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Daniel H Solomon

Publications and source records attributed to Daniel H Solomon.

At least 19 recordsLinked to original sources
PubMed2006

Development of classification and response criteria for rheumatic diseases.

RELEVANCE TO THE CLINICIAN: Clinicians already know that not all patients who are diagnosed with rheumatic diseases really have them. Moreover, determining which patients have improved and by how much is also difficult. Classification criteria allow clinical researchers to recruit patients with similar diseases (e.g., rheumatoid arthritis or systemic lupus erythematosus) into studies. Response criteria help to determine whether treatments really work, i.e., whether they actually produce clinically important improvement. As the science of clinical research advances, we must update our standards for considering classification and response criteria. In this editorial, members of the American College of Rheumatology (ACR) Subcommittee on Classification and Response Criteria describe the purpose of criteria sets, their development and validation, and the role of the ACR in adopting them.

Americas↗
PubMed2006

The validity of a rheumatoid arthritis medical records-based index of severity compared with the DAS28.

The objective of this work was to assess the convergent validity of a previously developed rheumatoid arthritis medical records-based index of severity (RARBIS) by comparing it with the 28-joint Disease Activity Score (DAS28). This study was conducted in subjects within the Brigham and Women's Hospital Rheumatoid Arthritis Sequential Study (BRASS). We selected 100 patients with rheumatoid arthritis (RA) from the BRASS with DAS28 scores equally distributed in four quartiles. The medical records were reviewed to calculate the RARBIS, which includes indicators from the following categories: prior surgical history, radiologic and laboratory findings, clinical and functional status, and extra-articular manifestations. The Spearman correlation between the RARBIS and the DAS28 was assessed in the total study population and in relevant subgroups. We re-weighted on subscales and recalculated the RARBIS score. This was performed based on findings of correlations between the DAS28 and subscales; and also the result from a multiple linear regression with the DAS28 (as a dependent variable) and five subscales (as independent variables). The mean RARBIS was 4.36 (range 0-11). Among the total study cohort, the RARBIS was moderately correlated with the DAS28 (r = 0.41, 95% confidence interval [CI] 0.23-0.56). In subgroup analyses, including age, gender, rheumatoid factor status, and disease duration, we found no statistically significant differences in the correlations. After re-weighting, the correlation between the RARBIS and the DAS28 was somewhat improved (r = 0.48, 95% CI 0.31-0.62). In conclusion, the RARBIS correlated moderately well with the DAS28 in this population. The RARBIS has both face and convergent validity for patients with RA and relevant subgroups and may have application for medical records studies in patients with RA.

Arthritis, Rheumatoid↗
PubMed2006

Prescription opioid use among older adults with arthritis or low back pain.

OBJECTIVE: To examine patterns of chronic opioid use in selected groups with arthritis and low back pain and compare them with patterns among persons with ischemic heart disease. METHODS: The study database consisted of Medicare beneficiaries who were enrolled in a drug benefit program for low-to-moderate income Pennsylvania residents. We identified selected patients who had a diagnosis of rheumatoid arthritis, osteoarthritis, chronic low back pain, or ischemic heart disease since 1995. Chronic opioid use, defined as at least six 30-day prescriptions in a year, was the endpoint of interest. We examined the proportion of patients meeting this definition during the period 1996-2001 and determined predictors based on multivariable Cox proportional hazards models. RESULTS: Four percent of subjects with rheumatoid arthritis used opioids chronically in 2001, compared with <1% in each of the other groups. There was no increase in the chronic use of opioids over the 6-year study period. Low-potency opioids were the most commonly prescribed preparations for chronic users from all patient groups. The prior use of medicines for psychiatric illness, including benzodiazepines or barbiturates, was associated with chronic prescription opioid use across all diagnoses. However, subjects with a prior diagnosis of psychiatric illness were less likely to receive chronic opioids. CONCLUSION: Chronic opioid use is relatively uncommon, even among older individuals with arthritis or low back pain. The proportion of these individuals receiving such medicines has not increased in the late 1990s. There seems to be a complex relationship between psychiatric medication use, psychiatric diagnoses, and the use of chronic opioids among these individuals.

Aged↗
PubMed2006

Development of a preliminary index that predicts adverse events after total knee replacement.

OBJECTIVE: We undertook this study to assess the relationships between hospital characteristics, volume of procedures, and perioperative outcomes after total knee replacement (TKR), and to use this information to construct a simple predictive index for perioperative outcomes that incorporates hospital- and patient-level characteristics. METHODS: We studied Medicare beneficiaries who underwent TKR in 4 US states in 2000. Orthopedic surgery administrators from hospitals caring for patients in this sample were surveyed about a range of hospital characteristics. The relationships between these hospital characteristics, patient variables, and 90-day postoperative adverse events (including death, pulmonary embolus, pneumonia, deep wound infection, and acute myocardial infarction) were assessed using generalized estimating equations adjusting for hospital volume. These relationships were assessed in low- and high-risk patient groups. Variables from the final multivariate model were used to create an index that was tested against 90-day adverse event rates. RESULTS: Three hundred twenty-seven (3.6%) of the patients undergoing TKR in our sample experienced an adverse event. In the final multivariate regression models, variables that predicted adverse perioperative events included low hospital volume (fewer than 23 TKRs in the Medicare population per year), absence of a preoperative teaching program, fewer TKRs conducted in a dedicated orthopedic surgery operating room, patient age >70 years, male sex, and at least 1 comorbid condition. The effect of volume on perioperative adverse events was evident both in patients with few risk factors and in patients with several risk factors. An index including the 6 patient and hospital variables discriminated well, with adverse events occurring in 2.0% (95% confidence interval [95% CI] 1.4-2.7%) of patients in the lowest risk category and in 7.4% (95% CI 4.5-12.3%) of patients in the highest risk category (P for trend < 0.001). The index predicted adverse event rates both in hospitals with a low volume of TKRs and in those with a high volume of TKRs. CONCLUSION: Characteristics of hospital care, procedure volume, and patient-level factors are all associated with perioperative outcomes of TKR. A preliminary index combining hospital characteristics and volume is moderately predictive of adverse perioperative outcomes. The index is predictive of outcome in low- and high-volume hospitals.

Aged↗
PubMed2006

Cardiovascular outcomes in new users of coxibs and nonsteroidal antiinflammatory drugs: high-risk subgroups and time course of risk.

OBJECTIVE: Controversy persists regarding the cardiovascular risks of treatment with selective cyclooxygenase 2 inhibitors (coxibs) and nonselective nonsteroidal antiinflammatory drugs (NSAIDs). This study was undertaken to examine, in a large group of new users of coxibs and NSAIDs, the rate of cardiovascular events, their time course, and whether baseline cardiovascular risk modified the rate ratios (RRs) for future events. METHODS: This cohort study included Medicare beneficiaries who enrolled in a state-run prescription drug plan that fully covered NSAIDs and coxibs without restriction. All study patients started use of a coxib or NSAID after January 1, 1999. The primary composite end point was a hospital admission for either myocardial infarction or ischemic stroke. Predefined exposure groups included the 3 coxibs available in the US during the study period (celecoxib, rofecoxib, and valdecoxib), as well as oral formulations of diclofenac, ibuprofen, naproxen, and a composite of all other NSAIDs. We compared the rate of cardiovascular events associated with each of these agents with that in a reference group of patients who did not use NSAIDs or coxibs, but started other medications unrelated to cardiovascular risk. Daily exposure to all study drugs was assessed based on filled prescription data. A Cox proportional hazards model stratified on calendar year that included other baseline cardiovascular risk factors constituted the primary analysis. RESULTS: We identified 74,838 users of NSAIDs or coxibs, and 23,532 comparable users of other drugs comprised the reference group. Adjusted models demonstrated a significant elevation in the event rate for rofecoxib (RR 1.15, 95% confidence interval [95% CI] 1.06-1.25) and a significant reduction in the rate for naproxen (RR 0.75, 95% CI 0.62-0.92). No other coxib or NSAID was associated with a significant increase or decrease in cardiovascular event rate. The increased rate associated with rofecoxib was seen in the first 60 days of use (adjusted RR 1.14, 95% CI 1.01-1.29) and thereafter (adjusted RR 1.14, 95% CI 1.02-1.28). Kaplan-Meier event curves showed a similar pattern of risk (early and persistent separation of the event curves) among long-term rofecoxib users at low or high baseline cardiovascular risk. CONCLUSION: We found an increased cardiovascular event rate among users of rofecoxib, and a decreased rate with naproxen use. Other coxibs and NSAIDs did not appear to be associated with a difference in event rate compared with users of other drugs. The increase in rate associated with rofecoxib was seen within the first 60 days and persisted. There was no important modification of the event rate based on the patient's baseline cardiovascular risk.

Aged↗
PubMed2006

The cardiovascular manifestations of rheumatic diseases.

PURPOSE OF REVIEW: To review the cardiovascular manifestations of several more common rheumatic conditions in the light of the recent reported literature. RECENT FINDINGS: Evidence that chronic inflammation is associated with the occurrence of cardiac events in people both with and without chronic inflammatory joint disease is emerging. Both atherosclerosis and rheumatic diseases, however, have a complicated cause, and it is likely that inflammation contributes to other environmental and host risk factors in these patients. Treatments used to suppress inflammation in many rheumatic conditions have the potential to reduce cardiovascular disease morbidity as well as improve musculoskeletal function. SUMMARY: Cardiovascular morbidity and mortality have been found to be increased in association with many of the rheumatic diseases. In particular, coronary heart disease seems to be associated with inflammatory rheumatic conditions. Whilst it is likely that chronic systemic inflammation promotes accelerated atherosclerosis in these patients, the mechanisms by which this occurs are complex and the effects of treatment and other cardiovascular risk factors need to be considered.

Cardiovascular Diseases↗
PubMed2006

Evaluating short-term drug effects using a physician-specific prescribing preference as an instrumental variable.

BACKGROUND: Postmarketing observational studies of the safety and effectiveness of prescription medications are critically important but fraught with methodological problems. The data sources available for such research often lack information on indications and other important confounders for the drug exposure under study. Instrumental variable methods have been proposed as a potential approach to control confounding by indication in nonexperimental studies of treatment effects; however, good instruments are hard to find. METHODS: We propose an instrument for use in pharmacoepidemiology that is based on a time-varying estimate of the prescribing physician's preference for one drug relative to a competing therapy. The use of this instrument is illustrated in a study comparing the effect of exposure to COX-2 inhibitors with nonselective, nonsteroidal antiinflammatory medications on gastrointestinal complications. RESULTS: Using conventional multivariable regression adjusting for 17 potential confounders, we found no protective effect due to COX-2 use within 120 days from the initial exposure (risk difference = -0.06 per 100 patients; 95% confidence interval = -0.26 to 0.14). However, the proposed instrumental variable method attributed a protective effect to COX-2 exposure (-1.31 per 100 patients; -2.42 to -0.20) compatible with randomized trial results (-0.65 per 100 patients; -1.08 to -0.22). CONCLUSIONS: The instrumental variable method that we have proposed appears to have substantially reduced the bias due to unobserved confounding. However, more work needs to be done to understand the sensitivity of this approach to possible violations of the instrumental variable assumptions.

Aged↗
PubMed2006

Prior authorization policies for selective cyclooxygenase-2 inhibitors in Medicaid: a policy review.

BACKGROUND: Many state Medicaid programs use prior authorization programs to limit spending on cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs (coxibs). However, the evidence base for the prior authorization criteria has not been examined previously. METHODS: We determined whether prior authorization was required for coxibs in state Medicaid programs and collected data on what precise criteria needed to be met for a coxib prescription to be authorized. Prior authorization criteria were compared to clinical evidence regarding which patients are most likely to benefit from coxibs. RESULTS: By mid-2004, 35 states had implemented prior authorization requirements for coxibs. Of 5 major clinical factors that identify patients likely to benefit from coxibs, 18 states (51%) included all 5 factors and 9 states (26%) included 2 or fewer. Most states (33/35; 94%) required a previous trial of nonselective nonsteroidal anti-inflammatory drugs before a coxib would be authorized. Several prior authorization programs included factors that had no connection to the clinical evidence. CONCLUSIONS: State Medicaid prior authorization policies for coxibs are heterogeneous in terms both of the criteria required to obtain a coxib and of the relationship of those criteria to clinical evidence. Development of clinically rational prescription drug policies should be a goal for all health insurers and represents an important priority for Medicare's prescription drug benefit program.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2006

Incidental vertebral fractures on chest radiographs. Recognition, documentation, and treatment.

BACKGROUND: Recognition of incidental vertebral fractures may be an important opportunity for identifying and treating osteoporosis. OBJECTIVE: To assess osteoporosis documentation rates in patients with vertebral fractures, and to define patient and hospitalization characteristics associated with osteoporosis management. DESIGN: Hospital and outpatient records were abstracted for patients with vertebral fractures on inpatient radiograph reports. The primary outcome of interest was discharge summary fracture documentation. Covariates associated with fracture documentation and treatment were examined with multivariate regression models. Secondary outcomes included osteoporosis documentation and management 6 months following discharge. PATIENTS: Women > or =50 years hospitalized at an academic medical center. RESULTS: Among 10,291 women with chest radiographs, 142 (1.4%) had vertebral fractures reported. Among patients with a reported fracture, 58 (41%) had their fracture noted in the findings section but not in the final impression. Only 23 (16%) discharge summaries documented a vertebral fracture. Factors associated with documentation of the fracture in the discharge summary included notation of the fracture in the impression section (odds ratio [OR] 3.7, 95% confidence interval [CI] 1.0 to 13.1), tobacco use (OR 3.7; 95% CI 1.1 to 12.2), discharge from a medical service (OR 7.6; 95% CI 0.9 to 66.2) and glucocorticoid use (OR 3.7; 95% CI 0.8 to 17.0). Only 36% of patients were using any osteoporosis medications at discharge. Fracture notation in the impression section was associated with fracture documentation in subsequent outpatient notes (OR 3.6, 95% CI 0.9 to 13.8). Discharge summary fracture documentation was associated with an increased likelihood of starting an osteoporosis medication by 6 months (OR 2.8; 95% CI 0.8 to 9.2). CONCLUSIONS: Incidental vertebral fractures from inpatient chest radiographs may represent a missed opportunity for osteoporosis management.

Aged↗
PubMed2006

Effect of the Women's Health Initiative on osteoporosis therapy and expenditure in Medicaid.

UNLABELLED: Decreasing HRT use among postmenopausal women may have a reciprocal impact on other osteoporosis therapy. Time series analysis of prescribing trends for millions of Medicaid beneficiaries revealed a 57% decline in HRT without augmenting the pace of bisphosphonate use. Prescribing changes dramatically increased Medicaid spending on osteoporosis therapy over the last decade and requires further evaluation of cost effectiveness. INTRODUCTION: Hormone replacement therapy (HRT) has been commonly prescribed to postmenopausal women, but its use is decreasing because adverse cardiac outcomes were reported by the Women's Health Initiative (WHI) in July 2002. The reciprocal impact of the WHI on other osteoporosis medications use and expenditure is unknown. MATERIALS AND METHODS: We conducted a time series analysis on prescription data from 50 state Medicaid programs between 1995 and 2004. Five medication categories were used: HRT, bisphosphonates, calcium, calcitonin, and raloxifene. RESULTS: HRT was increasing before publication of the WHI, reaching 5 million prescriptions per year by mid-2002 (136 prescriptions per 1000 beneficiaries). Bisphosphonate prescribing rose in parallel until mid-2002. WHI publication was associated with a rapid reduction in HRT use, declining 57% by mid-2004 to an average of 59 prescriptions per 1000 beneficiaries (p = 0.01). WHI publication did not augment bisphosphonates' nearly linear rate of rise (p = 0.43) as their prescribing pace continued, whereas HRT declined. Medicaid spending on osteoporosis therapy also changed dramatically during the last decade, as yearly expenditure increased 664% from 1465 US dollars to 9742 US dollars per 1000 beneficiaries. Over this period, a significant shift from daily to weekly bisphosphonates also occurred. CONCLUSIONS: A dramatic decline in HRT and continued rise in bisphosphonate prescribing has occurred since the publication of the WHI. During this time, there have also been substantial increases in osteoporosis medication spending within Medicaid. Determining whether these trends are clinically appropriate and cost effective for osteoporosis therapy will have important implications for the development of future drug reimbursement programs, especially for elderly patients.

Calcitonin↗
PubMed2006

The patient's perspective on the recall of Vioxx.

OBJECTIVE: Rofecoxib was recalled in September 2004 when studies identified increased cardiovascular risk compared with placebo among patients taking rofecoxib. We examined the reactions of people with arthritis to this recall. METHODS: Telephone interviews were conducted between December 2004 and February 2005 in a previously assembled community based cohort (n = 1085) with disabling hip/knee osteoarthritis (OA) residing in 2 regions of Ontario, Canada (one urban, one rural). Respondents' self-reported experience with cyclooxygenase (COX-2) selective nonsteroidal antiinflammatory drugs (NSAID; coxibs), issues around communication of the recall, attitudes about pain medications, and understanding of the rofecoxib-associated cardiovascular risks were assessed. Participants were also asked about contraindications for traditional NSAID use (specific clinical conditions, use of blood thinners and glucocorticoids, and history of gastrointestinal (GI) ulcer and/or bleeding). RESULTS: The response rate was 93.5%; 968 completed the survey. Half (53.0%) had used a coxib for arthritis; 277 (28.6%) had used rofecoxib. Only 3.8% of "ever" coxib users reported previous GI ulcer or hemorrhage. 94.8% of respondents had heard about the recall; most (94.7%) had heard via television. Among the 83 individuals taking rofecoxib at recall, 90.4% had been offered another pain medication, mainly another coxib. Most of the 968 participants (> 60%) were unfamiliar with rofecoxib-associated cardiovascular risks. Of those with an opinion, most overestimated the absolute risk associated with rofecoxib (55.7% cited a risk > 5 events/100 people/year). CONCLUSION: In an elderly community cohort with OA, the prevalence of coxib use was high despite few major contraindications to NSAID. Many were unaware of or overestimated the absolute risks associated with rofecoxib use, highlighting the need for strategies by which physicians/pharmacists can provide their patients with timely and accurate drug safety information.

Aged↗
PubMed2006

Interactive voice response telephone calls to enhance bone mineral density testing.

OBJECTIVE: Bone mineral density (BMD) testing is a key tool used to diagnose and treat osteoporosis. We assessed the rate of scheduling BMD tests among health plan members at risk for osteoporosis who received interactive voice response (IVR) calls. STUDY DESIGN: Cohort study. METHODS: Study patients included persons age 45 years with either a prior fracture or 90 days of glucocorticoid use and all women age 65 years during the 2-year baseline period. The IVR call provided educational content and then offered members an opportunity to transfer to schedule a BMD test. The primary outcome was scheduling a BMD test. RESULTS: We targeted 1402 health plan members, and 708 (50%) were successfully contacted. Of 54 patients who transferred to schedule a BMD test, only 3 actually did so. Because so few patients scheduled a BMD test, predictors of transfer were examined as a secondary end point. In a multivariate model, only self-reported intention to schedule a BMD test was a significant predictor (odds ratio = 4.4, 95% confidence interval = 2.2, 8.8). Members' age, sex, history of a prior fracture, self-report of a BMD test in the previous 2 years, acknowledgement of barriers to BMD testing, and discussion of BMD testing with one's physician were not related to transferring to schedule a BMD test. CONCLUSION: A letter and an IVR call prompted few to schedule a BMD test. More interventions to improve BMD testing should be developed and tested.

Aged↗
PubMed2005

Risk of death in elderly users of conventional vs. atypical antipsychotic medications.

BACKGROUND: Recently, the Food and Drug Administration (FDA) issued an advisory stating that atypical antipsychotic medications increase mortality among elderly patients. However, the advisory did not apply to conventional antipsychotic medications; the risk of death with these older agents is not known. METHODS: We conducted a retrospective cohort study involving 22,890 patients 65 years of age or older who had drug insurance benefits in Pennsylvania and who began receiving a conventional or atypical antipsychotic medication between 1994 and 2003. Analyses of mortality rates and Cox proportional-hazards models were used to compare the risk of death within 180 days, less than 40 days, 40 to 79 days, and 80 to 180 days after the initiation of therapy with an antipsychotic medication. We controlled for potential confounding variables with the use of traditional multivariate Cox models, propensity-score adjustments, and an instrumental-variable analysis. RESULTS: Conventional antipsychotic medications were associated with a significantly higher adjusted risk of death than were atypical antipsychotic medications at all intervals studied (< or =180 days: relative risk, 1.37; 95 percent confidence interval, 1.27 to 1.49; <40 days: relative risk, 1.56; 95 percent confidence interval, 1.37 to 1.78; 40 to 79 days: relative risk, 1.37; 95 percent confidence interval, 1.19 to 1.59; and 80 to 180 days: relative risk, 1.27; 95 percent confidence interval, 1.14 to 1.41) and in all subgroups defined according to the presence or absence of dementia or nursing home residency. The greatest increases in risk occurred soon after therapy was initiated and with higher dosages of conventional antipsychotic medications. Increased risks associated with conventional as compared with atypical antipsychotic medications persisted in confirmatory analyses performed with the use of propensity-score adjustment and instrumental-variable estimation. CONCLUSIONS: If confirmed, these results suggest that conventional antipsychotic medications are at least as likely as atypical agents to increase the risk of death among elderly persons and that conventional drugs should not be used to replace atypical agents discontinued in response to the FDA warning.

Aged↗
PubMed2005

Compliance with osteoporosis medications.

BACKGROUND: Long-term compliance with pharmacologic treatments for many asymptomatic conditions may be suboptimal, but little is known about compliance with medications used for osteoporosis. This study was undertaken to assess the level and determinants of compliance with drugs prescribed for osteoporosis. METHODS: This retrospective cohort study used pharmacy claims data from US Medicare and filled prescriptions from a state pharmaceutical benefits program. We included persons 65 years or older who initiated use of a medication for osteoporosis (alendronate sodium, calcitonin, hormone therapy, raloxifene hydrochloride, or risedronate) from January 1, 1996, through December 31, 2002. The outcome of interest was suboptimal medication compliance, defined as equal to or less than 66% of days with medication during a 60-day period. RESULTS: One year after initiating treatment for osteoporosis, 45.2% of the 40,002 patients were not continuing to fill prescriptions. Five years after initiation, 52.1% of patients were not continuing to fill prescriptions for an osteoporosis medication. Several characteristics independently predicted compliance: female sex, younger age, fewer comorbid conditions, using fewer nonosteoporosis medications, bone mineral density testing before and after initiating a medication, a fracture before and after initiating a medication, and nursing home residence during the 12 months before initiating a medication. However, models adjusted for the significant patient variables explained only 6% of the variation in compliance. CONCLUSIONS: Most patients who initiate a medication for osteoporosis do not continue to take it as prescribed. Although several patient characteristics significantly correlated with compliance, adjusted models explained little of the variation.

Age Distribution↗
PubMed2005

Explained variation in a model of therapeutic decision making is partitioned across patient, physician, and clinic factors.

BACKGROUND AND OBJECTIVE: Data on therapeutic decision making have a multilevel structure that can include patient-, provider-, and facility-level variables. A statistical method is presented for attributing explained variation in patient care to different levels of aggregation in a multilevel model with the aim of prioritizing and targeting quality improvement interventions. STUDY DESIGN AND SETTING: The proposed method is used in an analysis of adherence to evidence-based guidelines for the care of patients at risk of osteoporosis. Explained variation from a multilevel model of appropriate care is partitioned across patient-, physician-, and clinic-level factors. RESULTS: The combination of patient, physician, and clinic factors explained 20.0% of the variation in patient care. Individual physician effects explained 14.0% of the variation in the data; however, more than half of this explained variation could have been attributed to the individual clinic effect. Patient fixed effects alone explained 13.4% of the variation in the observed clinical decisions. CONCLUSION: The proposed approach is an intuitive and statistically valid method for attributing explained variation in a multilevel analysis of therapeutic decision making.

Administration, Oral↗
PubMed2005

Nonsteroidal antiinflammatory drugs and nonunion of humeral shaft fractures.

OBJECTIVE: To analyze the relationship between nonunion of humeral shaft fractures and nonsteroidal antiinflammatory drug (NSAID) exposure in older adults. METHODS: A cohort of 9,995 patients with humeral shaft fractures was identified using diagnosis and procedure codes from a Medicare database of >500,000 patients. Prescription NSAID as well as prescription opioid use was assessed from pharmacy claims data for 3 30-day periods immediately after the initial fracture. Nonunion was defined by the presence of procedure codes for repair of nonunion 90-365 days after the index fracture. We examined the association between NSAIDs and nonunion using multivariate Cox proportional hazards models. RESULTS: Of the 9,995 humeral shaft fractures, 105 patients developed nonunions (1.1%), and 1,032 (10.3%) were exposed to NSAIDs in the 90 days after fracture. NSAID exposure within the first 90 days was significantly associated with nonunion (relative risk [RR] 3.7, 95% confidence interval [95% CI] 2.4-5.6). When indicators for exposure to NSAIDs during each of the 3 30-day windows were placed into the same multivariate model, only the period 61-90 days post-fracture was significantly associated with nonunion (RR 3.9, 95% CI 2.0-6.2). We observed a similar association between opioids and nonunion, with exposure to opioids between 61 and 90 days associated with nonunion (RR 2.7, 95% CI 1.5-5.2), but exposure to opioids during neither of the 2 earlier 30-day periods significantly associated with nonunion. CONCLUSION: We found that exposure to nonselective NSAIDs or opioids in the period 61-90 days after a humeral shaft fracture was associated with nonunion. Although these associations may be causal, they are more likely to reflect the use of analgesics by patients with painful nonhealing fractures.

Aged↗
PubMed2005

Development and assessment of indicators of rheumatoid arthritis severity: results of a Delphi panel.

OBJECTIVE: To develop a set of indicators for assessing the severity of rheumatoid arthritis (RA) through medical records. METHODS: A list of 47 potential indicators of RA was reviewed by an expert Delphi panel of 6 rheumatologists. The Delphi method is a formal approach for gathering expert opinion. The 47 potential indicators included items from the following 5 categories: radiologic and laboratory findings, clinical and functional status measures, extraarticular manifestations, prior surgical history, and medications. The panelists rated the potential indicators' relationship to RA disease severity. Each panelist rated each indicator on a scale of 0-6, in which 0 indicated no relationship at all with severe RA and 6 indicated a perfect relationship with severe RA. After a baseline set of ratings, a literature review was distributed to the panelists along with the panel's initial mean ratings and the ranges. The panelists then met to discuss the literature and rerate all indicators. RESULTS: After repeat ratings and review of relevant literature, the panel rated 28 of 47 (60%) potential indicators as having a strong or very strong relationship to severe RA. These 28 indicators were drawn from all 5 categories of potential indicators. There was agreement among the panelists on ratings for 41 of 47 indicators. Agreement was defined as a range of scores among the panelists </=3. CONCLUSION: A Delphi panel of rheumatologists agreed that data generally available in medical records may serve as potential indicators of severe RA.

Antirheumatic Agents↗