Bilal Khokhar

Patterns of Depression Treatment in Medicare Beneficiaries with Depression after Traumatic Brain Injury

There are no clinical guidelines addressing the management of depression after traumatic brain injury (TBI). The objectives of this study were to (1) describe depression treatment patterns among Medicare beneficiaries with a diagnosis of depression post-TBI; (2) compare them with depression treatment patterns among beneficiaries with a diagnosis of depression pre-TBI; and (3) quantify the difference in prevalence of use. We conducted a retrospective analysis of Medicare beneficiaries hospitalized with TBI during 2006-2010. We created two cohorts: beneficiaries with a new diagnosis of depression pre-TBI (n=4841) and beneficiaries with a new diagnosis of depression post-TBI (n=4668). We searched for antidepressant medications in Medicare Part D drug event files and created variables indicating antidepressant use in each 30-day period after diagnosis of depression. We used provider specialty and current procedural terminology to identify psychotherapy in any location. We used generalized estimating equations to quantify the effect of TBI on receipt of depression treatment during the year after diagnosis of depression. Average monthly prevalence of antidepressant use was 42% among beneficiaries with a diagnosis of depression pre-TBI and 36% among those with a diagnosis post-TBI (p<0.001). Beneficiaries with a diagnosis of depression post-TBI were less likely to receive antidepressants compared with a depression diagnosis pre-TBI (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.82, 0.92). There was no difference in receipt of psychotherapy between the two groups (OR 1.08; 95% CI 0.93, 1.26). Depression after TBI is undertreated among older adults. Knowledge about reasons for this disparity and its long-term effects on post-TBI outcomes is limited and should be examined in future work.

A Systematic Review of the Benefits and Risks of Anticoagulation Following Traumatic Brain Injury.

Objective:To synthesize the existing literature on benefits and risks of anticoagulant use after traumatic brain injury (TBI). Design:Systematic review. A literature search was performed in MEDLINE, International Pharmaceutical Abstracts, Health Star, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on October 11, 2012, and updated on September 2, 2013, using terms related to TBI and anticoagulants. Main Measures:Human studies evaluating the effects of post-TBI anticoagulation on venous thromboembolism, hemorrhage, mortality, or coagulation parameters with original analyses were eligible for the review. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was followed throughout the conduct of the review. Results:Thirty-nine eligible studies were identified from the literature, of which 23 studies with complete information on post-TBI anticoagulant use and patient outcomes were summarized in this review. Meta-analysis was unwarranted because of varying methodological design and quality of the studies. Twenty-one studies focused on the effects of pharmacological thromboprophylaxis (PTP) post-TBI on venous thromboembolism and/or progression of intracranial hemorrhage, whereas 2 randomized controlled trials analyzed coagulation parameters as the result of anticoagulation. Conclusion:Pharmacological thromboprophylaxis appears to be safe among TBI patients with stabilized hemorrhagic patterns. More evidence is needed regarding effectiveness of PTP in preventing venous thromboembolism as well as preferred agent, dose, and timing for PTP.

Depression among older adults after traumatic brain injury: a national analysis.

OBJECTIVE Sequelae of traumatic brain injury (TBI) include depression, which could exacerbate the poorer cognitive and functional recovery experienced by older adults. The objective of this study was to estimate incidence rates of depression after hospital discharge for TBI among Medicare beneficiaries aged at least 65 years, quantify the increase in risk of depression after TBI, and evaluate risk factors for incident depression post-TBI. METHODS Using a retrospective analysis, the authors studied Medicare beneficiaries at least 65 years old hospitalized for TBI during 2006 to 2010 who survived to hospital discharge and had no documented diagnosis of depression before the study period (N = 67,347). RESULTS The annualized incidence rate of depression per 1,000 beneficiaries was 62.8 (95% confidence interval [CI]: 61.6, 64.1) pre-TBI and 123.9 (95% CI: 121.6, 126.2) post-TBI. Annualized incidence rates were highest immediately after hospital discharge and declined over the 12 months post-TBI. TBI increased the risk of incident depression in men (hazard ratio: 1.95; 95% CI: 1.84, 2.06; Wald χ(2) = 511.4, df = 1, p <0.001) and in women (hazard ratio: 1.69; 95% CI: 1.62, 1.77; Wald χ(2) = 589.3, df = 1, p <0.001). The strongest predictor of depression post-TBI for both men and women was discharge to a skilled nursing facility (men: odds ratio, 1.91; 95% CI, 1.77, 2.06; Wald χ(2) = 277.1, df = 1, p <0.001; women: odds ratio, 1.72; 95% CI, 1.63, 1.83; Wald χ(2) = 324.2, df = 1, p <0.001). CONCLUSION TBI significantly increased the risk of depression among older adults, especially among men and those discharged to a skilled nursing facility. Results from this study will help increase awareness of the risk of depression post-TBI among older adults.

New episodes of depression among Medicare beneficiaries with chronic obstructive pulmonary disease

Depression is a common comorbidity of chronic obstructive pulmonary disease (COPD) and is associated with increased exacerbations, healthcare utilization, and mortality. Among Medicare beneficiaries newly diagnosed with COPD, the objectives of this study were to (1) estimate the rate of new episodes of depression and (2) identify factors associated with depression.

Perceptions of patient provider agreements

Use of patient provider agreements (PPAs) is increasing, yet there is limited evidence on the effectiveness of PPAs to prevent prescription opioid misuse and diversion, and few guidelines for providers. We conducted eight focus groups to understand patient and prescriber perceptions of PPAs.

The association of antidepressant treatment with COPD maintenance medication use and adherence in a comorbid Medicare population: A longitudinal cohort study

The effect of treating comorbid depression to achieve optimal management of chronic obstructive pulmonary disease (COPD) has not yet empirically tested. We examined the association between antidepressant treatment and use of and adherence to COPD maintenance medications among patients with new‐onset COPD and comorbid depression.

Patterns of Statin Use in Older Medicare Beneficiaries With Traumatic Brain Injury

Background: In addition to lowering lipids, statins also may be beneficial for older adults sustaining a traumatic brain injury (TBI), as statin use prior to and following trauma may decrease mortality following injury. However, despite statins’ potential to reduce mortality, there is limited research regarding statin use among older adults. Objective: To characterize and investigate factors associated with statin use among older adults with TBI. Methods: A retrospective drug utilization study was used to characterize statin use among Medicare beneficiaries 65 and older hospitalized with a TBI during 2006 to 2010 and with continuous Medicare Parts A, B, and D coverage 6 months prior and 12 months following TBI. Logistic regression was used to investigate the factors associated with statin use. The exposure of interest was statin use prior to and following TBI. Results: Of the 75 698 beneficiaries included in the study, 37 874 (~50%) of beneficiaries used a statin at least once during the study period. The most common statin used was simvastatin, while fluvastatin was the least used statin. Statin users were more likely to have cardiovascular diseases when compared to nonusers. Hyperlipidemia was a major factor associated with statin use and had the greatest impact on statin use compared to nonuse (odds ratio = 9.54; 95% confidence interval = 9.07, 10.03). Conclusions: This national sample of older adults with TBI suggests that statins are commonly used. Future studies must next examine the impact of statin use on mortality and secondary injury in order to shape pharmacological therapy guidelines following TBI.

Risk of Stroke Among Older Medicare Antidepressant Users With Traumatic Brain Injury.

Objective: To estimate the risk of stroke associated with new antidepressant use among older adults with traumatic brain injury (TBI). Participants: A total of 64 214 Medicare beneficiaries aged 65 years or older meeting inclusion criteria and hospitalized with a TBI during 2006 to 2010. Design: New user design. Generalized estimating equations were used to estimate the relative risks (RRs) of stroke. Main Measures: Primary exposure was new antidepressant use following TBI identified through Medicare part D claims. The primary outcome was stroke following TBI. Ischemic and hemorrhagic strokes were secondary outcomes. Results: A total of 20 859 (32%) beneficiaries used an antidepressant at least once following TBI. Selective serotonin reuptake inhibitors accounted for the majority of antidepressant use. Selective serotonin reuptake inhibitor use was associated with an increased risk of hemorrhagic stroke (RR, 1.26; 95% confidence interval [CI], 1.06-1.50) but not ischemic stroke (RR, 1.04; 95% CI, 0.94-1.15). The selective serotonin reuptake inhibitors escitalopram (RR, 1.33; 95% CI, 1.02-1.74) and sertraline (RR, 1.46; 95% CI, 1.10-1.94) were associated with an increase in the risk of hemorrhagic stroke. Conclusion: Findings from this study will aid prescribers in choosing appropriate antidepressants to treat depression in older adults with TBI.