Thomas M. Richards

Glucagonlike Peptide 1–Based Therapies and Risk of Hospitalization for Acute Pancreatitis in Type 2 Diabetes Mellitus: A Population-Based Matched Case-Control Study

IMPORTANCE Acute pancreatitis has significant morbidity and mortality. Previous studies have raised the possibility that glucagonlike peptide 1 (GLP-1)-based therapies, including a GLP-1 mimetic (exenatide) and a dipeptidyl peptidase 4 inhibitor (sitagliptin phosphate), may increase the risk of acute pancreatitis. OBJECTIVE To test whether GLP-1-based therapies such as exenatide and sitagliptin are associated with an increased risk of acute pancreatitis. We used conditional logistic regression to analyze the data. DESIGN Population-based case-control study. SETTING A large administrative database in the United States from February 1, 2005, through December 31, 2008. PARTICIPANTS Adults with type 2 diabetes mellitus aged 18 to 64 years. We identified 1269 hospitalized cases with acute pancreatitis using a validated algorithm and 1269 control subjects matched for age category, sex, enrollment pattern, and diabetes complications. MAIN OUTCOME MEASURE Hospitalization for acute pancreatitis. RESULTS The mean age of included individuals was 52 years, and 57.45% were male. Cases were significantly more likely than controls to have hypertriglyceridemia (12.92% vs 8.35%), alcohol use (3.23% vs 0.24%), gallstones (9.06% vs 1.34), tobacco abuse (16.39% vs 5.52%), obesity (19.62% vs 9.77%), biliary and pancreatic cancer (2.84% vs 0%), cystic fibrosis (0.79% vs 0%), and any neoplasm (29.94% vs 18.05%). After adjusting for available confounders and metformin hydrochloride use, current use of GLP-1-based therapies within 30 days (adjusted odds ratio, 2.24 [95% CI, 1.36-3.68]) and recent use past 30 days and less than 2 years (2.01 [1.37-3.18]) were associated with significantly increased odds of acute pancreatitis relative to the odds in nonusers. CONCLUSIONS AND RELEVANCE In this administrative database study of US adults with type 2 diabetes mellitus, treatment with the GLP-1-based therapies sitagliptin and exenatide was associated with increased odds of hospitalization for acute pancreatitis.

Association of Antibiotics in Infancy With Early Childhood Obesity

IMPORTANCE Obesity in children and adults is associated with significant health burdens, making prevention a public health imperative. Infancy may be a critical period when environmental factors exert a lasting effect on the risk for obesity; identifying modifiable factors may help to reduce this risk. OBJECTIVE To assess the impact of antibiotics prescribed in infancy (ages 0-23 months) on obesity in early childhood (ages 24-59 months). DESIGN, SETTING, AND PARTICIPANTS We conducted a cohort study spanning 2001-2013 using electronic health records. Cox proportional hazard models were used to adjust for demographic, practice, and clinical covariates. The study spanned a network of primary care practices affiliated with the Childrens Hospital of Philadelphia including both teaching clinics and private practices in urban Philadelphia, Pennsylvania, and the surrounding region. All children with annual visits at ages 0 to 23 months, as well 1 or more visits at ages 24 to 59 months, were enrolled. The cohort comprised 64,580 children. EXPOSURES Treatment episodes for prescribed antibiotics were ascertained up to 23 months of age. MAIN OUTCOMES AND MEASURES Obesity outcomes were determined directly from anthropometric measurements using National Health and Nutrition Examination Survey 2000 body mass index norms. RESULTS Sixty-nine percent of children were exposed to antibiotics before age 24 months, with a mean (SD) of 2.3 (1.5) episodes per child. Cumulative exposure to antibiotics was associated with later obesity (rate ratio [RR], 1.11; 95% CI, 1.02-1.21 for ≥ 4 episodes); this effect was stronger for broad-spectrum antibiotics (RR, 1.16; 95% CI, 1.06-1.29). Early exposure to broad-spectrum antibiotics was also associated with obesity (RR, 1.11; 95% CI, 1.03-1.19 at 0-5 months of age and RR, 1.09; 95% CI, 1.04-1.14 at 6-11 months of age) but narrow-spectrum drugs were not at any age or frequency. Steroid use, male sex, urban practice, public insurance, Hispanic ethnicity, and diagnosed asthma or wheezing were also predictors of obesity; common infectious diagnoses and antireflux medications were not. CONCLUSIONS AND RELEVANCE Repeated exposure to broad-spectrum antibiotics at ages 0 to 23 months is associated with early childhood obesity. Because common childhood infections were the most frequent diagnoses co-occurring with broad-spectrum antibiotic prescription, narrowing antibiotic selection is potentially a modifiable risk factor for childhood obesity.

Medication Utilization and Annual Health Care Costs in Patients With Type 2 Diabetes Mellitus Before and After Bariatric Surgery

OBJECTIVE To examine the relationship of bariatric surgery with the use of diabetes medications and with total health care costs in patients with type 2 diabetes mellitus. DESIGN We studied 2235 adults with type 2 diabetes and commercial health insurance who underwent bariatric surgery in the United States during a 4-year period from January 1, 2002, through December 31, 2005. We used administrative claims data to measure the use of diabetes medications at specified time intervals before and after surgery and total median health care costs per year. SETTING Seven states in the Blue Cross/Blue Shield Obesity Care Collaborative. PATIENTS Two thousand two hundred thirty-five patients with type 2 diabetes mellitus who underwent bariatric surgery. RESULTS Surgery was associated with elimination of diabetes medication therapy in 1669 of 2235 patients (74.7%) at 6 months, 1489 of 1847 (80.6%) at 1 year, and 906 of 1072 (84.5%) at 2 years after surgery. Reduction of use was observed in all classes of diabetes medications. The median cost of the surgical procedure and hospitalization was

Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data.

29,959. In the 3 years following surgery, total annual health care costs per person increased by 9.7% (

Improving Adherence to Otitis Media Guidelines With Clinical Decision Support and Physician Feedback

616) in year 1 but then decreased by 34.2% (

Developing a Quality Improvement Database Using Health Insurance Data: A Guided Tour with Application to Medicare's National Claims History File

2179) in year 2 and by 70.5% (

Multi-Institutional Sharing of Electronic Health Record Data to Assess Childhood Obesity

4498) in year 3 compared with a preoperative annual cost of

Doctor shopping by overweight and obese patients is associated with increased healthcare utilization

6376 observed from 1 to 2 years before surgery. CONCLUSIONS Bariatric surgery is associated with reductions in the use of medication and in overall health care costs in patients with type 2 diabetes. Health insurance should cover bariatric surgery because of its health and cost benefits.

Impact of bariatric surgery on health care utilization and costs among patients with diabetes

IMPORTANCE Bariatric surgery is a well-documented treatment for obesity, but there are uncertainties about the degree to which such surgery is associated with health care cost reductions that are sustained over time. OBJECTIVE To provide a comprehensive, multiyear analysis of health care costs by type of procedure within a large cohort of privately insured persons who underwent bariatric surgery compared with a matched nonsurgical cohort. DESIGN Longitudinal analysis of 2002-2008 claims data comparing a bariatric surgery cohort with a matched nonsurgical cohort. SETTING Seven BlueCross BlueShield health insurance plans with a total enrollment of more than 18 million persons. PARTICIPANTS A total of 29 820 plan members who underwent bariatric surgery between January 1, 2002, and December 31, 2008, and a 1:1 matched comparison group of persons not undergoing surgery but with diagnoses closely associated with obesity. MAIN OUTCOME MEASURES Standardized costs (overall and by type of care) and adjusted ratios of the surgical groups costs relative to those of the comparison group. RESULTS Total costs were greater in the bariatric surgery group during the second and third years following surgery but were similar in the later years. However, the bariatric groups prescription and office visit costs were lower and their inpatient costs were higher. Those undergoing laparoscopic surgery had lower costs in the first few years after surgery, but these differences did not persist. CONCLUSIONS AND RELEVANCE Bariatric surgery does not reduce overall health care costs in the long term. Also, there is no evidence that any one type of surgery is more likely to reduce long-term health care costs. To assess the value of bariatric surgery, future studies should focus on the potential benefit of improved health and well-being of persons undergoing the procedure rather than on cost savings.

Laboratory Testing for and Diagnosis of Nutritional Deficiencies in Pregnancy Before and After Bariatric Surgery

OBJECTIVE: To assess the effects of electronic health record–based clinical decision support (CDS) and physician performance feedback on adherence to guidelines for acute otitis media (AOM) and otitis media with effusion (OME). METHODS: We conducted a factorial-design cluster randomized trial with primary care practices (n = 24) as the unit of randomization and visits as the unit of analysis. Between December 2007 and September 2010, data were collected from 139 305 otitis media visits made by 55 779 children aged 2 months to 12 years. When activated, the CDS system provided guideline-based recommendations individualized to the patient’s history and presentation. Monthly physician feedback reported adherence to guideline-based care, changes over time, and comparisons to others in the practice and network. RESULTS: Comprehensive care (all recommended guidelines were adhered to) was accomplished for 15% of AOM and 5% of OME visits during the baseline period. The increase from baseline to intervention periods in adherence to guidelines was larger for CDS compared with non-CDS visits for comprehensive care, pain treatment, adequate diagnostic evaluation for OME, and amoxicillin as first-line therapy for AOM. Although performance feedback was associated with improved antibiotic prescribing for AOM and pain treatment, the joint effects of CDS and feedback on guideline adherence were not additive. There was marked variation in use of the CDS system, ranging from 5% to 45% visits across practices. CONCLUSIONS: Clinical decision support and performance feedback are both effective strategies for improving adherence to otitis media guidelines. However, combining the 2 interventions is no better than either delivered alone.