Search PubMed⌕ Search

Biomedical subjects

Jerry Avorn

Publications and source records attributed to Jerry Avorn.

At least 37 records · Page 2Linked to original sources
PubMed2006

Poor short-term survival and low use of cardiovascular medications in elderly dialysis patients after acute myocardial infarction.

BACKGROUND: Beta-blockers, statins, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) are standard therapies after myocardial infarction (MI) in the general population. Their use and association with mortality in elderly dialysis patients after MI have not been studied sufficiently. METHODS: Claims records from Medicare and Medicaid patients aged 65 years and older who participated in prescription benefit plans of 2 eastern states were used to identify dialysis patients with MI between 1995 and 2003. Study outcomes were outpatient use of beta-blockers, statins, and ACE inhibitors and/or ARBs within 90 days after MI. We used multivariate logistic regression to assess predictors of such use. Multivariate Cox regression was applied to test for associations between beta-blocker, statin, and ACE-inhibitor and/or ARB use and 1-year mortality. RESULTS: We identified 902 dialysis patients who were hospitalized with MI. Of these, 39.5% died within 90 days and 63.6% died within 1 year after MI. Of 494 patients who were discharged within 21 days or less and survived longer than 90 days, 31.0% were administered an ACE inhibitor and/or ARB; 19.4%, a statin; and 34.2%, a beta-blocker after discharge. Use of ACE inhibitors and/or ARBs was associated with a 30% reduction in 1-year mortality (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.50 to 0.98), whereas statin (HR, 0.97; 95% CI, 0.65 to 1.45) and beta-blocker use (HR, 1.05; 95% CI, 0.78 to 1.43) were not. CONCLUSION: Elderly dialysis patients have excessively high mortality and low use of standard therapies after MI. Only ACE inhibitors and/or ARBs were associated with a reduced risk for death at 1 year in this population. Whether the high mortality rate in this population is attributable to such low use of preventive cardiovascular medications remains uncertain.

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

Angiotensin inhibition after myocardial infarction: does drug class matter?

BACKGROUND: Angiotensin converting enzyme-inhibitors (ACEI) and angiotensin-II-receptor blockers (ARB) are equally efficacious in reducing mortality after MI, although the latter are far more costly. Little is known about their relative use after MI in typical care settings, and about their relative effectiveness outside the clinical trial setting. OBJECTIVES: To assess temporal trends in the relative use of ACEI and ARB after myocardial infarction, and to test for differences in 1-year survival between users of these drug classes. DESIGN: Retrospective closed cohort study. PATIENTS: Medicare beneficiaries who survived >90 days after myocardial infarction, had full prescription drug coverage, and who filled a prescription for either ACEI or ARB within 90 days of myocardial infarction. MEASUREMENTS: Relative use of ACEI versus ARB over time. Adjusted relative 1-year mortality between ACEI and ARB users. RESULTS: Between 1995 and 2004, 14,190 patients met inclusion criteria. Mean age was 80 years, 75% were female, and 90% were white. Overall, 88% received an ACEI, and 12% an ARB, with the proportion receiving an ARB increasing from 2% (1995) to 25% (2004; P<.001). Multivariate-adjusted 1-year mortality did not differ between ARB and ACEI users (HR: 1.04; 95% confidence interval: 0.88 to 1.22). The findings were similar for new users of ACEI/ARB, and for those with preexisting heart failure. CONCLUSIONS: ARB users had the same 1-year mortality after myocardial infarction as ACEI users in routine care. Use of more costly ARB has increased dramatically over time, to a quarter of ACEI/ARB users, despite the lack of a therapeutic advantage for most patients.

Aged↗
PubMed2006

Efficacy and safety of angiotensin II receptor blockade in elderly patients with diabetes.

OBJECTIVE: While national guidelines recommend ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy in patients with diabetes and nephropathy, guidelines concerning elderly patients with diabetes have not endorsed these drugs. We sought to assess the nephroprotective efficacy and safety of ARB therapy in elderly patients by conducting age-specific subgroup analyses using data from the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study. RESEARCH DESIGN AND METHODS: We studied 1,513 patients with type 2 diabetes and nephropathy who randomly received either losartan or placebo. We tested for effect modification by age of the effect of losartan on the incidence of the predefined end points (doubling of serum creatinine, end-stage renal disease [ESRD], or death) and the risk of adverse events. RESULTS: Of 1,513 participants, 421 (27.8%) were aged >65 years (maximum age 74 years). Age did not modify the efficacy of losartan in reducing the risk of the primary outcome, a composite of doubling of serum creatinine, ESRD, or death (P(interaction) = 0.66) or its individual components (all P(interaction) > 0.44). In patients aged >65 years, losartan reduced the risk of ESRD by 50% (95% CI 30-81, P = 0.005). We found no evidence that older patients were more likely to experience adverse events from losartan such as a rise in serum creatinine or hyperkalemia than younger patients. CONCLUSIONS: Elderly patients had the same level of benefits and risks as younger patients from treatment with losartan. Underuse of ACEI and ARB therapy in elderly patients because of the perceived lack of efficacy or a greater risk of adverse events appears unjustified.

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

A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods.

OBJECTIVE: Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling. STUDY DESIGN AND METHODS: Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003. RESULTS: Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N=60) or surgical interventions (N=51), mainly in cardiology and cardiac surgery (N=90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented. CONCLUSIONS: Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.

Bias↗
PubMed2005

Adjusting effect estimates for unmeasured confounding with validation data using propensity score calibration.

Often, data on important confounders are not available in cohort studies. Sensitivity analyses based on the relation of single, but not multiple, unmeasured confounders with an exposure of interest in a separate validation study have been proposed. In this paper, the authors controlled for measured confounding in the main cohort using propensity scores (PS's) and addressed unmeasured confounding by estimating two additional PS's in a validation study. The "error-prone" PS exclusively used information available in the main cohort. The "gold standard" PS additionally included data on covariates available only in the validation study. Based on these two PS's in the validation study, regression calibration was applied to adjust regression coefficients. This propensity score calibration (PSC) adjusts for unmeasured confounding in cohort studies with validation data under certain, usually untestable, assumptions. The authors used PSC to assess the relation between nonsteroidal antiinflammatory drugs (NSAIDs) and 1-year mortality in a large cohort of elderly persons. "Traditional" adjustment resulted in a hazard ratio for NSAID users of 0.80 (95% confidence interval (CI): 0.77, 0.83) as compared with an unadjusted hazard ratio of 0.68 (95% CI: 0.66, 0.71). Application of PSC resulted in a more plausible hazard ratio of 1.06 (95% CI: 1.00, 1.12). Until the validity and limitations of PSC have been assessed in different settings, the method should be seen as a sensitivity analysis.

Aged↗
PubMed2005

Effects of noncardiovascular comorbidities on antihypertensive use in elderly hypertensives.

Although the benefits of antihypertensive drugs have been clearly established, they remain underused by vulnerable older populations. We examined whether the presence of noncardiovascular comorbidity deters use of antihypertensives in elderly with hypertension. We conducted a retrospective cohort study among 51,517 patients > or =65 years of age in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE) Program during 1999 and 2000. All were hypertensive and had diagnoses and used treatments during 1999 to qualify for entry into 1 of the following 5 mutually exclusive cohorts: asthma/chronic obstructive pulmonary disease (COPD), depression, gastrointestinal (GI) disorders, osteoarthritis, or none of the 4 comorbidities. Proportions using antihypertensives in 2000 were assessed. Logistic regression analysis was used to identify the independent effects on antihypertensive use of the 4 comorbidities of interest, sociodemographic characteristics, other cardiovascular and noncardiovascular comorbidity, and health care utilization variables. After adjustments in multivariable analyses, antihypertensive use was consistently lower in patients with asthma/COPD (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.40 to 0.47), depression (OR, 0.50; 95% CI, 0.45 to 0.55), GI disorders (OR, 0.59; 95% CI, 0.54 to 0.64), and osteoarthritis (OR, 0.63; 95% CI, 0.59 to 0.67) relative to those without these conditions. Reduced antihypertensive use was also associated with older age, female gender, white race, more severe other comorbidities, absence of some cardiovascular indications, hospitalizations, nursing home care, physician visits, and use of fewer other medications. Highly prevalent, noncardiovascular conditions appear to deter use of antihypertensives in elderly with hypertension.

Aged↗
PubMed2005

The hepatotoxicity of antifungal medications in bone marrow transplant recipients.

BACKGROUND: Systemic antifungal medications can be lifesaving but can also have important toxicities. With a number of new antifungal drugs being introduced, there is a compelling need to define the toxicities associated with existing therapies. METHODS: We identified cases of hepatotoxicity among patients who underwent bone marrow transplantation and selected matched control subjects from the same population. Multivariable logistic regression modeling was used to control for patient characteristics in evaluating the relationship between hepatotoxicity and exposure to antifungal medications. Follow-up analyses were performed for patients who continued receiving antifungal medications after developing hepatotoxicity. RESULTS: The unadjusted incidence of hepatotoxicity was 0.78 cases per 100 patient-days of exposure to amphotericin deoxycholate, 0.98 for fluconazole, and 1.50 for liposomal amphotericin B. Case-control analyses found that liposomal amphotericin B was associated with a substantial increase in the risk of hepatotoxicity in these patients (odds ratio [OR], 3.33; 95% confidence interval [CI], 1.61-6.88); a smaller increase in risk was found for fluconazole (OR, 1.99; 95% CI, 1.21-3.26). There was no statistically significant association between amphotericin B deoxycholate and the development of hepatotoxicity. Patients had greater elevations of serum transaminase values associated with exposure to larger cumulative doses of liposomal amphotericin B. In the follow-up analysis of patients who developed hepatotoxicity and who continued receiving antifungal medication, one-third of those receiving liposomal amphotericin B had marked increases in bilirubin levels, as opposed to 8% of patients treated with fluconazole. CONCLUSIONS: In these bone marrow transplant recipients, liposomal amphotericin B and fluconazole were both associated with increased risk of hepatotoxicity, independent of other treatments received or patient characteristics; the magnitude of the risk was larger for liposomal amphotericin B. Patients who develop hepatotoxicity appear to tolerate continued therapy with fluconazole, but a large fraction of those who received liposomal amphotericin B have worsening conditions with continued treatment.

Adult↗
PubMed2005

Over-the-counter statins.

In late 2004, the British government decided to allow a lipid-lowering agent to be sold as an over-the-counter medication. In contrast, the U.S. Food and Drug Administration recently decided not to do so. The United States and other countries will soon face similar decisions for other statins. Although statins have infrequent side effects and have been shown to be effective in moderate-risk primary prevention populations, many questions remain unanswered about their effectiveness at lower doses in over-the-counter use, the ability of patients to self-select themselves for appropriate therapy, and the social and economic implications associated with this method of distribution for preventive medications. A rational policy decision concerning over-the-counter statin use will require an effectiveness trial to provide data on how such drugs would be used in this context, as well as on the clinical outcomes that could be expected from this novel "route of administration."

Community Participation↗
PubMed2005

Analytic strategies to adjust confounding using exposure propensity scores and disease risk scores: nonsteroidal antiinflammatory drugs and short-term mortality in the elderly.

Little is known about optimal application and behavior of exposure propensity scores (EPS) in small studies. In a cohort of 103,133 elderly Medicaid beneficiaries in New Jersey, the effect of nonsteroidal antiinflammatory drug use on 1-year all-cause mortality was assessed (1995-1997) based on the assumption that there is no protective effect and that the preponderance of any observed effect would be confounded. To study the comparative behavior of EPS, disease risk scores, and "conventional" disease models, the authors randomly resampled 1,000 subcohorts of 10,000, 1,000, and 500 persons. The number of variables was limited in disease models, but not EPS and disease risk scores. Estimated EPS were used to adjust for confounding by matching, inverse probability of treatment weighting, stratification, and modeling. The crude rate ratio of death was 0.68 for users of nonsteroidal antiinflammatory drugs. "Conventional" adjustment resulted in a rate ratio of 0.80 (95% confidence interval: 0.77, 0.84). The rate ratio closest to 1 (0.85) was achieved by inverse probability of treatment weighting (95% confidence interval: 0.82, 0.88). With decreasing study size, estimates remained further from the null value, which was most pronounced for inverse probability of treatment weighting (n = 500: rate ratio = 0.72, 95% confidence interval: 0.26, 1.68). In this setting, analytic strategies using EPS or disease risk scores were not generally superior to "conventional" models. Various ways to use EPS and disease risk scores behaved differently with smaller study size.

Aged↗
PubMed2005

Guided prescription of psychotropic medications for geriatric inpatients.

BACKGROUND: Inappropriate use or excessive dosing of psychotropic medications in the elderly is common and can lead to a variety of adverse drug events including falls, oversedation, and cognitive impairment. METHODS: We developed a database of psychotropic medication dosing and selection guidelines for elderly inpatients. We displayed these recommendations to physicians through a computerized order entry system at a tertiary care academic hospital. The system was activated for 2 of 4 six-week study periods in an off-on-off-on pattern. Main outcome measures were agreement with the recommended daily dose for the initial drug order, incidence of dosing at least 10-fold greater than the recommended daily dose, prescription of nonrecommended drugs, inpatient falls, altered mental status as measured by a brief nursing assessment, and hospital length of stay. RESULTS: A total of 7456 initial orders for psychotropic medications were prescribed for 3718 hospitalized elderly patients with a mean +/- SD age of 74.7 +/- 6.7 years. The intervention increased the prescription of the recommended daily dose (29% vs 19%; P<.001), reduced the incidence of 10-fold dosing (2.8% vs 5.0%; P<.001), and reduced the prescription of nonrecommended drugs (10.8% vs 7.6% of total orders; P<.001). Patients in the intervention cohort had a lower in-hospital fall rate (0.28 vs 0.64 falls per 100 patient-days; P = .001). No effect on hospital length of stay or days of altered mental status was found. CONCLUSION: A geriatric decision support system for psychotropic medications increased the prescription of recommended doses, reduced the prescription of nonrecommended drugs, and was associated with fewer inpatient falls.

Accidental Falls↗