Alai Tan

Trends in Otitis Media–Related Health Care Use in the United States, 2001-2011

IMPORTANCE Otitis media (OM) is a leading cause of pediatric health care visits and the most frequent reason children consume antibiotics or undergo surgery. During recent years, several interventions have been introduced aiming to decrease OM burden. OBJECTIVE To study the trend in OM-related health care use in the United States during the pneumococcal conjugate vaccine (PCV) era (2001-2011). DESIGN, SETTING, AND PARTICIPANTS An analysis of an insurance claims database of a large, nationwide managed health care plan was conducted. Enrolled children aged 6 years or younger with OM visits were identified. MAIN OUTCOMES AND MEASURES Annual OM visit rates, OM-related complications, and surgical interventions were analyzed. RESULTS Overall, 7.82 million unique children (5.51 million child-years) contributed 6.21 million primary OM visits; 52% were boys and 48% were younger than 2 years. There was a downward trend in OM visit rates from 2004 to 2011, with a significant drop that coincided with the advent of the 13-valent vaccine (PCV-13) in 2010. The observed OM visit rates in 2010 (1.00/child-year) and 2011 (0.81/child-year) were lower than the projected rates based on the 2005-2009 trend had there been no intervention (P < .001). Recurrent OM (≥3 OM visits within 6-month look-back) rates decreased at 0.003/child-year (95% CI, 0.002-0.004/child-year) in 2001-2009 and at 0.018/child-year (95% CI, 0.008-0.028/child-year) in 2010-2011. In the PCV-13 premarket years, there was a stable rate ratio (RR) between OM visit rates in children younger than 2 years and in those aged 2 to 6 years (RR, 1.38; 95% CI, 1.38-1.39); the RR decreased significantly (P < .001) during the transition year 2010 (RR 1.32; 95% CI, 1.31-1.33) and the postmarket year 2011 (RR 1.01; 95% CI, 1.00-1.02). Tympanic membrane perforation/otorrhea rates gradually increased (from 3721 per 100,000 OM child-years in 2001 to 4542 per 100,000 OM child-years in 2011; P < .001); the increase was significant only in the older children group. Mastoiditis rates substantially decreased (from 61 per 100,000 child-years in 2008 to 37 per 100,000 child-years in 2011; P < .001). Ventilating tube insertion rate decreased by 19% from 2010 to 2011 (P = .03). CONCLUSIONS AND RELEVANCE There was an overall downward trend in OM-related health care use from 2001 to 2011. The significant reduction in OM visit rates in 2010-2011 in children younger than 2 years coincided with the advent of PCV-13. Although tympanic membrane perforation/otorrhea rates steadily increased during that period, mastoiditis and ventilating tube insertion rates decreased in the last years of the study.

Complications and continuation of intrauterine device use among commercially insured teenagers.

OBJECTIVE: Many U.S. health care providers remain reluctant to prescribe intrauterine devices (IUDs) to teenagers as a result of concerns about serious complications. This study examined whether 15–19-year-old IUD users were more likely to experience complications, failure, or early discontinuation than adult users aged 20–24 years and 25–44 years and whether there were differences in these outcomes between users of levonorgestrel-releasing intrauterine systems and copper IUDs. METHODS: A retrospective cohort study was conducted using health insurance claims obtained from a private insurance company of 90,489 women who had an IUD inserted between 2002 and 2009. Logistic regression models were used to estimate the odds of experiencing complications, method failure, or early discontinuation within 12 months of insertion by age group and type of IUD inserted. RESULTS: Serious complications, including ectopic pregnancy and pelvic inflammatory disease, occurred in less than 1% of patients regardless of age or IUD type. Women aged 15–19 years were more likely than those aged 25–44 years to have a claim for dysmenorrhea (odds ratio [OR] 1.4, confidence interval [CI] 1.1–1.6), amenorrhea (OR 1.3, CI 1.1–1.5), or normal pregnancy (OR 1.4, CI 1.1–1.8). Overall, early discontinuation did not differ between teenagers and women aged 25–44 years (13% compared with 11%, P>.05). However, use of the levonorgestrel-releasing intrauterine system was associated with fewer complications and less early discontinuation than the copper IUD in all age groups. CONCLUSIONS: The IUD is as appropriate for teenagers to use as it is for older women, with serious complications occurring infrequently in all groups. The levonorgestrel-releasing intrauterine system may be a better choice than the copper IUD as a result of lower odds of complications, discontinuation, and failure. LEVEL OF EVIDENCE: II

Completion of the human papillomavirus vaccine series among insured females between 2006 and 2009

Completion of the human papillomavirus (HPV) vaccine in a large percentage of young females is an important goal to prevent anogenital cancers associated with HPV. The current study examined whether the percentage of insured women who complete the vaccine series has changed across time, and how provider type and age at initiation affects rates of completion.

Development of food allergies in patients with Gastroesophageal Reflux Disease treated with gastric acid suppressive medications

The prevalence of food allergy has steadily increased, especially in children. Reflux disease, a very common problem in children, is often treated with gastric acid suppressive (GAS) medications which may alter the processing of food allergens, thereby affecting oral mucosal tolerance.

Variation Among Primary Care Physicians in Prostate-Specific Antigen Screening of Older Men

No organization recommends prostate-specific antigen (PSA) screening in men older than 75 years. Nevertheless, testing rates remain high.1,2 We hypothesized that primary care physicians (PCPs) would vary substantially in PSA screening rates and that much of the variance in whether an older man received a PSA test would depend on which PCP he saw.

Predicting Life Expectancy for Community-dwelling Older Adults From Medicare Claims Data

Estimates of life expectancy are useful in assessing whether different prevention strategies are appropriate in different populations. We developed sex-specific Cox proportional-hazard models that use Medicare claims data to predict life expectancy and risk of death at up to 10 years for older adults. We identified a cohort of Medicare beneficiaries 66-90 years of age from the 5% Medicare claims data in 2000 (n = 1,137,311) and tracked each subjects vital status until December 31, 2009. Subjects were split randomly into training and validation samples. Models were developed from the training sample and validated by comparison of predicted to actual survival in the validation sample. The C statistics for the models including predictors of age and Elixhauser comorbidities were 0.76-0.79 for men and women for prediction of death at the 1-, 5-, 7-, and 10-year follow-up periods. More than 80% of subjects with <25% risk of death at 5, 7, and 10 years survived longer than the chosen cutoff years. More than 80% of subjects with ≥75% risk of death at 5, 7, and 10 years died by those cutoff years. The models overestimated the risk of death at 1 year for the high-risk groups. Sex-specific models that use age and Elixhauser comorbidities can accurately predict patient life expectancy and risk of death at 5-10 years.

Hypoglycemia After Antimicrobial Drug Prescription for Older Patients Using Sulfonylureas

IMPORTANCE Certain antimicrobial drugs interact with sulfonylureas to increase the risk of hypoglycemia. OBJECTIVE To determine the risk of hypoglycemia and associated costs in older patients prescribed glipizide or glyburide who fill a prescription for an antimicrobial drug. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort study of Texas Medicare claims from 2006 to 2009 for patients 66 years or older who were prescribed glipizide or glyburide and who also filled a prescription for 1 of the 16 antimicrobials most commonly prescribed for this population. METHODS We assessed hypoglycemia events and associated Medicare costs in patients prescribed 1 of 7 antimicrobial agents thought to interact with sulfonylureas, using noninteracting antimicrobials as a comparison. We used a repeated measure logistic regression, controlling for age, sex, ethnicity, Medicaid eligibility, comorbidity, prior emergency department visits for hypoglycemia, prior hospitalizations for any cause, nursing home residence, and indication for the antimicrobial. We estimated odds of hypoglycemia, number needed to harm, deaths during hospitalization for hypoglycemia, and Medicare costs for hypoglycemia treatment. MAIN OUTCOMES AND MEASURES Any hospitalization or emergency department visit owing to hypoglycemia within 14 days of antimicrobial exposure. RESULTS In multivariable analyses controlling for patient characteristics and indication for antimicrobial drug use, clarithromycin (odds ratio [OR], 3.96 [95% CI, 2.42-6.49]), levofloxacin (OR, 2.60 [95% CI, 2.18-3.10]), sulfamethoxazole-trimethoprim (OR, 2.56 [95% CI, 2.12-3.10]), metronidazole (OR, 2.11 [95% CI, 1.28-3.47]), and ciprofloxacin (OR, 1.62 [95% CI, 1.33-1.97]) were associated with higher rates of hypoglycemia compared with a panel of noninteracting antimicrobials. The number needed to harm ranged from 71 for clarithromycin to 334 for ciprofloxacin. Patient factors associated with hypoglycemia included older age, female sex, black or Hispanic race/ethnicity, higher comorbidity, and prior hypoglycemic episode. In 2009, 28.3% of patients prescribed a sulfonylurea filled a prescription for 1 of these 5 antimicrobials, which were associated with 13.2% of all hypoglycemia events in patients taking sulfonylureas. The treatment of subsequent hypoglycemia adds

Integrating Age and Comorbidity to Assess Screening Mammography Utilization

30.54 in additional Medicare costs to each prescription of 1 of those 5 antimicrobials given to patients taking sulfonylureas. CONCLUSIONS AND RELEVANCE Prescription of interacting antimicrobial drugs to patients on sulfonylureas is very common, and is associated with substantial morbidity and increased costs.

Prostate-Specific Antigen Testing in Men Aged 40–64 Years: Impact of Publication of Clinical Trials

BACKGROUND Most studies use age as a cutoff to evaluate screening mammography utilization, generally examining screening up to age 75 years (the age-cutoff method). However, many experts and guidelines encourage clinicians to consider patient health and/or life expectancy. PURPOSE To compare the accuracy of estimating screening mammography utilization in older women using the age-cutoff method versus using a method based on the projected life expectancy. METHODS Two cohorts were selected from female Medicare beneficiaries aged 67-90 years living in Texas in 2001 and 2006. The 2001 cohort (n=716,279) was used to generate life-expectancy estimates by age and comorbidity, which were then applied to the 2006 cohort (n=697,825). Screening mammography utilization during 2006-2007 was measured for the 2006 cohort. Data were collected in 2000-2007 and analyzed in 2011. RESULTS The screening rate was 52.7% in women aged 67-74 years based on age alone, compared to 53.5% in women in the same age group with a life expectancy of ≥7 years. A large proportion (63.4%) of women aged 75-90 years (n=370,583) had a life expectancy of ≥7 years. Those women had a screening rate of 42.7%. The screening rate was 35.7% in women aged 75-90 years based on age alone, compared to 16.3% in women in the same age group with a life expectancy of <5 years. CONCLUSIONS Estimating screening mammography utilization among older women can be improved by using projected life expectancy rather than the age-cutoff method.

Refining Physician Quality Indicators for Screening Mammography in Older Women: Distinguishing Appropriate Use from Overuse

We assessed the impact of the publication of trials and changes in recommendations on the rates of prostate-specific antigen (PSA) screening in men aged 40 to 64 years by analyzing monthly medical claims for PSA testing in a commercial insurance database from 2001 to 2011, covering more than 1.5 million men in each year. The testing rates for men aged 40 to 49 years, 50 to 59 years, and 60 to 64 years were 12.1%, 32.7%, and 42.7%, respectively, in 2001 vs 15.7%, 34.2%, and 42.0%, respectively, in 2011. Men aged 40 to 49 years experienced a gradual increase in testing rate from 2001 through 2008 (annual change in PSA testing per 10,000 men [AC] = 4.37; P < .001), which became flat from mid-2009 through 2011(AC = -0.06; P =.98). The slope of PSA testing rates did not change in men aged 50 to 59 years or 60 to 64 years with the publication of the results of the large trials in 2009 or with the subsequent changes in recommendations on PSA testing.