Alice Jacobson

Current Use of Unopposed Estrogen and Estrogen Plus Progestin and the Risk of Acute Myocardial Infarction Among Women With Diabetes The Northern California Kaiser Permanente Diabetes Registry, 1995–1998

Background—Little is known about hormone replacement therapy (HRT) and risk for myocardial infarction (MI) in diabetic women. We examined associations of current HRT, estrogen dosage, and time since HRT initiation with risk of acute MI in diabetic women. Methods and Results—Cox proportional hazards models, with current HRT modeled as a time-dependent covariate, were used to assess the 3-year risk of MI. Among 24 420 women without a recent MI (mean age 64.9 years), 1110 incident MIs were identified. After adjustment for cardiovascular risk factors, current HRT was associated with reduced MI risk (relative hazard [RH] 0.84, 95% CI 0.72 to 0.98). The RH for MI associated with current estrogen plus progestin use was 0.77 (95% CI 0.61 to 0.97), and the RH for MI associated with current unopposed estrogen use was 0.88 (95% CI 0.73 to 1.05). Women were at reduced MI risk if they were taking a low or medium dose of estrogen (equivalent to <0.625 or 0.625 mg of conjugated estrogen, respectively) but not a high dose (>0.625 mg of conjugated estrogen or its equivalent). Among those whose current use of HRT was <1 year, the RH for MI was 1.03 (95% CI 0.74 to 1.44), whereas among users for ≥1 year, the RH was 0.81 (95% CI 0.66 to 1.00). Among 580 women with a recent MI (mean age 69.2 years), 89 recurrent MIs were identified. An increased risk of recurrent MI was observed among current HRT users (RH 1.78, 95% CI 1.06 to 2.98), which was higher among those with current use for <1 year (RH 3.84, 95% CI 1.60 to 9.20). Conclusions—In women without a recent MI, use of estrogen plus progestin was associated with decreased risk of MI. However, HRT was associated with increased risk of MI in women with history of a recent MI. Data from clinical trials in diabetic women are needed.

Effectiveness of a pharmacist-based gout care management programme in a large integrated health plan: results from a pilot study

Objectives The study objective was to determine the feasibility of using a pharmacist-staffed, protocol-based structured approach to improving the management of chronic, recurrent gout. Setting The study was carried out in the outpatient clinic of a single Kaiser Permanente medical centre. This is a community-based clinic. Participants We report on 100 consecutive patients between the ages of 21 and 94 (75% men) with chronic or recurrent gout, referred by their primary physicians for the purpose of management of urate-lowering therapy. Patients with stage 5 chronic kidney disease or end-stage kidney disease were excluded. Interventions The programme consisted of a trained clinical pharmacist and a rheumatologist. The pharmacist contacted each patient by phone, provided educational and dietary materials, and used a protocol that employs standard gout medications to achieve and maintain a serum uric acid (sUA) level of 6 mg/dL or less. Incident gout flares or adverse reactions to medications were managed in consultation with the rheumatologist. Primary outcome measure The primary outcome measure was the achievement and maintenance of an sUA of 6 or less for a period of at least 3 months. Results In 95 evaluable patients enrolled in our pilot programme, an sUA of 6 mg/dL or less was achieved and maintained in 78 patients with 4 still in the programme to date. Five patients declined to participate after referral, and another 13 patients did not complete the programme. (The majority of these were due to non-adherence.) Conclusions A structured pharmacist-staffed programme can effectively and safely lower and maintain uric acid levels in a high percentage of patients with recurrent gout in a primary care setting. This care model is simple to implement, efficient and warrants further validation in a clinical trial.

Is migraine a risk factor for pediatric stroke

Importance Our understanding of risk factors for childhood stroke is incomplete. In adults, migraine with aura is associated with a two-fold increase in ischemic stroke risk. Objective In this cohort study we examine the association between migraine and stroke among children in Kaiser Permanente Northern California (KPNC). Design, setting, and participants Children ages 2–17 years who were members of KPNC for ≥6 months between 1997 and 2007 were included. Migraine cohort members had one or more of: an ICD-9 code for migraine, migraine listed as a significant health problem, or a prescription for a migraine-specific medication. The comparison group was children with no evidence of headache. Main outcome measures Main outcome measures included stroke incidence rates and incidence rate ratios (IR). Results Among the 1,566,952 children within KPNC during the study period, 88,164 had migraine, and 1,323,142 had no evidence of headache. Eight migraineurs had a stroke (three (38%) hemorrhagic; five (63%) ischemic). Eighty strokes occurred in children without headache (53 (66%) hemorrhagic; 27 (34%) ischemic). The ischemic stroke incidence rate was 0.9/100,000 person-years in migraineurs vs. 0.4/100,000 person-years in those without headache; IR 2.0 (95% CI 0.8–5.2). A post-hoc analysis of adolescents (12–17 years) showed an increased risk of ischemic stroke among those with migraine; IR 3.4 (95% CI 1.2–9.5). The hemorrhagic stroke incidence rate was 0.5/100,000 person-years in migraineurs and 0.9/100,000 person-years in those without headache; IR 0.6 (95% CI 0.2–2.0). Conclusions There was no statistically significant increase in hemorrhagic or ischemic stroke risk in pediatric migraineurs in this cohort study. A post-hoc analysis found that ischemic stroke risk was significantly elevated in adolescents with migraine. Future studies should focus on identifying risk factors for ischemic stroke among adolescent migraineurs. Based on adult data, we recommend that migraine aura status should be studied as a possible risk factor for ischemic stroke among adolescent migraineurs.

A Pharmacist-Staffed, Virtual Gout Management Clinic for Achieving Target Serum Uric Acid Levels: A Randomized Clinical Trial.

CONTEXT Relatively few patients with gout receive appropriate treatment. OBJECTIVE To determine whether a pharmacist-staffed gout management program is more effective than usual care in achieving target serum uric acid (sUA) levels in gout patients. DESIGN A parallel-group, randomized controlled trial of a pharmacist-staffed, telephone-based program for managing hyperuricemia vs usual care. Trial duration was 26 weeks. MAIN OUTCOME MEASURES Primary outcome measure was achieving sUA levels at or below 6 mg/dL at the 26-week visit. Secondary outcome was mean change in sUA levels in the control and intervention groups. Participants were adults with recurrent gout and sUA levels above 6.0 mg/dL. Participants were randomly assigned to management by a clinical pharmacist following protocol or to monitoring of sUA levels but management of their gout by their usual treating physician. RESULTS Of 102 patients who met eligibility criteria, 77 subjects obtained a baseline sUA measurement and were entered into the trial. Among 37 participants in the intervention group, 13 (35%) had sUA levels at or below 6.0 mg/dL at 26 weeks, compared with 5 (13%) of 40 participants in the control group (risk ratio = 2.8, 95% confidence interval [CI] = 1.1 to 7.1, p = 0.03). The mean change in sUA levels among controls was +0.1 mg/dL compared with -1.5 mg/dL in the intervention group (sUA difference = -1.6, 95% CI = -0.9 to -2.4, p < 0.001). CONCLUSIONS A structured pharmacist-staffed program was more effective than usual care for achieving target sUA levels. These results suggest a structured program could greatly improve gout management.

Prevalence of migraine in a diverse community--electronic methods for migraine ascertainment in a large integrated health plan.

Introduction The growing availability of electronic health data provides an opportunity to ascertain diagnosis-specific cases via systematic methods for sample recruitment for clinical research and health services evaluation. We developed and implemented a migraine probability algorithm (MPA) to identify migraine from electronic health records (EHR) in an integrated health plan. Methods We identified all migraine outpatient diagnoses and all migraine-specific prescriptions for a five-year period (April 2008–March 2013) from the Kaiser Permanente, Northern California (KPNC) EHR. We developed and evaluated the MPA in two independent samples, and derived prevalence estimates of medically-ascertained migraine in KPNC by age, sex, and race. Results The period prevalence of medically-ascertained migraine among KPNC adults during April 2008–March 2013 was 10.3% (women: 15.5%, men: 4.5%). Estimates peaked with age in women but remained flat for men. Prevalence among Asians was half that of whites. Conclusions We demonstrate the feasibility of an EHR-based algorithm to identify cases of diagnosed migraine and determine that prevalence patterns by our methods yield results comparable to aggregate estimates of treated migraine based on direct interviews in population-based samples. This inexpensive, easily applied EHR-based algorithm provides a new opportunity for monitoring changes in migraine prevalence and identifying potential participants for research studies.

PS2-5: Prevalence of Migraine in a Diverse Community – Electronic Methods for Migraine Ascertainment in a Large Integrated Health Plan

Background/Aims Migraine, a common neurological disorder, is among the top 20 causes of disability worldwide. One-year prevalence of migraine in the US is estimated to range from 8–15%, with women affected at approximately three times the rate of men. Current methods for migraine ascertainment from headache clinics and surveys are costly, affected by clinic-ascertainment bias, and do not work in situations where patient contact is not feasible. With the growing use of electronic medical records (EMR), new methods must be developed for identifying and tracking migraine prevalence over time. We sought to develop an EMR algorithm, to identify migraine, and to characterize its prevalence in Kaiser Permanente Northern California (KPNC). Methods From EMRs of all KPNC members, we collected all outpatient migraine diagnoses (ICD9 code 346.xx) and migraine-specific prescriptions (ergots, triptans, and acetaminophen with caffeine) for 2006–2010. We chart-reviewed a random sample to develop an electronic Migraine Probability Algorithm (score 0–100). We tested the algorithm in a second independent chart review. Using membership data, we calculated prevalences by age, race, and gender. Results We identified 313,174 KPNC members with evidence of migraine - 233,620 women and 79,554 men. The 5-year period-prevalence of migraine among KPNC adults was 17.1% for women and 5.9% for men. Among children, rates did not differ by gender (<2%) until the age of 10, when prevalences were higher - 5.8% for girls and 3.5% for boys. For women, prevalence peaked at ages 25–29. In contrast, males experienced flat prevalence with age (range 5%–6%). Overall, Whites had higher prevalence than Asians, but Blacks did not differ appreciably. Conclusions We used EMR data to capture migraine diagnoses and show prevalence patterns similar to those reported in the literature. Prevalence of diagnosed migraine in KPNC was 2.5–3 times higher in women than men; migraine peaked with age in women, but remained flat for men; and prevalence of migraine among Asian adults was roughly 2/3 that of Whites. These methods for ascertainment of migraine are inexpensive and easy to implement and have applications and implications that extend well to other institutions and debilitating pain conditions.