limited power may increase the risk of type 2 error (not finding significant associations of predictors with incident fractures).

Heart failure risk among patients with rheumatoid arthritis starting a TNF antagonist

BACKGROUND

While heart failure (HF) is associated with elevations in tumor necrosis factor (TNF)α, several trials of TNF antagonists showed no benefit and possibly worsening of disease in those with known severe HF. We studied the risk of new or recurrent HF among a group of patients receiving these agents to treat rheumatoid arthritis (RA).

METHODS

We used data from four different US healthcare programmes. Subjects with RA receiving methotrexate were eligible to enter the study cohort if they added or switched to a TNF antagonist or another non-biological disease modifying antirheumatic drug (nbDMARD). These groups were compared in Cox regression models stratified by propensity score decile and adjusted for oral glucocorticoid dosage, prior HF hospitalisations, and the use of loop diuretics.

RESULTS

We compared 8656 new users of a nbDMARD with 11 587 new users of a TNF antagonist with similar baseline covariates. The HR for the TNF antagonists compared with nbDMARD was 0.85 (95% CI 0.63 to 1.14). The HR was also not elevated in subjects with a history of HF. But, it was elevated prior to 2002 (HR 2.17, 95% CI 0.45 to 10.50, test for interaction p=0.036). Oral glucocorticoids were associated with a dose-related gradient of HF risk: compared with no use, 1≤5 mg HR 1.30 (95% CI 0.91 to 1.85), ≥5 mg HR 1.54 (95% CI 1.09 to 2.19).

CONCLUSIONS

TNF antagonists were not associated with a risk of HF hospital admissions compared with nbDMARDs in this RA population.

Defining physiologically "normal" vitamin D in African Americans

The relationship between serum 25(OH)D and intact parathyroid hormone (iPTH) was evaluated in the Multicenter Osteoarthritis Study (MOST). No further change in iPTH was observed for African Americans with 25(OH)D levels above 20 ng/ml, suggesting that compared to Caucasians, lower vitamin D targets for sufficiency may be appropriate for African Americans.

INTRODUCTION

Vitamin D levels ≥30 ng/ml are commonly considered "normal" based upon maximal suppression of iPTH; however, this has recently been challenged and the optimal 25(OH)D level among non-Caucasians is unclear. We evaluated the cross-sectional relationship between serum 25(OH)D and iPTH in a sample of Caucasian and African American adults.

METHODS

We used baseline serum samples of participants from the Multicenter Osteoarthritis Study (MOST) for this analysis and used three methods to model the relationship between 25(OH)D and iPTH: ordinary least squares regression (OLS), segmented regression and Helmert contrasts.

RESULTS

Among Caucasians (n = 1,258), 25(OH)D and iPTH ranged from 4 to 51 ng/ml and 2 to 120 pg/ml and from 3 to 32 ng/ml and 3 to 119 pg/ml in African Americans (n = 423). We observed different thresholds between African Americans and Caucasians using each analytic technique. Using 25(OH)D as a categorical variable in OLS, iPTH was statistically higher at lower 25(OH)D categories than the 24-32 ng/ml referent group among Caucasians. However, in African Americans, the mean iPTH was only significantly higher at 25(OH)D levels below 15 ng/ml. Using segmented regression, iPTH appeared to stabilize at a lower 25(OH)D level in African Americans (19-23 ng/ml) compared to in Caucasians (>32 ng/ml). Helmert contrasts also revealed a lower threshold in African Americans than Caucasians.

CONCLUSION

Among MOST participants, the 25(OH)D thresholds at which no further change in iPTH was observed was approximately 20 ng/ml in African Americans versus approximately 30 ng/ml in Caucasians, suggesting optimal vitamin D levels in Caucasians may not be applicable to African Americans.

Incidence and risk factors for progressive multifocal leukoencephalopathy among patients with selected rheumatic diseases

OBJECTIVE

To ascertain the incidence of progressive multifocal leukoencephalopathy (PML) in patients with selected rheumatic diseases, to describe the characteristics of PML cases occurring in this setting, and to evaluate the extent to which such cases occurred in the context of biologic therapies such as rituximab or tumor necrosis factor antagonists.

METHODS

We conducted a large population-based study to describe the incidence and risk factors for PML among patients with rheumatoid arthritis, psoriatic arthritis, psoriasis, juvenile idiopathic arthritis, inflammatory bowel disease, and ankylosing spondylitis using national inpatient and outpatient administrative data from the entire Center for Medicare and Medicaid Services from 2000-2009. Suspected PML cases were identified using hospital discharge diagnosis codes. Risk factors for PML were evaluated using outpatient data ≥6 months prior to PML diagnosis.

RESULTS

Among 2,030,578 patients with autoimmune diseases of interest, a total of 53 PML cases were identified (2.6 per 100,000 patients). Most PML cases had human immunodeficiency virus (HIV) and/or cancer. Nine PML cases had evidence for biologic use prior to PML hospitalization, of which 3 had neither HIV nor malignancy and were exposed to biologics within 12 (rituximab) or 6 months (all other biologics) prior to PML diagnosis. PML occurred at an estimated incidence of 0.2 per 100,000 patients with autoimmune diseases who did not have HIV or malignancy.

CONCLUSION

PML occurs at a very low incidence among patients with rheumatic diseases but can occur even in the absence of HIV or malignancy.

Mycobacterial diseases and antitumour necrosis factor therapy in USA

OBJECTIVE

In North America, tuberculosis and nontuberculous mycobacterial (NTM) disease rates associated with antitumour necrosis factor α (anti-TNFα) therapy are unknown.

METHODS

At Kaiser Permanente Northern California, the authors searched automated pharmacy records to identify inflammatory disease patients who received anti-TNF therapy during 2000-2008 and used validated electronic search algorithms to identify NTM and tuberculosis cases occurring during anti-TNF drug exposure.

RESULTS

Of 8418 anti-TNF users identified, 60% had rheumatoid arthritis (RA). Among anti-TNF users, 18 developed NTM and 16 tuberculosis after drug start. Anti-TNF associated rates of NTM and tuberculosis were 74 (95% CI: 37 to 111) and 49 (95% CI: 18 to 79) per 100 000 person-years, respectively. Rates (per 100, 000 person-years) for NTM and tuberculosis respectively for etanercept were 35 (95% CI: 1 to 69) and 17 (95% CI: 0 to 41); infliximab, 116 (95% CI: 30 to 203) and 83 (95% CI: 10 to 156); and adalimumab, 122 (95% CI: 3 to 241) and 91 (95% CI: 19 to 267). Background rates for NTM and tuberculosis in unexposed RA-patients were 19.2 (14.2 to 25.0) and 8.7 (5.3 to 13.2), and in the general population were 4.1 (95% CI 3.9 to 4.4) and 2.8 (95% CI 2.6 to 3.0) per 100, 000 person-years. Among anti-TNF users, compared with uninfected individuals, NTM case-patients were older (median age 68 vs 50 years, p<0.01) and more likely to have RA (100% vs 60%, p<0.01); whereas, tuberculosis case-patients were more likely to have diabetes (37% vs 16%, p=0.02) or chronic renal disease (25% vs 6%, p=0.02).

CONCLUSIONS

Among anti-TNF users in USA, mycobacterial disease rates are elevated, and NTM is associated with RA.

End of life care in Italian intensive care units: where are we now?

Most patients in the ICU are unable to make decisions for themselves at the end of life (EOL), and the responsibility for these decisions falls to the medical staff and patients' relatives. Therefore, clinicians must frequently communicate with patients' relatives to understand the patients' values and preferences as they perform medical decision making. The family's role in this process varies: the entire burden of decision making could rest with the family, or family members could be informed of the decisions without admission into the decision-making process. In contrast to these two extremes, clinicians and family members may also enter into shared decision making: an exchange of views and opinions between clinicians and the patient's family to enable the two parties to reach decisions together. In this latter scenario, the effectiveness of the discussions that take place between clinicians and family members becomes a crucial marker of high-quality intensive care. In this review, we provide an overview of the current literature concerning the state of EOL care in European and Italian ICUs and then summarize several European and American recommendations for improving EOL care in the ICU. Finally, we examine the opportunity to use shared decision making to improve EOL care in the ICU through interdisciplinary communication, open and realistic discussion of prognosis with families, and an approach respecting different cultural perspectives.

Improving osteoporosis care through multimodal interventions: insights from the University of Alabama at Birmingham Center for Education and Research on Therapeutics

Despite the many advances in scientific research over the last several decades, cutting edge technologies and therapeutics often take many years to find their way into widespread use. The dissemination and uptake of best practices into clinical care is sometimes a neglected component of research that is essential to improve the population's health. Type 2 translational research, sometimes called "Proof in Practice Research," seeks to maximize the yield of what has been learned from the bench and from carefully controlled clinical trials and to extend those benefits to a larger population. One aspect of type 2 translational research, sometimes called evidence implementation or implementation science, applies what has been learned about clinical medicine to achieve best practices across providers and health systems. This article describes evidence implementation as applied to osteoporosis care, drawing from several published or ongoing studies to illustrate challenges and potential solutions in improving the quality of osteoporosis care.

Medical costs of osteoporosis in the elderly Medicare population

Prior national cost estimates of osteoporosis and fractures in the USA have been based on diverse sets of provider data or selected commercial insurance claims. Based on a random population-based sample of older adults, the US medical cost of osteoporosis and fractures is estimated at $22 billion in 2008.

INTRODUCTION

National cost estimates of osteoporosis and fractures in the USA have been based on diverse sets of provider data or selected commercial insurance claims. We sought to characterize prevalence and costs for osteoporosis using a random population-based sample of older adults.

METHODS

A cross-sectional estimate of medical cost was made with 2002 data from the Medicare Current Beneficiary Survey (MCBS). MCBS combines health interviews with claims information from all payers to profile a random sample of 12,700 Medicare recipients. Three cohorts aged 65 or over were defined: (1) patients experiencing a fracture-related claim in 2002; (2) patients with a diagnosis, medication, or self-report for osteoporosis or past hip fracture; and (3) non-case controls. The total cost of patient claims was compared to that of controls using multiple regression.

RESULTS

Of 30.2 million elderly Medicare recipients in 2002, 1.6 million (5%) were treated for a fracture that year, and an additional 7.2 million (24%) have osteoporosis without a fracture. The estimated mean impact of fractures on annual medical cost was $8,600 (95% confidence interval, $6,400 to $10,800), implying a US cost of $14 billion ($10 to $17 billion). Half of the non-fracture osteoporosis patients received drug treatment, averaging $500 per treated patient, or $2 billion nationwide.

CONCLUSIONS

The annual cost of osteoporosis and fractures in the US elderly was estimated at $16 billion, using a national 2002 population-based sample. This amount corroborates previous estimates based on substantially different methodologies. Projected to 2008, the national cost of osteoporosis and fractures was $22 billion.

Clinical and demographic factors associated with fractures among older Americans

Medicare claims data were used to investigate associations between history of previous fractures, chronic conditions, and demographic characteristics and occurrence of fractures at six anatomic sites. The study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.

INTRODUCTION

This study investigates the associations of a history of fracture, comorbid chronic conditions, and demographic characteristics with incident fractures among Medicare beneficiaries. The majority of fracture incidence studies have focused on the hip and on white females. This study examines a greater variety of fracture sites and more population subgroups than prior studies.

METHODS

We used Medicare claims data to examine the incidence of fracture at six anatomic sites in a random 5% sample of Medicare beneficiaries during the time period 2000 through 2005.

RESULTS

For each type of incident fracture, women had a higher rate than men, and there was a positive association with age and an inverse association with income. Whites had a higher rate than nonwhites. Rates were lowest among African-Americans for all sites except ankle and tibia/fibula, which were lowest among Asian-Americans. Rates of hip and spine fracture were highest in the South, and fractures of other sites were highest in the Northeast. Fall-related conditions and depressive illnesses were associated with each type of incident fracture, conditions treated with glucocorticoids with hip and spine fractures and diabetes with ankle and humerus fractures. Histories of hip and spine fractures were associated positively with each site of incident fracture except ankle; histories of nonhip, nonspine fractures were associated with most types of incident fracture.

CONCLUSIONS

This study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.

Consistency of knee pain: correlates and association with function

OBJECTIVE

The extent and factors associated with knee pain fluctuation are not well-known. We evaluated the prevalence, correlates, and association with function of consistency of knee pain.

DESIGN

Participants of the Multicenter Osteoarthritis (MOST) Study, a cohort of individuals with or at high risk of knee osteoarthritis (OA) had baseline knee X-rays, questionnaires, and a question about frequent knee pain (FKnP) (pain on most of the past 30 days) at two time points: a telephone screen and a later clinic visit. We computed the prevalence of inconsistent knee pain (positive answer to FKnP question at only one time point) and consistent knee pain (positive answer to FKnP question at both time points). We evaluated the association of consistency of FKnP with a number of sociodemographic factors, pain severity, and function.

RESULTS

There were 2940 participants with complete data (5867 knees) [mean age 62, mean body mass index (BMI) 30.7, 60% female]. Of those, 2977 knees had pain, with 43% having inconsistent and 57% having consistent knee pain. Those with radiographic OA [odds ratio (OR) 0.46], depressive symptoms (OR 0.73), and widespread pain (OR 0.68) (all P<0.05) were less likely to have inconsistent compared with consistent knee pain. Pain, function, and strength were significantly better in persons with two knees that had inconsistent compared with consistent pain.

CONCLUSIONS

A substantial proportion of persons with knee pain have inconsistent knee pain, associated with better physical function and strength (adjusting for pain severity). Such pain may be suggestive of an earlier stage of disease.