Myde Boles

Inhibitors of hydroxymethylglutaryl-coenzyme A reductase and risk of fracture among older women

BACKGROUND Inhibitors of hydroxymethylglutaryl-coenzyme A reductase (statins) increase new bone formation in rodents and in human cells in vitro. Statin use is associated with increased bone mineral density of the femoral neck. We undertook a population-based case-control study at six health-maintenance organisations in the USA to investigate further the relation between statin use and fracture risk among older women. METHODS We investigated women aged 60 years or older. Exposure, outcome, and confounder information was obtained from automated claims and pharmacy data from October, 1994, to September, 1997. Cases had an incident diagnosis of non-pathological fracture of the hip, humerus, distal tibia, wrist, or vertebrae between October, 1996, and September, 1997. Controls had no fracture during this period. We excluded women with records of dispensing of drugs to treat osteoporosis. FINDINGS There were 928 cases and 2747 controls. Compared with women who had no record of statin dispensing during the previous 2 years, women with 13 or more statin dispensings during this period had a decreased risk of non-pathological fracture (odds ratio 0.48 [95% CI 0.27-0.83]) after adjustment for age, number of hospital admissions during the previous year, chronic disease score, and use of non-statin lipid-lowering drugs. No association was found between fracture risk and fewer than 13 dispensings of statins or between fracture risk and use of non-statin lipid-lowering drugs. INTERPRETATION Statins seem to be protective against non-pathological fracture among older women. These findings are compatible with the hypothesis that statins increase bone mineral density in human beings and thereby decrease the risk of osteoporotic fractures.

Chronic disease score as a predictor of hospitalization

Background. The Chronic Disease Score is a risk-adjustment metric based on age, gender, and history of dispensed drugs. We compared four versions of the score for their ability to predict hospitalization among members of eight health maintenance organizations nationwide. Methods. The study included 29,247 women age 45 years and older. Logistic regression models were constructed using rank quintile and rank decile indicators for each of four scores as predictors of hospitalization during the year after 1 October 1995. Discrimination and model fit were compared using several model properties including the C statistic and the odds ratio comparing highest with lowest quantiles. Results. All Chronic Disease Score versions performed similarly, with the version that predicts total healthcare cost, proposed by Clark et al. (Med Care 1995;33:783–795), performing somewhat better than the other three. The overall risk of hospitalization was 12%. Individuals with higher quantile ranks had a higher risk of hospitalization. Among the Chronic Disease Score versions, the risk of hospitalization ranged from 4% for the lowest decile to 27–29% for the highest decile. Odds ratios comparing the highest with the lowest deciles ranged from 8.9 to 10.2. Conclusions. The Chronic Disease Score predicts hospitalization and therefore may be a useful indicator of baseline comorbidity for control of confounding.

Validation of diagnoses of peptic ulcers and bleeding from administrative databases: a multi-health maintenance organization study

The automated health plan data and data from medical chart abstractions from eight large health maintenance organizations were used to evaluate the positive predictive values (PPVs) of the International Classification of Diseases, 9th revision (ICD-9) codes for cases of peptic ulcers and upper gastrointestinal bleeding. Overall, 207 of 884 cases of peptic ulcers and upper gastrointestinal bleeding (23%) were confirmed by surgery, endoscopy, X-ray, or autopsy. The PPVs were 66% for hospitalizations with codes for duodenal ulcer (ICD-9-CM 532), 61% for gastric/gastrojejunal ulcer (ICD-9-CM 531, 534), 1% for peptic ulcer (ICD-9-CM 533), and 9% for gastrointestinal hemorrhage (ICD-9-CM578). The overall and diagnostic category-specific PPVs were generally similar for the various HMOs. This study, using data from a large number of health plans located in different geographical regions, underscores the importance of evaluating the accuracy of the diagnoses from automated health plan databases.

Practical Methods to Increase Use of Advance Medical Directives

OBJECTIVE: To compare the effectiveness of two means for increasing the use of advance medical directives: written materials only versus written materials and an educational videotape.DESIGN: Population-based, randomized controlled trial with 3-month follow up.SETTING: Kaiser Permanente Colorado Region, a not-for-profit group-model health maintenance organization.PARTICIPANTS: A population-based sample of all 1,302 members aged 75 years and older who used the Franklin Medical Office, excluding 55 persons who died or disenrolled during the study period or were identified by their physicians as blind or cognitively impaired.INTERVENTIONS: All subjects were mailed a 10-page cartoon-illustrated educational pamphlet on patient choices, a selection of Colorado advance medical directive forms, and a guide to their completion; 619 subjects also were mailed a 20-minute videotape on advance directives. Both groups had access to a study nurse for assistance in completing and placing advance medical directives.MEASUREMENTS AND MAIN RESULTS: The main outcome measure is the proportion of subjects who placed a directive in their medical record for the first time. Placement rates increased almost identically, from 21.2% to 35.0% in the written materials-only group and from 18.9% to 32.6% in the group receiving the videotape (95% confidence interval for difference −0.04, 0.04, p=.952).CONCLUSIONS: In an elderly population with a substantial baseline placement rate, mailing of written materials substantially increased placement of an advance directive in the medical record, but the addition of a videotape did not. Mailing the video did increase the use of treatment trials and made patients more aware of reasons not to use advance directives.

Primary Prevention Studies and the Healthy Elderly: Evaluating Barriers to Recruitment

Although primary prevention studies are important tools in helping the healthy elderly stay healthy, recruiting from a community-based cohort of healthy elderly individuals for a primary prevention study involves numerous barriers. To better identify and understand these barriers, we conducted and evaluated a comprehensive recruitment strategy for a primary prevention study testing aspirin in an HMO population. In the recruitment phase, we identified healthy individuals (65 years of age or older) who were members of a large, group-model HMO in Oregon and Washington, and used computerized medical database screening, statistical sampling, health plan mailings, e-mail communication with primary care providers, and the experience of a well-established research clinic in an effort to enroll health elderly in this primary prevention trial. Among a random sample of 47,453 eligible patients over the age of 65, 44% responded to recruitment efforts, but only 3% were enrolled—an overall yield of slightly less than 2%. To evaluate these results, we then conducted focus groups with 225 randomly selected “eligible refusers.” We determined that healthy elders were hesitant to give up their choice to use aspirin, unwilling to travel to the research center, and reluctant to risk their tenuous hold on good health to participate in a study of primary prevention. Awareness of these attitudes is an indispensable step toward designing effective recruitment strategies for primary prevention studies involving the healthy elderly.

Variations in Pharmacotherapy for Attention Deficit Hyperactivity Disorder in Managed Care

The purpose of this study was to identify the patterns of pharmacotherapy in the treatment of children diagnosed with attention deficit hyperactivity disorder (ADHD) in a large, non-profit, group-model managed care organization from January 1997 through July 1998. We sought to determine whether children with uncomplicated ADHD use different drug therapies when compared to children with ADHD and psychiatric comorbidity. We also examined the relationships between the use of specialty mental health services and the use of various psychotropic medications for treatment of ADHD. We found that children with ADHD and psychiatric comorbidity were less likely to use psychostimulants (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.55-0.93, p = 0.01) but more likely to use antidepressants (OR = 2.74, 95% CI = 1.95-3.86, p < 0.01), alpha adrenergic agonists (OR = 2.63, 95% CI = 1.93-3.57, p < 0.01), and other psychotropic medications (OR = 2.40, 95% CI = 1.27-4.50, p < 0.01) than children with uncomplicated ADHD (who were more likely to use stimulants only). Additionally, children with psychiatric comorbidity were more likely to use multiple psychotropic drugs (p < 0.01). The results of this study indicate that children with potentially more complex mental health needs are being treated with more varied drug therapy and/or specialty mental health care services.