Biomedical subjects

J Avorn

Publications and source records attributed to J Avorn.

At least 37 records · Page 2Linked to original sources

PubMed2001

Paradoxical relations of drug treatment with mortality in older persons.

Medication use patterns provide popular surrogate measures of disease, yet selective under-use of drugs by elderly patients with potentially unmeasured comorbidity may lead to artifactual "protective" associations between use of specific drugs and mortality. We examined the relation between use of 20 common classes of drugs and mortality among the 129,111 residents of New Jersey 65-99 years of age who had at least one hospitalization during the years 1991-1994 and filled prescriptions through either Medicaid or that state's Pharmacy Assistance for the Aged and Disabled program. Each study drug class was used by more than 5,000 subjects during the 120 days before hospitalization; 41,930 subjects died in the hospital or during the year after discharge. Users of drugs from each of seven therapeutic classes had reduced age- and sex-adjusted rates of death relative to non-users: lipid-lowering agents, nonsteroidal anti-inflammatory agents, beta blockers, thiazides, glaucoma drugs, calcium channel blockers, and anti-anxiety drugs. Adjustment for comorbidity and polypharmacy had little effect on these results. We found similar results in a separate nonhospitalized cohort of 132,071 elderly persons. Much of this observed association appears to be nonetiologic. These findings raise concerns about using observational studies in high-risk populations to infer associations between drug use and outcomes.

Age Factors↗

PubMed2001

Zolpidem use and hip fractures in older people.

OBJECTIVES: The widespread use of sedative-hypnotics in older populations makes it imperative to identify hazardous regimens that should be avoided and safer regimens that may be used preferentially by older people. Although benzodiazepines have been shown to increase fall and fracture risk, zolpidem, a nonbenzodiazepine hypnotic, has been advocated as a safer alternative. DESIGN: Case-control study of hip fracture cases and controls in 1994. SETTING: All subjects were age 65 and older and enrolled in Medicare, and in Medicaid or the Pharmaceutical Assistance to the Aged and Disabled program of New Jersey. PARTICIPANTS: Cases (n=1,222) were patients who underwent surgical repair of a hip fracture. They were frequency-matched to four controls (n=4,888) based on age and gender. MEASUREMENTS: Use of sedative-hypnotics and other medications was assessed in the 180 days before the index event. We assessed other covariates, including demographic, clinical, and healthcare utilization variables in the prior 180 days. RESULTS: Zolpidem use was associated with a significant increased risk of hip fracture (adjusted odds ratio (AOR) 1.95; 95% confidence interval (CI)=1.09-3.51). Other psychotropic medication classes with significantly increased risks included benzodiazepines (AOR 1.46; 95% CI=1.21-1.76), antipsychotic medications (AOR 1.61; 95% CI=1.29-2.01), and antidepressants (AOR 1.46; 95% CI=1.22-1.75). In subanalyses, preferential use of zolpidem by subjects at greater risk of hip fracture did not appear to explain the apparent risk of hip fracture with zolpidem use. CONCLUSION: Use of zolpidem by older people was associated with nearly twice the risk of hip fracture, even after controlling for possible demographic and clinical confounders. Rather than being a safer alternative, zolpidem may be associated with risks that are as great as those seen with conventional benzodiazepines in older patients.

Aged↗

PubMed2001

Predictors of uncontrolled hypertension in ambulatory patients.

Hypertension remains poorly controlled in the United States. Improvement of its management will require an understanding of the patient characteristics and treatment factors associated with uncontrolled hypertension. We studied antihypertensive medication use, comorbidity, and blood pressure measurements for 525 hypertensive patients in 3 different healthcare systems over a 1-year period. We concomitantly conducted comprehensive patient interviews covering demographic factors, knowledge of hypertension and its treatment, and medication side effects. Ordinal logistic regression was used to identify factors associated with poor blood pressure control. Mean age of the patients was 65+/-11 years. Mean systolic blood pressure (SBP) was 143+/-15 mm Hg; and mean diastolic blood pressure (DBP), 80+/-9 mm Hg. Only 39% (203/525) of patients had mean blood pressure <140/90 mm Hg during the study period; about half (257/525) had stage 1 hypertension (mean SBP 140 to 159 mm Hg and/or mean DBP 90 to 99 mm Hg), and 12% (65/525) had stage 2 or greater hypertension (SBP >160 mm Hgand/or DBP >100 mm Hg). Multivariate analysis revealed several independent predictors of poor control: older age, multi-drug regimens, lack of knowledge by the patient of their target SBP, and a report of antihypertensive drug side effects. Patients with angina had a higher likelihood of adequate blood pressure control. Fewer than 40% of the treated patients studied had a mean blood pressure </=140/90 mm Hg, and specific patient-related factors appear to predict poor control. Some of these may be amenable to modification. Further identification of patients at risk of poor control can lead to targeted interventions to improve management.

Aged↗

PubMed2001

Hazardous benzodiazepine regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture.

OBJECTIVE: While benzodiazepine treatment is known to increase the risk of hip fracture in older populations, controversy persists over which characteristics of benzodiazepine use (e.g., elimination half-life, dosage, duration of use) are most associated with such risks. METHOD: The authors reviewed the health care utilization data of 1,222 hip fracture patients and 4,888 comparison patients frequency matched on the basis of age and gender (all were at least 65 years old). Patients were enrolled in Medicare as well as in the New Jersey Medicaid or Pharmaceutical Assistance to the Aged and Disabled programs. Benzodiazepine use, as well as other covariates, were assessed before the index date (which was either the date of hospital admission for hip fracture surgical repair or, for the comparison subjects, a randomly assigned, frequency-matched date). RESULTS: All benzodiazepine doses > or =3 mg/day in diazepam equivalents significantly increased the adjusted risk of hip fracture by 50%. Significantly increased adjusted risks of hip fracture were seen during the initial 2 weeks of use (60% increase) and after more than 1 month of continuous use (80% increase) but not for 2-4 weeks of continuous use. Use of benzodiazepines other than long-acting agents significantly increased the risk of hip fracture by 50%. CONCLUSIONS: Even at modest doses, including some low doses currently advocated in prescribing guidelines for older patients, treatment with benzodiazepines appears to increase the risk of hip fracture. Patients appear to be particularly vulnerable immediately after initiating therapy and after more than 1 month of continuous use. Benzodiazepines with shorter half-lives appear to be no safer than longer half-life agents. Clinicians should be aware of these risks and weigh them against potential benefits when prescribing for elderly patients.

Aged↗

PubMed2000

Immune tolerance induction in hemophilia patients with inhibitors: costly can be cheaper.

The development of inhibitory antibodies to factor VIII (FVIII) occurs in approximately 30% to 40% of patients with severe hemophilia A. Management options for patients with inhibitor include eradicating it via immune tolerance induction (ITI) or treating bleeding episodes with large quantities of hemostatic agents. ITI is costly, approaching $1 million for the average 5-year-old, but if successful results in improved clinical outcomes. We constructed a decision analysis using the Markov process to model expected clinical outcomes and costs over a lifetime for a typical 5-year-old hemophiliac with high inhibitor levels. Estimates of relevant variables were based on a thorough review of the medical literature. Outcomes modeled included total lifetime costs as well as life expectancy. The decision analytic model revealed that the ITI strategy was associated with an increase in projected life expectancy of 4.6 years. Total estimated lifetime costs for the ITI strategy were approximately $1.7 million less per patient. Sensitivity analyses over clinically and economically reasonable ranges did not change these findings. The insight that ITI can achieve an improved clinical outcome while being cost-saving is not reflected in many current treatment regimens. This example also illustrates that expensive therapy for patients with a chronic disease may be cost effective when analyzed from a societal perspective over the patient's lifetime. This finding has important policy implications for medical decision makers at many levels and reinforces the need to undertake pharmacoeconomic analyses and choose therapies from a long-term, societal perspective. (Blood. 2000;96:1698-1702)

Cost-Benefit Analysis↗

PubMed2000

Incidence and preventability of adverse drug events in nursing homes.

PURPOSE: Adverse drug events, especially those that may have been preventable, are among the most serious concerns about medication use in nursing homes. We studied the incidence and preventability of adverse drug events and potential adverse drug events in nursing homes. METHODS: We performed a cohort study of all long-term care residents of 18 community-based nursing homes in Massachusetts during a 12-month observation period. Potential drug-related incidents were detected by stimulated self-report by nursing home staff and by periodic review of the records of nursing home residents by trained nurse and pharmacist investigators. Each incident was classified by 2 independent physician-reviewers, using a structured implicit review process, by whether or not it constituted an adverse drug event or potential adverse drug event (those that may have caused harm, but did not because of chance or because they were detected), by the severity of the event (significant, serious, life-threatening, or fatal), and by whether it was preventable. Examples of significant events included nonurticarial rashes, falls without associated fracture, hemorrhage not requiring transfusion or hospitalization, and oversedation; examples of serious events included urticaria, falls with fracture, hemorrhage requiring transfusion or hospitalization, and delirium. RESULTS: During 28,839 nursing home resident-months of observation in the 18 participating nursing homes, 546 adverse drug events (1.89 per 100 resident-months) and 188 potential adverse drug events (0.65 per 100 resident-months) were identified. Of the adverse drug events, 1 was fatal, 31 (6%) were life-threatening, 206 (38%) were serious, and 308 (56%) were significant. Overall, 51% of the adverse drug events were judged to be preventable, including 171 (72%) of the 238 fatal, life-threatening, or serious events and 105 (34%) of the 308 significant events (P < 0.001). Errors resulting in preventable adverse drug events occurred most often at the stages of ordering and monitoring; errors in transcription, dispensing, and administration were less commonly identified. Psychoactive medications (antipsychotics, antidepressants, and sedatives/hypnotics) and anticoagulants were the most common medications associated with preventable adverse drug events. Neuropsychiatric events were the most common types of preventable adverse drug events. CONCLUSIONS: Adverse drug events are common and often preventable in nursing homes. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the ordering and monitoring stages of pharmaceutical care.

Accidental Falls↗

PubMed2000

Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics.

The use of antibiotics in both ambulatory and inpatient settings is heavily shaped by cultural and economic factors as well as by microbiological considerations. These nonpharmacologic factors are relevant to clinicians and policymakers because of the clinical and fiscal toll of inappropriate antibiotic prescribing, including excessive use, preventable adverse effects, and the increasing prevalence of resistant organisms. An understanding of the determinants of antibiotic consumption is critical to explain current patterns of use and to devise programs to reduce inappropriate use. Patient motivations include the desire for a tangible product of the clinical encounter coupled with incorrect perceptions of the effectiveness of antibiotics, particularly in viral infections. Physician behavior can be explained by such factors as lack of information, a desire to satisfy patient demand, and pressure from managed care organizations to speed throughput. Marketing campaigns directed at both physicians and patients further serve to increase demand, especially for newer, costlier products. Studies of antibiotic use patterns in inpatient and outpatient care consistently demonstrate considerable inappropriate prescribing, which is likely to exacerbate the emergence of resistant organisms. Several approaches have been shown to improve the rationality of antibiotic use. Computer-based algorithms or reminders can prompt physicians to improve antibiotic choices at the time of prescribing; paper-based order entry forms can achieve the same goal. Interactive educational outreach ("academic detailing") is a practical implementation of social marketing principles to improve antibiotic use. Public education programs directed at consumers can help to reduce the inappropriate patient demand that helps to drive much improper antibiotic prescribing.

Anti-Bacterial Agents↗

PubMed2000

HMG-CoA reductase inhibitors and the risk of hip fractures in elderly patients.

CONTEXT: Recent animal studies have found that 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) lipid-lowering drugs (statins) substantially increase bone formation, but whether statin use in humans results in clinically meaningful bone formation or a reduction in the risk of osteoporotic fractures is not known. OBJECTIVE: To determine whether the use of statins is associated with reduced hip fracture risk. DESIGN: Case-control study. SETTING AND PATIENTS: A total of 6110 New Jersey residents aged 65 years or older and enrolled in Medicare and either Medicaid or the Pharmacy Assistance for the Aged and Disabled program. Case patients (n=1222) underwent surgical repair of a hip fracture in 1994. Control patients (n=4888) were identified at a ratio of 4:1 and frequency-matched to case patients for age and sex. MAIN OUTCOME MEASURE: Adjusted odds ratio (OR) of hip fracture by statin use in the 180 days and 3 years prior to the index date (the earliest date of admission for surgery), adjusted for demographic and clinical characteristics and health care utilization. RESULTS: Use of statins in either the prior 180 days (adjusted OR, 0.50; 95% confidence interval [CI], 0.33-0.76) or prior 3 years (adjusted OR, 0.57; 95% CI, 0.40-0.82) was associated with a significant reduction in the risk of hip fracture, even after controlling for variables such as race, insurance status, psychoactive medications, estrogen and thiazide use, ischemic heart disease, cancer, and diabetes mellitus. No significant relationship was observed between use of nonstatin lipid-lowering agents and hip fracture risk. Clear relationships were observed between the degree of reduction in hip fracture risk and the extent of statin use; there was no evidence of such relationships with nonstatin lipid-lowering agents. After adjusting for extent of statin use in the prior 3 years, current use (on the index date) was associated with a 71% reduction in risk (adjusted OR, 0.29; 95% CI, 0.10-0.81). The relationship between statin use and hip fracture risk persisted after controlling for variables such as the number of medications, the Charlson comorbidity index score, and hospitalization or nursing home stay in the last 180 days, as well as after excluding patients who were in a nursing home prior to their index date or who died in the year after their index date. Use of nonstatin lipid-lowering agents was not observed to be associated with reduction in hip fracture risk in any of these alternative models or analyses. CONCLUSIONS: These findings support an association between statin use by elderly patients and reduction in the risk of hip fracture. Controlled trials are needed to exclude the possibility of unmeasured confounders. JAMA. 2000;283:3211-3216

Aged↗

PubMed2000

Cost-effectiveness of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor therapy in older patients with myocardial infarction.

BACKGROUND: 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy has proven efficacy in reducing the rate of coronary and cerebrovascular events in patients 75 years of age or younger with a history of myocardial infarction. However, in patients older than 75 years of age, the efficacy and potential cost-effectiveness of statins are unknown. OBJECTIVE: To estimate the incremental cost-effectiveness of statin therapy compared with usual care in patients 75 to 84 years of age with previous myocardial infarction. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Published data from cohort studies. TARGET POPULATION: Patients 75 to 84 years of age with a history of myocardial infarction. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTION: Statin therapy. OUTCOME MEASURES: Life expectancy, quality-adjusted life expectancy, and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: The incremental cost-effectiveness of statin therapy compared with usual care in patients 75 to 84 years of age with previous myocardial infarction was $18800 per quality-adjusted life-year (QALY). RESULTS OF SENSITIVITY ANALYSIS: On the basis of a probabilistic sensitivity analysis, there is a 75% chance that statin therapy costs less than $39800 per QALY compared with usual care. If the cost of statin therapy and efficacy of statin therapy at reducing myocardial infarction were set to their most favorable values, statin therapy cost $5400 per QALY; if cost and efficacy were set to their least favorable values, statin therapy cost $97800 per QALY. CONCLUSIONS: The cost-effectiveness ratios of statin therapy in older patients with previous myocardial infarction are reasonable under a wide variety of assumptions about drug efficacy, drug cost, and rates of cardiac and cerebrovascular events. Pending results of randomized, controlled trials of secondary prevention in patients in this age group, statin therapy seems to be as cost-effective as many routinely accepted medical interventions in this setting.

Aged↗

PubMed2000

Strategies for improving comorbidity measures based on Medicare and Medicaid claims data.

Claims-based measures of comorbid illness severity have generally relied on the diagnoses listed for a single hospitalization. Unfortunately, such diagnostic information is often limited because patients have not been hospitalized during periods of interest, because of incomplete coding of diagnoses on claims forms, or because listed diagnoses represent complications of the hospitalization rather than pre-existing comorbid conditions. To address these limitations, we developed and tested four comorbidity index scores for patients with breast cancer, each based on different sources of health services claims from Medicare and Medicaid: hospitalization for breast cancer surgery; outpatient care prior to the hospitalization; other inpatient care prior to the hospitalization; and all sources combined. Varying the number and type of sources of diagnostic information yielded only very small improvements in the prediction of mortality at 1 and 3 years. Surprisingly, even simpler measures of comorbidity (crude number of diagnoses) and of prior health care utilization (total days spent in the hospital) performed at least as well in predicting mortality as did the more complex index scores which assigned points and weights for specific conditions. The greatest improvement in explanatory power was observed when another source of clinical information (cancer stage derived from a population-based cancer registry) was used to supplement claims information. Expanding the source of claims diagnoses and focusing on time periods prior to an index hospitalization are insufficient for substantially improving the explanatory power of claims-based comorbidity indices. Other improvements suggested by our results should include: increasing the completeness and accuracy of claims diagnoses; supplementing diagnoses with health care utilization information in claims data; and supplementing claims data with other sources of clinical information.

Aged↗

PubMed2000

Use of prevalence and incidence measures to describe age-related prescribing of antidepressants with and without anticholinergic effects.

To evaluate whether physicians avoid prescribing highly anticholinergic antidepressants (AAD) in the elderly, a population-based retrospectively data analysis was performed using databases from a Dutch health insurance company. Data collected on approximately 240,000 persons covered the period from 1 July 1993 to 1 January 1996. The prevalence and the incidence (number of new starters) of antidepressant use was measured over 1994 and 1995. Use of AAD was proportionally higher in the elderly in terms of both prevalence and incidence rates; the ratio of starters of AAD versus starters of non-AAD in 1994 increased steadily with age (from 0.54 in the age group 20-29 to 1.15 in the age group 60-69). In 1995 these incidence ratios decreased (0.41 to 0.99, respectively); however, the decrease was higher in the younger age groups. The data indicate that in the population studied, physicians do not refrain from prescribing highly anticholinergic agents to older patients despite their potential adverse drug reactions in this age group. This study also indicates that prevalence and incidence rates can be extracted from reimbursement data and give insight into actual prescribing practices.

Adult↗

PubMed2000

Failure of evidence-based medicine in the treatment of hypertension in older patients.

OBJECTIVE: Throughout the 1990s, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommended initial antihypertensive therapy with a thiazide diuretic or a beta-blocker based on evidence from randomized, controlled trials, unless an indication existed for another drug class. The committee also recommended beta-blockers in hypertensive patients with a history of myocardial infarction (MI), and angiotensin-converting enzyme (ACE) inhibitors in patients with congestive heart failure (CHF). Our objective was to determine whether prescribing practices for older hypertensive patients are consistent with evidence-based guidelines. METHODS: We examined prescription patterns from January 1, 1991 through December 31, 1995 for 23,748 patients 65 years or older with a new diagnosis of hypertension from the New Jersey Medicaid program and that state's Pharmacy Assistance for the Aged and Disabled program (PAAD). We linked drug use data with information on demographic variables and comorbid medical conditions. RESULTS: During the study period, calcium channel blockers were the most commonly prescribed initial therapy for hypertension (41%), followed by ACE inhibitors (24%), thiazide diuretics (17%), and beta-blockers (10%). Eliminating patients with diabetes mellitus, CHF, angina, or history of MI did not substantially affect these results. Overall, initial use of a thiazide declined from 22% in 1991 to 10% in 1995, while initial use of a calcium channel blocker increased from 28% to 43%, despite publication during these years of studies demonstrating a benefit of thiazides in older patients. Only 15% of older hypertensive patients with a history of MI received beta-blockers. CONCLUSIONS: Prescribing practices for older hypertensive patients are not consistent with evidence-based guidelines. Interventions are needed to encourage evidence-driven prescribing practices for the treatment of hypertension.

Aged↗

PubMed2000

Adherence to guidelines for oral anticoagulation after venous thrombosis and pulmonary embolism.

OBJECTIVE: Guidelines for oral anticoagulation after deep venous thrombosis (DVT) or pulmonary embolism (PE) have recommended that patients be anticoagulated for at least 3 months after hospital discharge. We sought to determine whether this recommendation was being followed and what patient characteristics predict a shorter than recommended duration of therapy. DESIGN: Retrospective cohort study using linked health care claims data. SETTING: Routine clinical practice. PATIENTS: Five hundred seventy-three members of New Jersey's Medicaid or Pharmacy Assistance for the Aged and Disabled programs aged 65 years and older who were hospitalized for DVT or PE between January 1, 1991 and June 30, 1994. RESULTS: Of the 573 patients, 129 (23%) filled prescriptions covering less than 90 days of oral anticoagulant therapy. In multivariate models, African-American race was associated with an increased risk of a shorter than recommended duration of therapy (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.14 to 3.08), but age and gender were not. Patients who used anticoagulants in the year prior to admission were less likely to have a short duration of therapy (OR, 0.30; 95% CI, 0.12 to 0.78), than were patients with PE (OR, 0.58; 95% CI, 0.38 to 0.88). CONCLUSIONS: Nearly a quarter of those anticoagulated following DVT or PE received therapy for less than the recommended length of time after hospital discharge, with African Americans more likely to have a shorter than recommended course of treatment. Further research is needed to evaluate the causes of shorter than recommended duration of therapy and racial disparities in anticoagulant use.

Black or African American↗

PubMed2000

Which patients are treated for glaucoma? An observational analysis.

PURPOSE: More than one million patients in the United States are treated for glaucoma, although little is known about the typical clinical characteristics of this group of patients and the type of therapy they receive. This study was conducted to describe the demographic and diagnostic characteristics of patients beginning long-term drug therapy for glaucoma. METHODS: This cross-sectional study included 544 patients beginning topical glaucoma medication regimens who received care at a group model health-maintenance organization (HMO) located in central Massachusetts. The primary medical records of 544 patients beginning topical glaucoma medication between 1987 and 1990 were reviewed to ascertain the presence of three clinical findings: intraocular pressure (IOP) > or = 22 mmHg; optic disc changes including cup-to-disc ratio > or = 0.8, cup-to-disc asymmetry > or = 0.2, or morphologic disc changes consistent with glaucomatous optic neuropathy; and visual field defect consistent with glaucoma. RESULTS: A majority of the 544 patients (86%) were diagnosed as having primary open-angle glaucoma (POAG) by their physicians. Almost half (44.7%) of these patients had only an elevation in IOP without other clinical findings, and 9% met none of the above criteria for glaucoma according to information in the medical record. CONCLUSION: In this setting, most patients who were prescribed drug therapy for POAG were treated for an elevation in IOP alone in the absence of other ophthalmologic characteristics of glaucoma.

Adrenergic beta-Antagonists↗

PubMed2000

Post-modern drug evaluation. The deconstruction of evidence-based regulation.

Traditionally in medicine, nearly all prescribing decisions were made by the treating physician. The patient had relatively little input and hardly any access to alternative sources of information bearing on that decision; the cost of the prescription was covered by the patient or by an insurer, and neither was likely to provide any feedback to the physician to shape his or her decision. Now, all that has changed. Beginning with the consumerist movement of recent decades and culminating in the explosion of health-related information on the Internet, patients are increasingly vocal participants in the prescribing decision, on both clinical and economic grounds. Payers have become participants as well, and increasingly seek to influence prescribing decisions in the light of their own economic imperatives. Added to all these cross-currents is an additional wild card: the proliferation of 'alternative medicines,' 'nutraceuticals' and other nostrums that society has placed beyond the reach of the evidence-based discourse and regulations that govern conventional drug therapy. In a country where patients struggle to cover the cost of prescription therapies proven both safe and effective in rigorous clinical trials, billions of dollars per year are spent on alternative treatments in the US, unencumbered by concerns about whether they actually work or that they might be toxic. While these patterns of communication, education, disinformation and economic influence are much more chaotic than those that prevailed in the 'good old days,' this very ferment may also present opportunities for improvement of rational pharmacotherapy and public health. This paper briefly outlines the above changes in patterns of communication and influence as they relate to medication use in today's industrialised world (particularly the US), and suggests both hopeful and terrifying scenarios describing where these trends might lead in the coming decade.

Community Participation↗

PubMed2000

Patterns of drug use in rheumatoid arthritis.

OBJECTIVE: Treatment strategies for rheumatoid arthritis (RA) are rapidly evolving, but few data exist on current prescribing patterns in distinct populations of patients and physicians. We described patterns of drug use for RA in a large population including use of nonsteroidal antiinflammatory drugs (NSAID), disease modifying antirheumatic drugs (DMARD), and corticosteroids. METHODS: We identified a cohort of 10,262 New Jersey Medicaid/Medicare/PAAD (Pharmacy Assistance for the Aged and the Disabled) beneficiaries with at least one episode of care for RA between January 1, 1992, and January 1, 1995, and at least one episode of care after December 31, 1995. All patients were present for the entire study period and thus constituted a closed cohort. All filled prescriptions, hospitalizations, nursing home care, and physician visits during 1995 were analyzed. RESULTS: The cohort was 67 years old on average, 82% female, and 63% white; 63% were enrolled in Medicaid and 9% were in a nursing home at the beginning of followup. During the study year, 68% of patients filled at least one prescription for any of the drug groups studied. The most frequently prescribed medication was an NSAID (57%), followed by corticosteroids (23%) and DMARD (13%). Thirty-nine percent of patients used only NSAID, 2% only DMARD, and 6% only corticosteroid. Patients taking NSAID used them on average for 3 months during the study year, corticosteroids for 4 months, and DMARD for over 7 months. During the study year, one-third of DMARD users stopped all DMARD therapy. One-third of prednisone users were taking doses higher than 10 mg/day. CONCLUSION: While our RA cohort was older than would be expected, they represent a typical Medicare and Medicaid or PAAD population. In this cohort of patients with a diagnosis of RA cared for by either general practitioners or rheumatologists, NSAID were the most commonly prescribed medication, with substantially lower rates of use for DMARD and corticosteroids. Drug discontinuation and medication switching were common.

Adrenal Cortex Hormones↗

PubMed1999

Agreement between drug treatment data and a discharge diagnosis of diabetes mellitus in the elderly.

The authors examined agreement between drug treatment data and a discharge diagnosis of diabetes, considered whether agreement was modified by demographic variables and measures of comorbidity, and evaluated construct validity through consideration of relations with subsequent mortality. The study sample comprised 81,700 residents of New Jersey aged 65-99 years who had prescription drug coverage either through Medicaid or that state's Pharmacy Assistance for the Aged and Disabled program and had at least one hospitalization between July 1, 1989, and June 30, 1991. In this population, 16.4% filled a prescription for insulin or an oral hypoglycemic agent during the 120 days before admission, and 16.3% had a discharge diagnosis of diabetes. Overall agreement between these two indicators was modest (kappa = 0.67, 95% confidence interval 0.66-0.67) and was weaker in those aged 85 years and above (kappa = 0.58, 95% confidence interval 0.56-0.60), those in nursing homes (kappa = 0.42, 95% confidence interval 0.39-0.44), and those with a high level of comorbidity (modified Charlson index > or =5; kappa = 0.59, 95% confidence interval 0.56-0.62). Presence of a diagnosis of diabetes was associated with an apparent 24% reduction in the risk of death during the study interval (p<0.001), while prior treatment for diabetes had little relation to mortality (p = 0.15). These paradoxical associations with mortality and the lower agreement between discharge diagnoses and drug treatments associated with older age, nursing home residence, and comorbidity suggest limitations in the use of claims data to identify diabetes in the elderly.

Aged↗

PubMed1999

Predictors of decreased renal function in patients with heart failure during angiotensin-converting enzyme inhibitor therapy: results from the studies of left ventricular dysfunction (SOLVD)

BACKGROUND: Although angiotensin-converting enzyme inhibitor therapy reduces mortality rates in patients with congestive heart failure (CHF), it may also cause decreased renal function. Little information is available to predict which patients are at highest risk for this complication. OBJECTIVE: To quantify specific clinical predictors of reduction in renal function in patients with CHF who are prescribed angiotensin-converting enzyme inhibitor therapy. METHOD: We analyzed data from the Studies of Left Ventricular Dysfunction (SOLVD), a randomized, double-blind, placebo-controlled trial of enalapril for the treatment of CHF. There were 3379 patients randomly assigned to enalapril with a median follow-up of 974 days and 3379 patients randomly assigned to placebo with a mean follow-up of 967 days. Decreased renal function was defined as a rise in serum creatinine >/=0.5 mg/dL (44 micromol/L) from baseline. We used time-to-event analysis to identify potential predictors of decrease in renal function including age, baseline ejection fraction, baseline creatinine, low systolic blood pressure (<100 mm Hg), history of hypertension, diabetes, and use of antiplatelet, diuretic, and beta-blocker therapy. RESULTS: Patients randomly assigned to enalapril had a 33% greater likelihood of decreased renal function than controls (P =.003). By multivariate analysis, in both the placebo and enalapril groups older age, diuretic therapy, and diabetes were associated with decreased renal function, whereas beta-blocker therapy and higher ejection fraction were renoprotective. Older age was associated with a greater risk of developing decreased renal function in both groups, but significantly more so in the enalapril group (enalapril: risk ratio [RR] 1.42 per 10 years, 95% confidence interval [CI] 1.32-1.52 with enalapril; placebo: RR 1.18, 95% CI 1.12-1.25). Diuretic therapy was likewise associated with a greater risk of decreased renal function in the enalapril group (RR 1.89, 95% CI 1.70-2.08) than in the placebo group (RR 1.35, 95% CI 1.09-1.66). Conversely, enalapril had a relative renoprotective effect (RR 1.33, 95% CI 1.13-1.53) compared with placebo (RR 1.96, 95% CI 1.57-2.44) in patients with diabetes. A lower risk of renal impairment was seen in both groups with beta-blocker therapy (RR 0.70, 95% CI 0.57-0.85) and higher baseline ejection fraction (RR 0.93 per 5% increment, 95% CI 0.91-0. 96). CONCLUSIONS: Enalapril use caused a 33% increase in the risk of decreased renal function in patients with CHF. Diuretic use and advanced age increased this risk. Diabetes was associated with an increased risk of renal impairment in all patients with CHF, but this risk was reduced in the enalapril group compared with the placebo group. beta-Blocker therapy and higher ejection fraction were renoprotective in all patients regardless of therapy.

Adrenergic beta-Antagonists↗