Biomedical subjects

Kenneth G Saag

Publications and source records attributed to Kenneth G Saag.

At least 37 records · Page 2Linked to original sources

PubMed2006

Gout medication treatment patterns and adherence to standards of care from a managed care perspective.

OBJECTIVE: To determine allopurinol treatment patterns and adherence to published standards of care for patients with gout. PATIENTS AND METHODS: This retrospective claims analysis in a managed care database included patients 18 years or older, with continuous eligibility for 1 year before and after the start date and 2 or more visits during which the gout disease code (274.xx) was assigned or 1 or more pharmacy prescriptions for a gout-specific medication between January 1, 2000, and December 31, 2002 (intake period). Factors associated with compliance with allopurinol therapy were measured based on the medication possession ratio, and adherence to 2 quality-of-care indicators for gout management was assessed using multivariable logistic regression analysis. RESULTS: A total of 64.9% of allopurinol users had a modal daily dose or the most commonly observed daily dose of 300 mg/d, median length of therapy was 3 months, and a high proportion of patients had a medication possession ratio of 10% or less. Suggested quality-of-care Indicators for gout had low performance: 53% of patients with renal impairment received a modal daily dose of 300 mg or greater, and 83% of patients who started taking allopurinol did not have their serum urate levels measured within 180 days. Patients with gout flares were less likely to be compliant with allopurinol (odds ratio, 0.50; 95% confidence interval, 0.40-0.63). Patients with renal impairment at baseline were 3.2 times more likely to undergo serum urate testing than patients without renal impairment (odds ratio, 3.20; 95% confidence Interval, 1.25-8.23). CONCLUSION: There was low compliance with allopurinol therapy for treatment of gout. Patients potentially received suboptimal quality of care as measured by serum urate testing and appropriateness of allopurinol dosing in patients with renal impairment.

Adolescent↗

PubMed2006

Trends in prevention of glucocorticoid-induced osteoporosis.

OBJECTIVE: To determine longitudinal patterns and predictors for the utilization of bone mass measurements and anti-osteoporotic medications in the prevention of glucocorticoid-induced osteoporosis. METHODS: Within a managed care population of 7 million persons, we identified 3,125 adult men and women who had initiated longterm glucocorticoid therapy (>or=7.5 mg/day of prednisone equivalent for > 6 mo). The study population was examined by 3 biennial intervals between years 1996 and 2001 for receipt of a bone mass measurement and use of anti-osteoporotic medication (bisphosphonate, calcitonin, raloxifene, hormone replacement therapy). RESULTS: Receipt of a bone mass measurement increased among postmenopausal women from 10% in 1996-97 to 19% in 2000-01, but remained below 6% in all biennial intervals among women under age 50 and men. The use of anti-osteoporotic medication was most common among postmenopausal women, where it approached 50%. The largest absolute increase in anti-osteoporotic medication utilization was among women ages 65 and over, increasing from 24% in 1996-97 to 44% in 2000-01. The specialty of physician providing care was associated with receipt of both testing and treatment. Odds of receipt of a bone mass measurement and anti-osteoporotic medication were 3 to 4 times greater among patients of rheumatologists compared to those of internists or family practitioners. CONCLUSION: Among patients initiating longterm glucocorticoid therapy, the proportion of individuals receiving a bone mass measurement or anti-osteoporotic medication remains relatively low, but has improved temporally among postmenopausal women.

Adolescent↗

PubMed2005

Longitudinal patterns in the prevention of osteoporosis in glucocorticoid-treated patients.

OBJECTIVE: To evaluate patient and physician factors associated with prevention of glucocorticoid-induced osteoporosis and to describe temporal trends in screening and prevention of glucocorticoid-induced osteoporosis. METHODS: Using databases from a national managed care organization, enrollees who had been prescribed glucocorticoids (taken for at least 60 days) during an 18-month period were identified. Administrative data from January 2001 through June 2003 and linked survey data from October 2003 were examined for measurement of bone mass, prescription of antiresorptive medication, and use of over-the-counter calcium and/or vitamin D treatment. Factors associated with screening and bone-protective therapies were identified using multivariable logistic regression, focusing on physician specialty and survey respondent ethnicity. Trends in glucocorticoid-induced osteoporosis prevention were assessed using administrative data from 2001-2003 versus 1995-1998. RESULTS: We identified 6,281 patients who were prescribed glucocorticoids in 2001-2003 (mean +/- SD prescribed prednisone-equivalent dosage 16 +/- 14 mg/day). Forty-two percent underwent bone mass measurement and/or were prescribed bone-protective medication; rates were lowest for men (25%). Compared with patients of internists, the odds of bone mass measurement were lowest among patients prescribed glucocorticoids by family physicians (odds ratio [OR] 0.56 [95% confidence interval] [95% CI] 0.30-1.04) and highest among patients prescribed glucocorticoids by rheumatologists (OR 1.48 [95% CI 1.06-2.08]). Patients prescribed glucocorticoids by gastroenterologists were less likely to be treated with antiresorptive agents (OR 0.49 [95% CI 0.28-0.86]). African American patients were less likely than white patients to be screened (OR 0.55 [95% CI 0.40-0.75]) or treated (OR 0.71 [95% CI 0.51-0.98]). The frequency of bone mass measurement among glucocorticoid-treated patients in 2001-2003 increased 3-fold compared with 1995-1998, and the use of prescription antiresorptive medication increased approximately 2-fold. CONCLUSION: Despite significant temporal increases in the frequency of screening for and treatment of glucocorticoid-induced osteoporosis, absolute rates remain low, especially among men, African Americans, and patients of certain physician specialties.

Adult↗

PubMed2005

Recent advances in the epidemiology of gout.

Gout remains among the most common of all inflammatory arthridities with an incidence that appears to have risen. Evidence is accumulating to support lifestyle and dietary factors, such as heavy consumption of beer and liquor as well as diets rich in meats and seafood as important gout risk factors. There is also a renewed interest in important associations between gout and other comorbidities like hypertension and cardiovascular disease. The importance of hyperuricemia on health considerations beyond the musculoskeletal system is an area worthy of even more study.

Global Health↗

PubMed2005

Gout treatment: what is evidence-based and how do we determine and promote optimized clinical care?

Gout, a common form of inflammatory arthritis, has been markedly understudied relative to other rheumatologic conditions. As a result, evidence guiding clinical management in gout has traditionally been lacking. Burgeoning data suggests that quality of gout care in gout is frequently suboptimal. In this paper, we examine the evidence supporting gout management strategies in clinical practice. In addition, we examine consensus building efforts that have culminated in the recent publication of gout management quality indicators. We also discuss the need for future initiatives aimed at improving patient safety and quality of care in gout.

Anti-Inflammatory Agents↗

PubMed2005

Developments in glucocorticoid therapy.

Recent evidence for a disease-modifying potential of low-dose glucocorticoids (GCs) in the treatment of rheumatoid arthritis has renewed the debate on the risk benefit ratio with this therapy. Two recent developments are described that might have a positive influence on these risk benefit ratios. One is the improvement in new GC compounds--designer GCs, alterations in bioactivity, and alterations in formulations. The other is a better understanding and management of the toxicity of GCs.

Animals↗

PubMed2005

Racial disparities in the receipt of osteoporosis related healthcare among community-dwelling older women with arthritis and previous fracture.

OBJECTIVE: To examine potential racial/ethnic disparities in osteoporosis care among community-dwelling older women with self-reported arthritis and previous fracture. METHODS: We conducted a computer assisted telephone interview using a population based random sample drawn from 6 counties in Alabama, USA. Eligible respondents had self-reported arthritis and were over 50 years of age; 1424 people responded to the survey. Logistic regression was used to examine the association of race/ethnicity with the receipt of dual energy x-ray absorptiometry (DEXA) and prescription osteoporosis treatments (including bisphosphonates, calcitonin, hormone replacement, or selective estrogen receptor modulators) among older women with a history of fracture. RESULTS: Of eligible African American and Caucasian female respondents, 251 (25%) reported a history of fracture after 45 years of age. Women with a history of self-reported fracture were predominantly Caucasian (n = 178, 71%) and had a mean age of 68 +/- 11 years. After multivariable adjustment, African American women with a fracture history were less likely than Caucasian women with a history of fracture to receive a DEXA (OR 0.39, 95% CI 0.19-0.81) or prescription osteoporosis medicines (OR 0.17, 95% CI 0.08-0.37). CONCLUSION: In this population of community-dwelling older women, African American respondents at high risk for fracture were far less likely than Caucasians to receive osteoporosis related healthcare.

Absorptiometry, Photon↗

PubMed2005

A group randomized trial to improve safe use of nonsteroidal anti-inflammatory drugs.

OBJECTIVE: To determine whether audit/feedback and educational materials improve adherence to recommendations for laboratory monitoring and cytoprotective agents to detect and prevent adverse events caused by nonsteroidal anti-inflammatory agents (NSAIDs). STUDY DESIGN: Controlled, cluster-randomized trial. METHODS: Physicians commonly prescribing NSAIDs were identified within a large managed care organization and randomized to a control or an intervention group (audit/feedback with peer-derived benchmarks and continuing medical education). Medical records were examined 10 months before and after the intervention for clinical data and receipt of complete blood count (CBC), creatinine testing, and cytoprotective agents (process measures). Primary analysis compared intervention versus control physicians among those who initially performed below a peer-derived benchmark. General estimating equations accounted for patient clustering. RESULTS: Of 101 physicians initially randomized, 85 remained eligible (38 internists, 36 family physicians, 11 rheumatologists) postintervention. Mean percent change in performance between intervention and control physicians for CBC monitoring was 16% versus 10%; for creatinine monitoring, 0% versus 17%; and use of cytoprotective agents, -3% versus -1%. None of these changes were significant. Rheumatology specialty, number of NSAID prescriptions and physician visits, and patient risk factors for NSAID-related toxicity were more strongly associated with improved safety practices than the intervention. CONCLUSIONS: Audit/feedback and educational materials had no observed effect on improving NSAID-related safety practices. Potentially contributing factors include high baseline performance (ceiling effect), dilution of the intervention effect by case mix and provider factors, nonreceipt of intervention materials, and diverse indications for lab tests.

Adult↗

PubMed2005

Prevalence of osteoporosis and osteopenia among African Americans with early rheumatoid arthritis: the impact of ethnic-specific normative data.

PURPOSE: To examine the prevalence of osteopenia and/or osteoporosis among African Americans with early rheumatoid arthritis (RA) and to assess the effect of using race/ethnicity-specific normative data. METHODS: Bone mineral density (BMD) of the hip and spine was assessed in African Americans with early RA. To examine the impact of using different normative data on disease classification, we calculated two sets of T scores, the first using sex-matched reference data from Caucasians and the second using data from African Americans. Osteoporosis was defined as a BMD at either site > or =2.5 SD below the young adult mean. Osteopenia was defined as a BMD > or =1 SD and <2.5 SD below this mean. RESULTS: Using Caucasian referent data, 33% (n=48) of patients had osteopenia or worse (n=48, 32.9%) and 5% (n=8) were osteoporotic. With the use of African-American normative data, 55% (n=94) were osteopenic or worse, and 16% (n=27) were osteoporotic. CONCLUSION: African Americans with RA are at risk of osteopenia and/or osteoporosis. Different diagnostic classifications may occur in this population based solely on the normative data used for assessing fracture risk. These results underscore the need for a standardized approach in defining osteopenia and osteoporosis in African Americans.

Absorptiometry, Photon↗

PubMed2004

Measuring quality in arthritis care: the Arthritis Foundation's quality indicator set for analgesics.

OBJECTIVE: To develop systematically validated quality indicators (QIs) addressing analgesic safety. METHODS: A comprehensive literature review of existing quality measures, clinical guidelines, and evidence supporting potential QIs concerning nonselective (traditional) nonsteroidal anti-inflammatory drugs (NSAIDs) and newer cyclooxygenase 2-selective NSAIDs was undertaken. An expert panel then validated or refuted potential indicators utilizing a proven methodology. RESULTS: Eleven potential QIs were proposed. After panel review, 8 were judged to be valid; an additional 10 were proposed by the panel, of which 7 were rated as valid. Quality indicators focused upon informing patients about risk, NSAID choice and gastrointestinal prophylaxis, and side effect monitoring. CONCLUSION: The 15 validated indicators were combined, where appropriate, to yield 10 validated processes of care indicators for the safe use of NSAIDs. These indicators developed by literature review and finalized by our expert panel process can serve as a basis to compare the quality of analgesic use provided by health care providers and delivery systems.

Analgesics↗

PubMed2004

Measuring quality in arthritis care: methods for developing the Arthritis Foundation's quality indicator set.

OBJECTIVE: To develop a comprehensive set of explicit process measures to assess the quality of health care for osteoarthritis, rheumatoid arthritis, and analgesics use. METHODS: Potential quality measures and a summary of existing data to support or refute the relationship between the processes of care proposed in the indicators and relevant clinical outcomes were developed through a comprehensive literature review. The proposed measures and literature summary were presented to a multidisciplinary panel of experts in arthritis and pain. Using a modification of the RAND/UCLA Appropriateness Method, the panel rated each proposed measure for its validity as a measure of health care quality. RESULTS: Among 66 proposed indicators, the expert panel rated 51 as valid measures of health care including 14 for osteoarthritis, 27 for rheumatoid arthritis, and 10 for analgesics use. CONCLUSIONS: Sufficient scientific evidence and expert consensus exist to support a comprehensive set of measures to assess the quality of heath care for osteoarthritis, rheumatoid arthritis, and analgesics use. These measures can be used to gain an understanding of the quality of care for patients with arthritis.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed2004

Vitamin D intake is inversely associated with rheumatoid arthritis: results from the Iowa Women's Health Study.

OBJECTIVE: Vitamin D is a potent regulator of calcium homeostasis and may have immunomodulatory effects. The influence of vitamin D on human autoimmune disease has not been well defined. The purpose of this study was to evaluate the association of dietary and supplemental vitamin D intake with rheumatoid arthritis (RA) incidence. METHODS: We analyzed data from a prospective cohort study of 29,368 women of ages 55-69 years without a history of RA at study baseline in 1986. Diet was ascertained using a self-administered, 127-item validated food frequency questionnaire that included supplemental vitamin D use. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were estimated using Cox proportional hazards regression, adjusting for potential confounders. RESULTS: Through 11 years of followup, 152 cases of RA were validated against medical records. Greater intake (highest versus lowest tertile) of vitamin D was inversely associated with risk of RA (RR 0.67, 95% CI 0.44-1.00, P for trend = 0.05). Inverse associations were apparent for both dietary (RR 0.72, 95% CI 0.46-1.14, P for trend = 0.16) and supplemental (RR 0.66, 95% CI 0.43-1.00, P for trend = 0.03) vitamin D. No individual food item high in vitamin D content and/or calcium was strongly associated with RA risk, but a composite measure of milk products was suggestive of an inverse association with risk of RA (RR 0.66, 95% CI 0.42-1.01, P for trend = 0.06). CONCLUSION: Greater intake of vitamin D may be associated with a lower risk of RA in older women, although this finding is hypothesis generating.

Aged↗

PubMed2004

Quality of care indicators for gout management.

OBJECTIVE: Despite the significant health impact of gout, there is no consensus on management standards. To guide physician practice, we sought to develop quality of care indicators for gout management. METHODS: A systematic literature review of gout therapy was performed using the Medline database. Two abstractors independently reviewed each of the articles for relevance and satisfaction of minimal inclusion criteria. Based on the review of the literature, 11 preliminary quality indicators were developed and then reviewed and refined by an initial feasibility panel of community and academic rheumatologists. A twelfth indicator was added at the request of the first panel. Using a modification of the RAND/University of California at Los Angeles appropriateness method (bridging teleconference and white-board Internet technology were added), a second expert panel rated each of the proposed indicators for validity using a 9-point scale, in which ratings of 1-3, 4-6, and 7-9 were considered "invalid," "indeterminate," and "highly valid," respectively. Indicators were considered valid if the median panel rating was > or =7 and there was no evidence of panel disagreement (defined to occur when 2 of 6 panelists provided a validity rating of 1-3 and 2 panelists provided a validity rating of 7-9). RESULTS: Ten of the 12 draft indicators were rated to be valid by our second expert panel. Validated indicators pertained to 1) the use of urate-lowering medications in chronic gout, 2) the use of antiinflammatory drugs, and 3) counseling on lifestyle modifications. CONCLUSION: Using a combination of evidence and expert opinion, 10 indicators for quality of gout care were developed. These indicators represent an important initial step in quality improvement initiatives for gout care.

Gout↗

PubMed2004

Prevention of glucocorticoid-induced osteoporosis.

Patients taking low-dose glucocorticoids for 3 months or more are at risk for rapid bone loss. The loss may be as high as 15% in the first 3 to 6 months of treatment, and can lead to osteoporotic fractures, with an increase in morbidity and mortality. This article discusses an evidence-based approach to the prevention of glucocorticoid-induced osteoporosis.

Alendronate↗

PubMed2003

The effects of physician specialty and patient comorbidities on the use and discontinuation of coxibs.

OBJECTIVE: To examine the effects of physician specialty and comorbidities on cyclooxygenase 2-selective nonsteroidal antiinflammatory drugs (NSAIDs; coxibs) utilization. METHODS: Medical records of 452 patients from a regional managed care organization with >/=3 consecutive NSAID prescriptions from June 1998 to April 2001 were abstracted. Multivariable adjusted associations between coxib initiation and discontinuation and patient and provider characteristics were examined. RESULTS: A total of 1,142 NSAID prescriptions were written over 9,398 total patient-months of followup. Compared with patients seeing family or general practitioners, patients seeing rheumatologists (odds ratio [OR] 3.4, 95% confidence interval [95% CI] 2.1-5.7) and internists (OR 2.3, 95% CI 1.5-3.6) were significantly more likely to receive a coxib, as well as patients with a history of osteoarthritis (OR 2.6, 95% CI 1.7-3.8), gastrointestinal disease (OR 2.3, 95% CI 1.2-4.5), and congestive heart failure (OR 4.1, 95% CI 1.0-16.4). Although specialists were more likely than generalists to prescribe coxibs, only family or general practitioners were significantly more likely to selectively use coxibs among their patients with a history of gastrointestinal disease. Fifty-four percent of NSAID prescriptions were discontinued, and coxibs were significantly less likely to be discontinued than were traditional NSAIDs (OR 0.6, 95% CI 0.5-0.8). CONCLUSION: Our findings suggest significantly greater, but perhaps less selective use of coxibs among specialists, even after accounting for important covariates. The initiation and discontinuation of coxibs was influenced by physician specialty and by patient risk factors.

Aged↗

PubMed2003

Antioxidant micronutrients and risk of rheumatoid arthritis in a cohort of older women.

The association of antioxidant vitamins and trace elements from foods and supplements with risk of rheumatoid arthritis was evaluated in a prospective cohort study of 29,368 women who were aged 55-69 years at baseline in 1986. Through 1997, 152 cases of rheumatoid arthritis were identified. After controlling for other risk factors, greater intakes (highest tertile vs. lowest) of supplemental vitamin C (relative risk (RR) = 0.70, 95% confidence interval (CI): 0.48, 1.09; p-trend = 0.08) and supplemental vitamin E (RR = 0.72, 95% CI: 0.47, 1.12; p-trend = 0.06) were inversely associated with rheumatoid arthritis. There was no association with total carotenoids, alpha- or beta-carotene, lycopene, or lutein/zeaxanthin, while there was an inverse association with beta-cryptoxanthin (RR = 0.59, 95% CI: 0.39, 0.90; p-trend = 0.01). Greater use of supplemental zinc (RR = 0.39, 95% CI: 0.17, 0.88; p-trend = 0.03) was inversely associated with rheumatoid arthritis, while any use of supplemental copper (RR = 0.54, 95% CI: 0.28, 1.03) and manganese (RR = 0.50, 95% CI: 0.23, 1.07) showed suggestive inverse associations with rheumatoid arthritis. Greater intakes of fruit (RR = 0.72, 95% CI: 0.46, 1.12; p-trend = 0.13) and cruciferous vegetables (RR = 0.65, 95% CI: 0.42, 1.01; p-trend = 0.07) also exhibited trends toward inverse associations with risk. When the antioxidants were modeled together, only beta-cryptoxanthin and supplemental zinc were statistically significant predictors. Intake of certain antioxidant micronutrients, particularly beta-cryptoxanthin and supplemental zinc, and possibly diets high in fruits and cruciferous vegetables, may be protective against the development of rheumatoid arthritis.

Aged↗

PubMed2003

Bone mineral density changes within six months of renal transplantation.

BACKGROUND: The effective use of new steroid-sparing immunosuppressive regimens may lower cumulative glucocorticoid use among renal transplant recipients. However, it is unknown what effect this therapeutic trend has had on bone disease. METHODS: Unselected newly transplanted inpatients (n=45) were identified and comprehensively evaluated for metabolic bone disease at a median of 16 days (range 9-33) posttransplant. A follow-up evaluation was conducted a median of 5.7 months (range 4.8-9.3) later. Follow-up values for bone mineral density (BMD) and select laboratories were compared with baseline values using nonparametric statistics. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to describe the associations of baseline characteristics, select laboratory values, and cumulative prednisone and cyclosporine use with spinal BMD loss and were calculated using logistic regression. RESULTS: A significant decrease in intact parathyroid hormone (P<0.001) and a significant increase in calcitriol (P=0.02) were noted postengraftment. At follow-up, subjects had lost a mean of 2.4% BMD at the lumbar spine (P=0.003) but did not experience significant declines at the femoral neck. The highest tertiles of cumulative prednisone (OR=28.4; 95% CI 2.5-329 and OR=15.8; 95% CI 1.4-179, respectively) and past alcohol use (OR=9.3; 95% CI 1.46-58.5) were significantly associated with spinal BMD loss. CONCLUSIONS: Significant loss in lumbar BMD occurred within 6 months of transplantation in more than one third of a prospective cohort of renal transplant recipients. Lumbar bone loss seemed to be mediated primarily by glucocorticoid dose and a history of alcohol use.

Adult↗

PubMed2003

Estrogen and other female reproductive risk factors are not strongly associated with the development of rheumatoid arthritis in elderly women.

OBJECTIVE: Endogenous and exogenous reproductive hormones have been associated with rheumatoid arthritis (RA) in women, but data are inconsistent and no studies have assessed RA risk factors exclusively in elderly women. METHODS: The authors examined the association between reproductive factors, exogenous hormone exposure, and RA in a prospective cohort study of 31,336 Iowa women who were aged 55 to 69 years at cohort baseline in 1986. RESULTS: During 11 years of follow-up, 158 incident cases of RA were identified and validated. Age at last pregnancy (P trend =.01) and age at menopause (P trend =.03) were inversely associated with RA, whereas a history of polycystic ovary syndrome (relative risk [RR], 2.58; 95% confidence interval [CI], 1.06 to 6.30), endometriosis (RR, 1.72; 95% CI, 0.93 to 3.18), and former use of hormone replacement therapy (RR, 1.47; 95% CI, 1.04 to 2.06) were positively associated with RA. In multivariate analysis models, a history of polycystic ovary syndrome remained the most consistent predictor of RA, whereas the RRs for other factors attenuated. CONCLUSION: Few reproductive factors showed a strong or statistically significant association with RA in elderly women. The association of polycystic ovary syndrome may be indicative of perturbations of endocrine-immune activity that may influence the development of RA. This prospective cohort study adds to the understanding of the potential contribution of hormonal factors to the cause of RA in older women.

Aged↗