Essy Mozaffari

Reference Group Choice and Antibiotic Resistance Outcomes

Two types of cohort studies examining patients infected with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) were contrasted, using different reference groups. Cases were compared to uninfected patients and patients infected with the corresponding, susceptible organism. VRE and MRSA were associated with adverse outcomes. The effect was greater when uninfected control patients were used.

The direct and indirect cost burden of acutecoronary syndrome

Objective: Quantify the incremental health care costs and workplace absence and short-term disability costs, to payers and employers, of patients hospitalized for acute coronary syndrome (ACS). Methods: Retrospective study using medical insurance claims for the years 2002 to 2007. Patients were aged 18 to 64 years and hospitalized for ACS between January 1, 2003, and December 31, 2006; comparison patients without evidence of coronary artery disease were also selected. The incremental impact of ACS was estimated using weighted regression. Results: 30,200 ACS patients were selected. Incremental annual direct costs of ACS were

Economic consequences of ACS-related rehospitalizations in the US

40,671 (P < 0.001). For the indirect cost sub-analyses, incremental short-term disability costs of ACS were

Management of hypertension and hypercholesterolaemia in primary care in the Netherlands

999 (P < 0.001) and incremental absence costs were insignificant (P = 0.314) but from a small sample (N = 416). Conclusions: Patients with ACS impose a substantial direct cost burden on employers and payers and a substantial indirect cost burden on employers. Acute coronary syndrome is more costly to employers and payers than other health conditions that are common among employed persons. Rehospitalizations after the initial hospitalization are common and represent a large portion of the cost.

Clinical impact of early clopidogrel discontinuation following acute myocardial infarction hospitalization or stent implantation: analysis in a nationally representative managed-care population

Abstract Objective: To examine economic consequences related to rehospitalization following initial acute coronary syndrome (ACS) treatment in United States managed care settings. Study design: Retrospective observational studies. Research design and methods: Retrospective observational studies were conducted on two managed care populations to examine medical encounter insurance claims and charges for ACS-related rehospitalizations following an index hospitalization for new onset ACS (2002–2007). All charges were adjusted to year 2007 United States Dollars (USDs). Main outcome measures: The main outcomes for this study were the direct charges related to ACS rehospitalizations as captured in two separate medical encounter claims databases. Results: Of the 11,266 ACS patients identified for analysis in the health system plan, 3588 (32%) had at least one ACS rehospitalization. Of the 97,177 ACS patients enrolled in the nationally representative managed care database, 32,578 (34%) had at least one ACS-related rehospitalization. Multivariate analyses demonstrated that coronary artery bypass graft (CABG) was the strongest predictor of increased charges during the recurrence in both populations (p < 0.0001). When controlling for length of stay (LOS) in the model, CABG remained a significant predictor of increased charges, while percutaneous coronary intervention (PCI) and stent insertion became even stronger predictors of increased charges. Conclusions: The costs associated with ACS-related rehospitalizations in a real-world setting are high, even when controlling for known cost drivers such as length of stay.

Economic consequences of severe bleeding in patients with acute coronary syndrome in the USA

ABSTRACT Objective: Screening, treatment and monitoring guidelines for hypertension and hypercholesterolaemia have been developed to assist physicians in providing evidence-based health care. We conducted a retrospective study to assess the management of patients with these single or combined conditions. Research design and methods: This was a retrospective cohort study conducted using data from the Integrated Primary Care Information (IPCI) project based in the Netherlands. Management of hypertension and hypercholesterolaemia was assessed from 2000–2003 by measuring the numbers of patients screened for these conditions, treated pharmacologically and monitored for treatment success. Results: Approximately 11%, 3% and 10% of participants were eligible for screening for hypertension alone, hypercholesterolaemia alone and both conditions, respectively. Blood pressure screening was high in patients eligible for both blood pressure and cholesterol screening (> 86%), whereas cholesterol screening was low (< 56%). Among patients newly identified with hypertension or hypercholesterolaemia who were eligible for pharmacotherapy, 29% and 43% respectively were not treated within one year of diagnosis. Undertreatment was significantly lower in patients with both conditions (24% and 37% for antihypertensive and lipid-lowering treatment, respectively and 28% were not treated for both). Among newly treated patients, in the first year of treatment there was no record of a blood pressure or cholesterol assessment, for 35% and 72%, respectively. Conclusion: Management was sub-optimal in patients with hypertension or hypercholesterolaemia as well as in those with both of these conditions. The results of this study are likely to be widely applicable, particularly to other European and industrialised countries that have similar free-access health care systems to the Netherlands.

Clinical impact of early clopidogrel discontinuation following acute myocardial infarction hospitalization or stent implantation: analysis in a single integrated health network.

ABSTRACT Objectives: To evaluate the association between discontinuation of clopidogrel therapy and risk of acute myocardial infarction (AMI) hospitalization or cardiac revascularization in a nationally-representative patient population following hospitalization for an AMI or coronary stent insertion. Research design and methods: This observational cohort study was performed using data on patients from the PharMetrics Anonymous Patient-Centric Database who were hospitalized for an AMI or coronary stent insertion and subsequently treated with clopidogrel. Cox proportional hazard modeling was used to evaluate the association between clopidogrel discontinuation prior to 1 year post-initial AMI hospitalization and the primary endpoint of repeat AMI hospitalization or coronary intervention defined as percutaneous coronary intervention (PCI) with or without stent, or coronary artery bypass graft (CABG). Main outcome measures: The main outcome for this study was AMI hospitalization or coronary intervention defined as PCI with or without stent placement or CABG. Results: A total of 31 835 patients were included in the analyses. Patients were predominantly male and the average patient age was approximately 60 years. After controlling for baseline patient characteristics and follow-up time, discontinuation of clopidogrel was associated with a significantly higher rate of hospitalization for AMI or coronary intervention (HR 1.34, 95% CI 1.22–1.44). Conclusion: Within a population of ACS patients drawn from a database of 85 US health plans, clopidogrel discontinuation within 1 year following hospitalization for AMI or stent placement is associated with an increased risk of AMI hospitalization or coronary intervention. The results of this study should be interpreted within the context of observational research, which does not address cause and effect relationships.

Drug treatment discontinuation and achievement of target blood pressure and cholesterol in United Kingdom primary care

IntroductionPrevious studies have demonstrated increased costs associated with bleeding in clinical trials, but none have yet examined the association of bleeding with costs/charges in a real-world setting. This study examines the association between health care charges and severe bleeding events among patients with acute coronary syndrome (ACS) in a real-world US setting.MethodsThis retrospective study of ACS patients enrolled in a regional, 570,000-member commercial health plan evaluated resource utilization for patients with and without severe bleeding using medical encounter data in health care administrative records. Inclusion criteria were continuous health plan enrollment in the 6 months before initial ACS-related hospitalization, age of at least 18 years, and an inpatient ACS claim between January 1995 and May 2007. Severe bleeding events were defined as having an in-hospital record for: (a) bleeding plus blood transfusion, (b) intracranial hemorrhage, or (c) blood transfusion followed by death. Hospitalizations in which the patient had a nonsevere bleeding event, defined as having an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for bleeding without transfusion or death, were removed from analysis. Resource utilization was assessed using hospital charges. Multiple linear regression analyses controlling for key covariates were used to assess the association of severe bleeding during initial hospitalization with an ACS diagnosis/procedure with charges and length of stay (LOS).ResultsThere were 11,266 ACS patients identified: 928 patients (8.2%) had severe bleeding during initial hospitalization. Severe bleeding events were associated with significantly higher hospital charges and increased LOS than hospitalizations without severe bleeding events. After adjusting for patient characteristics, in-hospital ACS-related procedures, and LOS, patients with severe bleeding incurred initial hospitalization charges that were

Use of insurance claims data to assess outpatient antimicrobial therapy for gram-positive infections

48,114 higher than those of patients without bleeding (P<0.001).ConclusionIn a real-world setting, hospitalizations with both severe bleeding and an ACS diagnosis or procedure are associated with significantly higher hospitalization charges and resource use compared with ACS-related hospitalizations without bleeding events. However, due to the limitations of retrospective analyses, no causal relationship can be determined as patient comorbidities represent a possible source of confounding.

Persistence and Adherence With Topical Glaucoma Therapy

ABSTRACT Objective: To determine the association between the discontinuation of clopidogrel therapy prior to 1 year and the risk of acute myocardial infarction (AMI) hospitalization, coronary intervention or all-cause mortality in a cohort of managed-care patients following AMI hospitalization or stent insertion. Research design and methods: This observational cohort study included 1152 patients enrolled in the Health Alliance Plan who were hospitalized for AMI, or who underwent coronary stent placement. Clopidogrel use was assessed using pharmacy claims data. The association between discontinuation of clopidogrel prior to 1 year following the initial ACS event and the primary outcome of AMI hospitalization/procedure was assessed using Cox proportional hazards models. Additionally, an analysis was conducted to determine the association of discontinuation prior to 1 year with a secondary composite outcome of AMI hospitalization/coronary stent procedure or all-cause mortality. Main outcome measures: The primary outcome was AMI hospitalization or procedure. The secondary outcome was a composite of AMI hospitalization/ procedure, or all-cause mortality. Results: Discontinuation of clopidogrel in the total cohort of patients was associated with a significantly higher risk of the primary outcome of AMI hospitalization/ coronary intervention (HR 2.712, 95% CI 1.634–4.502). Consistent with this finding, discontinuation of clopidogrel was also associated with a significantly higher risk of the secondary composite endpoint (HR 1.844, 95% CI 1.281–2.653). Conclusions: In patients enrolled in an integrated health network, clopidogrel discontinuation prior to 1 year following AMI hospitalization or stent placement is associated with adverse outcomes including greater risk of death, AMI hospitalization or coronary intervention. These results should be interpreted within the context and limitations of observational research, which cannot attribute causality.