Hsien-Chang Lin

Use of electronic medical records differs by specialty and office settings

OBJECTIVE To assess differences in the use of electronic medical records (EMRs) among medical specialties and practice settings. METHODS A cross-sectional retrospective study using nationally representative data from the National Ambulatory Medical Care Survey for the period 2003-2010 was performed. Bivariate and multivariate analyzes compared EMR use among physicians of 14 specialties and assessed variation by practice setting. Differences in EMR use by geographic region, patient characteristics, and physician office settings were also assessed. RESULTS Bivariate and multivariate analysis demonstrated increased EMR use from 2003 to 2010, with 16% reporting at least partial use in 2003, rising to 52% in 2010 (p<0.001). Cardiologists, orthopedic surgeons, urologists, and family/general practitioners had higher frequencies of EMR use whereas psychiatrists, ophthalmologists, and dermatologists had the lowest EMR use. Employed physicians had higher EMR uptake than physicians who owned their practice (48% vs 31%, p<0.001). EMR uptake was lower among solo practitioners (23%) than non-solo practitioners (42%, p<0.001). Practices owned by Health Maintenance Organizations had higher frequencies of EMR use (83%) than practices owned by physicians, community health centers, or academic centers (all <45%, p<0.001). Patient demographics did not affect EMR use (p>0.05). CONCLUSIONS Uptake of EMR is increasing, although it is significantly slower in dermatology, ophthalmology, and psychiatry. Solo practitioners and owners of a practice have low frequencies of EMR use compared with non-solo practitioners and those who do not own their practice. Despite incentives for EMR adoption, physicians should carefully weigh which, if any, EMR to adopt in their practices.

Association of Geroprotective Effects of Metformin and Risk of Open-Angle Glaucoma in Persons With Diabetes Mellitus

IMPORTANCE Caloric restriction mimetic drugs have geroprotective effects that delay or reduce risks for a variety of age-associated systemic diseases, suggesting that such drugs might also have the potential to reduce risks of blinding ophthalmologic conditions for which age is a major risk factor. OBJECTIVE To determine whether the caloric restriction mimetic drug metformin hydrochloride is associated with reduced risk of open-angle glaucoma (OAG) in persons with diabetes mellitus. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of patients aged 40 years or older with diabetes mellitus and no preexisting record of OAG in a large US managed care network from January 1, 2001, through December 31, 2010. EXPOSURES Quantity of metformin and other prescribed diabetes medications as captured from outpatient pharmacy records. MAIN OUTCOMES AND MEASURES Risk of developing OAG. RESULTS Of 150 016 patients with diabetes mellitus, 5893 (3.9%) developed OAG. After adjusting for confounding factors, those prescribed the highest quartile of metformin hydrochloride (>1110 g in 2 years) had a 25% reduced OAG risk relative to those who took no metformin (hazard ratio = 0.75; 95% CI, 0.59-0.95; P = .02). Every 1-g increase in metformin hydrochloride use was associated with a 0.16% reduction in OAG risk (adjusted hazard ratio = 0.99984; 95% CI, 0.99969-0.99999; P = .04), which predicts that taking a standard dose of 2 g of metformin hydrochloride per day for 2 years would result in a 20.8% reduction in risk of OAG. After accounting for potential confounders, including metformin and diabetic medications, the risk of developing OAG was increased by 8% (hazard ratio = 1.08; 95% CI, 1.03-1.13; P = .003) for each unit of increase in glycated hemoglobin level. CONCLUSIONS AND RELEVANCE Metformin use is associated with reduction in risk of developing OAG, and risk is reduced even when accounting for glycemic control in the form of glycated hemoglobin level. Other diabetes medications did not confer a similar OAG risk reduction. This study suggests that metformin may be affecting OAG risk on multiple levels, some involving improved glycemic control and some involving mechanisms outside glycemic control such as neurogenesis, inflammatory systems, or longevity pathways targeted by caloric restriction mimetic drugs. If confirmed by prospective clinical trials, these findings could lead to novel treatments for this sight-threatening disease.

E-Cigarette Use and Intention to Initiate or Quit Smoking Among US Youths

OBJECTIVES We assessed whether e-cigarette use is associated with (1) intention to smoke cigarettes among never-smoking youths and youth experimenters, and (2) intention to quit smoking among current youth smokers. METHODS We categorized participants from the 2012 National Youth Tobacco Survey data (n = 20 193) as never-smoking youth (n = 16 238), youth experimenters (n = 3248), and current youth smokers (n = 707). We matched groups on the basis of a propensity score comprising covariates predicting e-cigarette use. RESULTS E-cigarette users who had never smoked cigarettes (adjusted odds ratio [AOR] = 3.62; 95% confidence interval [CI] = 2.04, 6.45) and who had experimented with smoking (AOR = 1.99; 95% CI = 1.50, 2.64) had elevated intention to smoke cigarettes compared with their counterparts who had never used e-cigarettes. We did not find any significant association between e-cigarette use and intention to quit smoking among current youth smokers (P = .33). CONCLUSIONS E-cigarette use among US youths is associated with intention to smoke but not with intention to quit smoking.

Diabetes and prognosis in older persons with colorectal cancer.

Background:Epidemiological studies have reported that diabetes significantly increases overall mortality in patients with colorectal cancer. However, it is unclear whether diabetes increases colorectal cancer-specific mortality. We used the US Surveillance Epidemiology and End Results (SEER) database linked with Medicare claims data to assess the influence of pre-existing diabetes on prognosis of patients with colorectal cancer.Methods:Data from 61 213 patients aged 67 or older with colorectal cancer diagnosed between 2003 and 2009 were extracted and prospectively followed through the date of death or the end of 2012 if the patient was still alive. Diabetes cases with and without complications were identified based on an algorithm developed for the Chronic Condition Data Warehouse (CCW). Cox models were used to estimate hazard ratios (HRs) for total mortality. The proportional subdistribution hazards model proposed by Fine and Gray was used to estimate HRs for colorectal cancer-specific mortality.Results:Compared with patients without diabetes, colorectal cancer patients with pre-existing diabetes had significantly higher risk of overall mortality (HR=1.20, 95 % confidence interval (95% CI): 1.17–1.23). The HR for overall mortality was more pronounced for patients who had diabetes with complications (HR=1.50, 95% CI: 1.42–1.58). However, diabetes was not associated with increased colorectal cancer-specific mortality after accounting for non-colorectal cancer outcomes as competing risk.Conclusions:Pre-existing diabetes increased risk of total mortality among patients with colorectal cancer, especially among cancer patients who had diabetes with complications. The increased risk of total mortality associated with diabetes was primarily explained by increased cardiovascular-specific mortality, not by increased colorectal cancer-specific mortality.

Medication use and associated health care outcomes and costs for patients with psoriasis in the United States

Abstract Background: The impacts of use of pharmacotherapy for psoriasis on patient outcomes and medication costs need further examination using up-to-date large nationally representative data. Objective: To examine the impacts of patient demographics and medication use on patients health status and associated medication costs. Methods: A retrospective cross-sectional study was conducted using the 2007 Medical Expenditure Panel Survey (MEPS) database. Information on patient demographics, health status, medication utilization, and medication costs were obtained representing 543 231 patients with psoriasis. Results: Weighted multiple linear regression analyses indicated that the use of biological/systemic agents yielded an increase in patient health status among all types of medications (β = 7.9, p < 0.05). Use of biological/systemic agents also yielded an increase in annual medication spending (β = 2.5, p < 0.01). Use of biological agents was elevated compared to previous studies. Conclusions: We observed an association between medication use for psoriasis treatment and its related patient health status and medication spending. The study findings could imply that encouraging the use of topical treatments may be an effective means to increase patient health status. The use of biologics needs further cost-effectiveness studies given the findings that biologics contribute to substantial increases in both drug expenditures and patient health status.

Hidradenitis Suppurativa Management in the United States: An Analysis of the National Ambulatory Medical Care Survey and MarketScan Medicaid Databases

Purpose: To present nationally representative data demonstrating how frequently hidradenitis suppurativa (HS) occurs in specific groups and how it is currently managed. Methods: We analyzed data from the 1990-2009 National Ambulatory Medical Care Survey (NAMCS) and the 2003-2007 MarketScan Medicaid databases for patients with a diagnosis of HS (ICD-9-CM code 705.83). Visits per 100,000 population of each race and ethnicity were calculated using the 2000 US Census data for specific demographics. Results: There were 164,000 patient visits (95% CI: 128,000-200,000) annually with a diagnosis of HS in the NAMCS, and 17,270 HS patients were found in the MarketScan Medicaid over the 5-year period. Antibiotics were the most common treatment, followed by pain medications, topical steroids, and isotretinoin. Prescriptions of biologics and systemic methotrexate, cyclosporine, and acitretin were not observed in the NAMCS. Physicians prescribed medications in 74% of visits and used procedures in 11% of visits. African Americans, females, and young adults had higher numbers of visits for HS. Conclusions: Our data showing a maximum of 0.06% of the population being treated for HS in a given year are consistent with the low estimates of HS prevalence. Compared to the current prescribing patterns, the more frequent prescription of biologics and systemic treatments may yield better outcomes.

Comprehensive US Statewide Smoke-Free Indoor Air Legislation and Secondhand Smoke Exposure, Asthma Prevalence, and Related Doctor Visits: 2007–2011

OBJECTIVES We evaluated the impact of comprehensive statewide smoke-free indoor air laws on secondhand smoke (SHS) exposure, asthma prevalence, and asthma-related doctor visits. METHODS We used the 2007-2011 Behavioral Risk Factor Surveillance System data sets. We employed a paired t test to determine whether comprehensive statewide smoke-free indoor air laws reduced SHS exposure. We performed weighted logistic and Poisson regressions to obtain likelihood of reporting asthma symptoms and incidence rate ratio (IRR) of doctor visits owing to severe asthma symptoms. RESULTS After such laws were enacted, people in states with comprehensive smoke-free indoor air laws had a lower level of SHS exposure (P < .01), decreased odds of reporting current asthma symptoms (adjusted odds ratio [AOR] = 0.57; 95% confidence interval [CI] = 0.51, 0.63), and a decreased frequency of doctors visits owing to severe asthma symptoms (IRR = 0.80; 95% CI = 0.69, 0.92) than did their counterparts in fully adjusted models. CONCLUSIONS Comprehensive statewide smoke-free indoor air laws appear to be effective in reducing SHS exposure and improving asthma outcomes. Regulations requiring smoke-free indoor environments and public areas are beneficial, and smoke-free indoor air laws should be enforced in all states.

Systemic corticosteroids are frequently prescribed for psoriasis.

Background: The use of systemic corticosteroids is discouraged in major psoriasis treatment guidelines. Purpose: Our objective was to assess how often systemic corticosteroids are prescribed for psoriasis and trends in their use over time. Methods: We used National Ambulatory Medical Care Survey (NAMCS) data to determine the systemic medications prescribed for psoriasis from 1989 to 2010. We confirmed the findings by analysis of 2003–2007 MarketScan Medicaid data. Results: Systemic corticosteroids were prescribed at 650,000 (95% CI 380,000–920,000) of 21,000,000 psoriasis visits; 93% of these visits were to dermatologists. Of the top nine systemic medications listed at psoriasis visits, three of them were corticosteroids. Corticosteroids were the second most commonly prescribed systemic medication for psoriasis. No significant change in the use of systemic corticosteroids for psoriasis over time was observed (p = .27). In the MarketScan data, prednisone was prescribed more commonly than either methotrexate or etanercept. Limitations: Corticosteroid doses and the length of treatment were not recorded in the NAMCS data. Conclusions: Systemic corticosteroids are among the most common systemic treatments used for psoriasis despite current guidelines. Data are acutely needed on the risks and benefits so that physicians and patients can make evidence-based decisions about their use.

Keratoplasty for Corneal Endothelial Disease, 2001–2009

PURPOSE To determine the rates of keratoplasty for corneal endothelial disease (CED) from 2001 to 2009 in a large managed care network in the United States, factors that affect which patients undergo this procedure and surgical outcomes. DESIGN A retrospective review of data from a longitudinal cohort study. PARTICIPANTS Beneficiaries with CED aged ≥ 40 years who were receiving eye care during 2001 to 2009. METHODS Rates of keratoplasty for CED were determined at 6-month intervals from January 2001 to December 2009. The mean number of postoperative visits and rates of severe adverse events in the year after keratoplasty surgery were monitored over the course of the decade. Univariable and multivariable logistic regression were performed to identify sociodemographic and other factors associated with undergoing keratoplasty for CED. MAIN OUTCOME MEASURES Odds of undergoing keratoplasty with 95% confidence intervals, changes in the number of postoperative visits, and rates of adverse events in the year after keratoplasty. RESULTS Of the 38 648 enrollees who met the inclusion criteria, 2187 underwent ≥ 1 keratoplasty surgeries from January 2001 to December 2009. After adjustment for confounding factors, individuals with CED had 47% increased odds of undergoing keratoplasty during 2007-2009 relative to 2001-2006. The mean number of postoperative visits to eyecare providers in the year after keratoplasty declined from 12.6 in 2001-2006 to 10.5 in 2007-2008. There was no difference in the proportion of enrollees who developed adverse events after keratoplasty over time. CONCLUSIONS In this analysis of claims data, from 2001 to 2009, a period during which there was an increase in the rate of endothelial keratoplasty, we observed a trend of greater rates of keratoplasty in patients with CED and fewer visits for postoperative care in the later years of the decade compared with the earlier years, along with no change in rates of severe adverse events.

The Supplemental Nutrition Assistance Program and frequency of sugar-sweetened soft drink consumption among low-income adults in the US:

Background: The Supplemental Nutrition Assistance Program (SNAP) was designed to help low-income people purchase nutritious foods in the US. In recent years, there has been a consistent call for banning purchases of sugar drinks in SNAP. Aim: The aim of this study was to examine the association between SNAP participation and the frequency of sugar-sweetened soft drink (SSD) consumption among low-income adults in the US. Method: Data came from the 2009–2010 National Health and Nutrition Examination Survey. Low-income adults aged ≥20 years with a household income ≤250% of the Federal Poverty Level (N = 1200) were categorized into two groups based on the household’s SNAP receipt: SNAP recipients (n = 393) and non-recipients (n = 807). Propensity-score matching was used to minimize observable differences between these two groups that may explain the difference in SSD consumption, generating the final sample of 393 matched pairs (SNAP recipients, n = 393; non-recipients, n = 393). An ordinal logistic regression was conducted on the matched sample. Results: SNAP recipients were more likely to report higher levels of SSD consumption, compared with non-recipients (adjusted odds ratio (AOR) = 1.55, 95% confidence interval (CI) = 1.17−2.07). Male gender (AOR = 1.69, 95% CI = 1.17−2.46), younger age (AOR = 0.97, 95% CI = 0.96−0.99), lower education level (AOR = 2.28, 95% CI = 1.33−3.89), and soda availability in homes (AOR = 2.24, 95% CI = 1.77−2.83) were also associated with higher levels of SSD consumption among low-income adults. Conclusions: SNAP participation was associated with frequent SSD consumption. To reduce SSD consumption, strategic efforts need to focus on educating people about the harms of SSD and promoting nutritious food choices with SNAP benefits.