A cross-sectional survey of work and income loss consideration among patients with herpes zoster when completing a quality of life questionnaire.

BACKGROUND: Prior research suggests that many patients do not spontaneously include work/income loss when responding to utility assessments, although this remains unconfirmed in the US due to almost no published US-based studies to date, and has not been previously studied among patients with herpes zoster (HZ). The objective of this study was to examine whether patients with HZ consider work and income loss when completing a quality of life survey. METHODS: A cross-sectional survey was administered to 2000 US adult commercial health plan enrollees aged 50-64 years with ≥ 1 HZ medical claim during 2014. The survey collected information related to health status (EQ-5D), work productivity, and HZ severity and clinical features. RESULTS: Mean respondent age was 58.4 years [standard deviation (SD) 4.1] and 62.0% were female. About 3 in 4 (76.8%) patients (N = 772) were employed either full (69.9%) or part time (6.9%). Less than half (45%) spontaneously considered work/income loss when responding to EQ-5D, and mean EQ-5D scores for patients who considered work/income loss were lower than for patients who did not [0.56 (SD = 0.28) vs. 0.69 (SD = 0.24); p < 0.001]. Overall, 43% of patients reported at least one full day missed (mean = 9 full days) and 29% reported at least one partial day missed (mean = 6 partial days) during the most recent shingles episode. Patients who considered work loss were more likely to have missed full (76.4% vs 26.0%, p < 0.001) or partial (70.9% vs. 35.2%, p < 0.001) days. Patients with absenteeism were more likely to consider work/income loss when completing EQ-5D [odds ratio (OR) = 7.91, 95% confidence interval (CI) 5.01-12.31]. Odds of absenteeism/presenteeism increased significantly with increasing levels of HZ severity, and higher odds were associated with pain located on the face/scalp/neck/eye/ear (OR 1.90, 95% CI 1.06-3.40) and with pain lasting 12+ months (OR = 2.91, 95% CI 1.14-7.42). CONCLUSIONS: HZ has considerable impact on the work and productivity of adults aged 50-64 years old. However, many patients with HZ do not spontaneously consider work/income loss when completing a standardized quality of life questionnaire. Studies that use health state utilities in HZ based on EQ-5D may not fully reflect the societal costs of work loss.

An open-label, pragmatic, randomized controlled clinical trial to evaluate the comparative effectiveness of daptomycin versus vancomycin for the treatment of complicated skin and skin structure infection.

BACKGROUND: Treatment of complicated skin and skin structure infection (cSSSI) places a tremendous burden on the health care system. Understanding relative resource utilization associated with different antimicrobials is important for decision making by patients, health care providers, and payers. METHODS: The authors conducted an open-label, pragmatic, randomized (1:1) clinical study (N = 250) to compare the effectiveness of daptomycin with that of vancomycin for treatment of patients hospitalized with cSSSI caused by suspected or documented methicillin-resistant Staphylococcus aureus infection. The primary study end point was infection-related length of stay (IRLOS). Secondary end points included health care resource utilization, cost, clinical response, and patient-reported outcomes. Patient assessments were performed daily until the end of antibiotic therapy or until hospital discharge, and at 14 days and 30 days after discharge. RESULTS: No difference was found for IRLOS, total LOS, and total inpatient cost between cohorts. Hospital LOS contributed 85.9% to the total hospitalization cost, compared with 6.4% for drug costs. Daptomycin showed a nonsignificant trend toward a higher clinical success rate, compared with vancomycin, at treatment days 2 and 3. In the multivariate analyses, vancomycin was associated with a lower likelihood of day 2 clinical success (odds ratio [OR] = 0.498, 95% confidence interval [CI], 0.249-0.997; P < 0.05). CONCLUSION: This study did not provide conclusive evidence of the superiority of one treatment over the other in terms of clinical, economic, or patient outcomes. The data suggest that physician and patient preference, rather than drug acquisition cost, should be the primary driver of initial antibiotic selection for hospitalized patients with cSSSI. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01419184 (Date: August 16, 2011).

Clinical Outcomes in Measurement-based Treatment (Comet): a trial of depression monitoring and feedback to primary care physicians.

BACKGROUND: Despite the availability of effective treatments for depression, many patients under the care of primary care physicians do not achieve remission. Clinical Outcomes in Measurement-based Treatment (COMET) was designed to assess whether communicating patient-reported depression symptom severity to primary care physicians affects patient outcomes at 6 months. METHODS: Nine hundred fifteen patients (intervention: n = 503; control: n = 412) diagnosed with major depressive disorder were enrolled in a prospective trial in which physician practice sites were assigned to either the intervention or control study arm. Only patients who were prescribed an antidepressant by their physician were eligible, but medication type was independent of the study protocol. Intervention-arm physicians received monthly updates on their patients' depression severity, which was determined with the nine-item Patient Health Questionnaire (PHQ-9) administered during telephone interviews. Remission was defined as a PHQ-9 score <5 at 6 months; response was defined as a score reduction ≥50%. RESULTS: Among patients with baseline PHQ-9 score ≥5, 45.0% achieved remission (46.7% intervention versus 42.8% control) and 63.9% responded (67.0% intervention versus 59.7% control) at 6 months. After adjusting for baseline demographic and clinical variables, odds of remission (odds ratio [OR], 1.59 [95% CI, 1.07-2.37]) or response (OR, 2.02 [95% CI, 1.36-3.02]) were significantly greater for the intervention group than for control patients. CONCLUSIONS: This study demonstrated that regular patient symptom monitoring with feedback to physicians improved outcomes of depression treatment in the primary care setting. Determining reasons for the high observed nonremission rates requires further investigation.

Impact of recent fracture on health-related quality of life in postmenopausal women.

UNLABELLED: The effect of fractures other than hip and spine on HRQoL in younger and older women has not been extensively studied. In a cohort of 86,128 postmenopausal women, we found the impact of recent osteoporosis-related fractures on HRQoL to be similar between women < 65 compared with those > or = 65 years of age. The impact of spine, hip, or rib fractures was greater than that of wrist fractures in both age groups. INTRODUCTION: Health-related quality of life (HRQoL) after vertebral and hip fractures has been well studied. Less is known about HRQoL after fractures at other sites. We studied the effect of recent clinical fractures on HRQoL, using Short Form-12 (SF-12). MATERIALS AND METHODS: This study included 86,128 postmenopausal participants in the National Osteoporosis Risk Assessment (NORA) who responded to two follow-up surveys during a 2-year interval. At each survey, they completed the SF-12 HRQoL questionnaire and reported new fractures of the hip, spine, wrist, and rib. The effect of recent fracture on HRQoL was assessed by comparing Physical Component Score (PCS) and Mental Component Score (MCS) means for women with and without new fractures at the second survey. Analyses were by fracture type and by age group (50-64 and 65-99) and were adjusted for PCS and MCS at the first survey. RESULTS: New fractures (320 hip, 445 vertebral, 657 rib, 835 wrist) occurring during the interval between the first and second follow-up surveys were reported by 2257 women. The PCS was poorer in both older and younger women who had fractured the hip, spine, or rib (p < or = 0.001). Wrist fractures had an impact on PCS in women < or = 65 years of age (p < 0.001), but not older women (p > 0.10). These differences in PCS by fracture status were similar to those reported for other chronic diseases such as asthma, chronic obstructive pulmonary disease (COPD), and osteoarthritis. MCS was less consistently changed by fracture status, but younger and older women with vertebral fracture (p < 0.004), older women with hip fracture (p < 0.004), and younger women with rib fracture (p < 0.004) had poorer MCS compared with those who did not fracture within their age cohort. CONCLUSIONS: Recent osteoporosis-related fractures have significant impact on HRQoL as measured by SF-12. The impact of recent fracture on HRQoL was similar for older and younger postmenopausal women. Fracture prevention and postfracture interventions that target the subsequent symptoms are needed for postmenopausal women of any age.

The Penn shoulder score: reliability and validity.

STUDY DESIGN: Psychometric evaluation of a cross-sectional survey. OBJECTIVES: The purpose of this study was to examine the psychometric properties of reliability and validity of the Penn Shoulder Score (PSS). BACKGROUND: Shoulder outcome measures are used to assess patient self-report levels of pain, satisfaction, and function. The PSS is a 100-point shoulder-specific self-report questionnaire consisting of 3 subscales of pain, satisfaction, and function. This scale has been utilized in the literature. However, the measurement properties of reliability and validity, including responsiveness, of the PSS subscales and overall scale need to be established. METHODS AND MEASURES: Patients (n = 40) with shoulder disorders undergoing a course of outpatient physical therapy completed the PSS at initial visit and again within 72 hours to assess test-retest reliability. The Constant Shoulder Score (CSS) and the American Shoulder and Elbow Surgeons Shoulder Score (ASES) were also completed at the initial visit and compared to the PSS to assess convergent construct validity. A separate cohort of patients (n = 109) completed the PSS at initial visit and 4 weeks later. These scores were used to assess internal consistency and responsiveness. RESULTS: Reliability analysis revealed a test-retest ICC2,1 of 0.94 (95% CI, 0.89-0.97). Internal consistency analysis revealed a Cronbach alpha of 0.93. The standard error of measurement (SEM) was +/- 8.5 scale points (based on a 90% CI) and the minimal detectable change (MDC) was +/- 12.1 scale points (based on a 90% CI). The minimal clinically important difference (MCID) for improvement was 11.4 points. Pearson product moment correlation coefficients between the PSS and the CSS and ASES were 0.85 and 0.87, respectively. Responsiveness analysis revealed an effect size of 1.01 and a standardized response mean of 1.27. CONCLUSIONS: This study has demonstrated that the PSS is a reliable and valid measure for reporting outcome of patients with various shoulder disorders.

An approach to identifying osteopenic women at increased short-term risk of fracture.

BACKGROUND: Identification and management of women to reduce fractures is often limited to T scores less than -2.5, although many fractures occur with higher T scores. We developed a classification algorithm that identifies women with osteopenia (T scores of -2.5 to -1.0) who are at increased risk of fracture within 12 months of peripheral bone density testing. METHODS: A total of 57 421 postmenopausal white women with baseline peripheral T scores of -2.5 to -1.0 and 1-year information on new fractures were included. Thirty-two risk factors for fracture were entered into a classification and regression tree analysis to build an algorithm that best predicted future fracture events. RESULTS: A total of 1130 women had new fractures in 1 year. Previous fracture, T score at a peripheral site of -1.8 or less, self-rated poor health status, and poor mobility were identified as the most important determinants of short-term fracture. Fifty-five percent of the women were identified as being at increased fracture risk. Women with previous fracture, regardless of T score, had a risk of 4.1%, followed by 2.2% in women with T scores of -1.8 or less or with poor health status, and 1.9% for women with poor mobility. The algorithm correctly classified 74% of the women who experienced a fracture. CONCLUSIONS: This classification tool accurately identified postmenopausal women with peripheral T scores of -2.5 to -1.0 who are at increased risk of fracture within 12 months. It can be used in clinical practice to guide assessment and treatment decisions.

Reasons for not initiating osteoporosis therapy among a managed care population.

BACKGROUND: Many women with osteoporosis do not initiate osteoporosis treatment. OBJECTIVE: To examine patients' reasons for not initiating osteoporosis treatment among women with osteoporosis. METHODS: Survey recipients were identified from a national US claims database and included women ≥55 years with an osteoporosis diagnosis from January 1, 2010 to March 31, 2012 as defined by: 1) osteoporosis diagnosis coupled with bone mineral density test within 183 days of diagnosis and/or 2) osteoporosis-related fracture. Eligibility required no claims for osteoporosis medication 1) at least 12 months and up to 5 years prior to osteoporosis diagnosis and 2) at least 6 months after osteoporosis diagnosis. Continuous enrollment for 18 months (6 months pre-osteoporosis and 12 months post-osteoporosis diagnosis) was also required. A total of 2,000 patients with the most recent osteoporosis diagnosis were mailed a survey. Respondents reporting that they did not initiate physician-recommended osteoporosis medication, after either their physician told them they had osteoporosis or they experienced a fracture since age 45 years, were asked for reasons why they did not initiate treatment. RESULTS: There were 430 patients who returned a complete survey; mean age was 61% and 21.6% had a fracture. A total of 197 (45.8%) patients reported their physician diagnosed osteoporosis and 117 (59.3%) of those were recommended osteoporosis medication; 44 of the 117 patients (37.6%) did not initiate recommended osteoporosis medication by the time of survey. The primary reasons for not initiating osteoporosis medication were concern over side effects (77.3%), medication costs (34.1%), and pre-existing gastrointestinal concerns (25.0%). CONCLUSION: Among respondents, 41% of patients whose physician diagnosed osteoporosis were not recommended osteoporosis treatment and 38% of patients who were recommended osteoporosis treatment did not initiate treatment within approximately 2 years of diagnosis. Concerns with side effects of osteoporosis treatment, medication costs, and pre-existing gastrointestinal concerns were the most common reasons for not initiating recommended treatment.

Patient-reported treatment satisfaction and choice of dosing frequency with biologic treatment for moderate to severe plaque psoriasis.

BACKGROUND: Moderate to severe plaque psoriasis has a serious effect on health-related quality of life. Patients treated with biologic medications place importance on satisfaction and treatment frequency options. We assessed patient-reported treatment satisfaction and dosing frequency choice with biologics. METHODS: We used a health care claims database to identify patients with moderate to severe plaque psoriasis. Participants completed the Treatment Satisfaction Questionnaire for Medication. Results were compared between patients experienced with biologics (adalimumab, etanercept, or ustekinumab) or not (cyclosporine or methotrexate). Participants were asked for their choices of dosing options of once every 1-2 weeks, 3-4 weeks, 1-2 months, or 2-3 months. Participants were also asked for their choices of dosing options of every 1, 2, 3, and so on up to every 12+ weeks. RESULTS: A total of 426 patients completed the survey (263 biologic-experienced and 163 biologic-naïve patients). Patient satisfaction with psoriasis treatment was significantly higher in the biologic-experienced cohort. The most frequently chosen option (38.8% of all participating patients) was every 2-3 months; 37.3% chose once every 1-2 weeks. Significant differences were found in the percentage of biologic-naïve patients choosing 2-3-month (49.7%) over 1-2-week (20.9%) dosing (P<0.001). Among biologic-experienced patients, the difference between the percentage of patients choosing the 2-3-month (35.7%) and 1-2-week (41.8%) options was not significant (P=0.264). The two most often week-specific intervals chosen by biologic-naïve patients were 12+ weeks (42.3%) and 4 weeks (15.6%). The biologic-experienced patients most often chose 12+ weeks (31.2%) and 1 week (25.9%). CONCLUSION: Patients using biologics reported satisfaction with their treatment, which may positively affect outcomes. Longer dosing intervals were chosen most frequently among all patients combined. Reports of patient satisfaction with prior treatments and choices regarding dosing frequency, among all other considerations, should be evaluated in determining an appropriate biologic medication for psoriasis.

Predictive value of low BMD for 1-year fracture outcomes is similar for postmenopausal women ages 50-64 and 65 and Older: results from the National Osteoporosis Risk Assessment (NORA).

UNLABELLED: The relationship of low bone mass and fracture in younger postmenopausal women has not been extensively studied. In a large cohort of postmenopausal women > or =50 years of age, we found the relationship of BMD measured at peripheral sites and subsequent 1-year fracture risk to be similar between women <65 and those > or =65 years of age. INTRODUCTION: Low bone mass and fractures are prevalent in older postmenopausal women. However, the frequency of low bone mass and fracture in younger postmenopausal women has not been studied extensively. There are very limited data regarding the association between BMD measurements and fractures in postmenopausal women who are between the ages of 50 and 64. MATERIALS AND METHODS: In the National Osteoporosis Risk Assessment (NORA) we studied the frequency of low bone mass and its association with fracture in women 50-64 years of age in comparison with women > or =65 of age. NORA enrolled 200,160 postmenopausal women > or =50 years of age who had no prior diagnosis of osteoporosis. Baseline BMD was measured at the heel, forearm, or finger. A 1-year follow-up survey requesting incident fractures since baseline was completed by 163,935 women, 87,594 (53%) of whom were 50-64 years of age. The association between BMD and fracture was assessed using logistic regression, adjusted for important covariates. RESULTS: Thirty-one percent of women 50-64 years of age had low bone mass (T scores < or = -1.0) compared to 62% of women > or =65 years of age. During the first year of follow-up, 2440 women reported fractures of wrist/forearm, rib, spine, or hip, including 440 hip fractures. Nine hundred four women 50-64 years of age reported fractures, including 86 hip fractures, accounting for 37% of fractures and 20% of hip fractures reported in the entire NORA cohort. Relative risk for osteoporotic fracture was 1.5 for each SD decrease in BMD for both the younger and older groups of women. CONCLUSION: Low BMD in younger postmenopausal women 50-64 years of age showed a 1-year relative risk of fracture similar to that found in women > or =65 years of age.

A population-based osteoporosis screening program: who does not participate, and what are the consequences?

OBJECTIVES: To describe differences in osteoporosis risk factors and rates of fracture and antiresorptive therapy use in women who did and did not participate in an osteoporosis screening program. SETTING: Group Health Cooperative, a health maintenance organization in western Washington state. PARTICIPANTS: A total of 9,268 women (aged 60-80) who were not using any antiresorptive therapy were invited to participate in an osteoporosis screening program. This study compares the 35% who participated with the 65% who did not. DESIGN: This observational cohort study of women invited to participate in a randomized, controlled trial of an osteoporosis screening program provided all participants with personalized feedback on their risk of osteoporosis. Some participants also received bone density testing. Automated administrative data were used to examine differences between participants and nonparticipants in fracture outcomes and medication initiation before and after invitation. RESULTS: Baseline fracture rates did not differ between participants and nonparticipants. After age adjustment, nonparticipants had a higher hip fracture rate (14.1 vs 8.3 per 1,000) and a lower rate of initiating any antiresorptive therapy (10.3 vs 17.9 per 100) than participants after an average of 28 to 29 months of follow-up. CONCLUSION: Participants had reduced hip fracture rates and increased initiation of antiresorptive therapy compared with nonparticipants. It was not possible to determine whether participating in the screening program, unmeasured confounding, or selection bias accounted for differences in hip fracture or therapy initiation rates. These results suggest that women who do not participate in osteoporosis screening should be pursued to identify individuals who could benefit from primary and secondary osteoporosis prevention.

Evaluation of decision rules to identify postmenopausal women for intervention related to osteoporosis.

Decision rules for intervention that utilize screening tools for bone mineral density (BMD) testing and incorporating the BMD findings and other risk factors to identify high-risk women to prevent fracture have not been evaluated. We examine the sensitivity and specificity of decision rules for intervention based on two pre-BMD screening tools: Simple Calculated Osteoporosis Risk Estimation (SCORE) and a Study of Osteoporotic Fractures (SOF)-based tool. Women 60 years of age and older without previous osteoporosis diagnosis were randomly selected from a managed care population and invited to receive a BMD test. Four hundred sixteen women had complete information and were included in the study. Women were classified as high risk requiring intervention using three different criteria: World Health Organization (t-score -2.5 or less), National Osteoporosis Foundation (t-score -2.0 or less, or -1.5 or less with one or more risk factors), and the SOF-based criteria (prior fracture; or age 60-64 with t-score less than -2.5 or age 65 or older with z-score less than -0.43 and five or more risk factors). SCORE identified 82% of the women as appropriate for BMD testing, whereas the SOF-based tool identified 26%. Sensitivity and specificity were 89.8%-96.5% and 23.8%-34.8%, respectively, for the decision rule using SCORE as the screening tool and 30.5%-84.9% and 76.0%-95.8%, respectively, for the decision rule based on SOF screening criteria. SCORE correctly identified more women who were at high risk for intervention, whereas the SOF-based tool correctly identified more women who do not meet intervention criteria. The appropriate selection of a screening tool depends upon the objective for intervention and trade-off between not identifying women for BMD testing who are at high risk and identifying more women for BMD testing who are at low risk.

Management of osteoporosis in women aged 50 and older with osteoporosis-related fractures in a managed care population.

This study describes the pattern of evaluation and management of osteoporosis in women aged 50 and older following an osteoporosis-related fracture, conducted as a retrospective cohort study using the administrative claims database of a managed care organization. Subjects were women, aged 50 years and older, with at least one osteoporosis-related fracture in the years 1996-1998 who were continuously enrolled in the system's health plan for at least 6 months prior to and post-fracture. Bone mineral density (BMD) testing, diagnosis of osteoporosis, and treatment with any Food and Drug Administration-approved medication for osteoporosis were identified using CPT, ICD-9, and National Drug Codes for the 6-month post-fracture period. There were 658 women with an osteoporosis-related fracture: 189 (29%) hip fractures, 226 (34%) wrist fractures, 127 (19%) vertebral fractures, and 116 (18%) rib fractures. In the post-fracture period, 46 (7%) underwent BMD testing, 153 (23%) had a diagnosis of osteoporosis, and 220 (31%) were treated with a medication approved for the prevention or treatment of osteoporosis. Of the 220 women with medication claims, 124 (56%) were for estrogen, and 96 (44%) were for other antiresorptive agents. Of the 507 women who did not have medication claims during the 6 months prior to the fracture, only 17% had new fills after the fracture. Management of osteoporosis in women aged 50 and older with fractures was inadequate, despite the high risk of subsequent fractures and recommendations that osteoporosis be the presumptive diagnosis. Significant opportunity exists for improvement in assuring post-fracture followup care.

Field testing the ENSEMBLE Minimum Dataset: performance of an instrument to address heterogeneity of treatment effects.

AIM: To assess the ability of ENterprising SElective Multi-instrument BLend for hEterogeneity analysis (ENSEMBLE) Minimum Dataset instrument dimensions to discriminate among subgroups of patients expected to have differential outcomes. MATERIALS & METHODS: Patients with Type 2 diabetes, knee osteoarthritis, ischemic heart disease or heart failure completed a survey designed to represent three dimensions (health, personality and behavior). Health-related outcomes and utilization were investigated using claims data. Discriminant validity and associations between the dimensions and outcomes were assessed. RESULTS: A total of 2625 patients completed the survey. The dimensions discriminated 50-100% of the outcome levels across disease cohorts; behavior dimension scores did not differ significantly among the healthcare utilization level subgroups in any disease cohort. CONCLUSION: ENSEMBLE Minimum Dataset dimensions discriminated health-related outcome levels among patients with varied diseases.

Depression monitoring and patient behavior in the Clinical Outcomes in MEasurement-Based Treatment (COMET) trial.

OBJECTIVE: In this secondary analysis of results of the Clinical Outcomes in MEasurement-Based Treatment (COMET) trial, patient behaviors that might account for the differences observed in clinical outcomes were examined. METHODS: Patients (N=914) diagnosed as having major depressive disorder participated in telephone interviews either monthly for six months (intervention) or at three and six months (usual care) asking about antidepressant medication-taking, use of psychotherapy or counseling, and participation in depression support groups. Physicians (N=83) in the intervention arm received monthly feedback regarding their patients' depression severity. RESULTS: A total of 664 (73%) patients completed the month 6 interview. The adjusted odds of current antidepressant use at six months were 85% greater (p=.01) for patients in the intervention (N=380) versus usual care (N=284) arms, according to multivariate regression analyses. CONCLUSIONS: More frequent measurement of depression symptoms was associated with greater medication persistence, which in turn may have mediated clinical improvements.

The burden of hypoglycemia on healthcare utilization, costs, and quality of life among type 2 diabetes mellitus patients.

OBJECTIVE: To assess the burden of hypoglycemia among type 2 diabetes patients on antidiabetic drugs with or without use of insulin. RESEARCH DESIGN AND METHODS: We used mail surveys, administrative claims data, and enrollment information from a sample of adult commercial health plan enrollees (n=813) with type 2 diabetes during a 12-month period. Patients' experience of hypoglycemia, its impact on patient perspectives and healthcare utilization were the outcomes evaluated. RESULTS: A greater percentage of patients in the antidiabetic with insulin cohort reported experiencing hypoglycemia compared with patients from sulfonylurea (SU) without insulin and non-SU without insulin cohorts (50% vs. 21% and 12%, respectively; p<0.01 for both comparisons). While 71% of the sample reported experiencing hypoglycemic symptoms with 28% confirmed by low blood glucose levels, only 10% of the patients had evidence of hypoglycemia event in the claims database. Patients with confirmed hypoglycemia had the highest Hypoglycemia Fear Survey behavior score (8) and worry subscale score (14). Significant differences were noted between the confirmed hypoglycemia and no hypoglycemia cohorts for the 12-item Short Form Health Survey's Mental Component Score (p<0.001) and Physical Component Score (p=0.002), and for the EQ-5D index (p<0.001). Diabetes-related annualized mean total healthcare costs were significantly higher for confirmed hypoglycemia vs. no hypoglycemia cohorts (p=0.004). CONCLUSIONS: Symptomatic hypoglycemia is a more significant burden among type 2 diabetes patients treated with antidiabetic drugs than is estimated by administrative claims data and needs to be considered when choosing therapy.

Effect of communicating depression severity on physician prescribing patterns: findings from the Clinical Outcomes in MEasurement-based Treatment (COMET) trial.

OBJECTIVE: In this secondary analysis from the Clinical Outcomes in MEasurement-based Treatment trial (COMET), we evaluated whether providing primary care physicians with patient-reported feedback regarding depression severity affected pharmacological treatment patterns. METHOD: Intervention-arm physicians received their patients' 9-item Patient Health Questionnaire scores monthly. Odds of having no change in antidepressant treatment during the 6-month study period were calculated. Relationships between depression symptom status (partial or nonresponse) at month 3 and treatment changes in months 3 through 6 were assessed. RESULTS: Among 503 intervention and 412 usual care (UC) patients with major depressive disorder, most received antidepressant monotherapy at baseline (79.4% UC vs. 88.4% intervention; P=.047). Few switched their baseline antidepressant (17.4%), increased their dose (12.4%) or augmented with a second medication (2%). Odds of having no change in antidepressant therapy did not differ significantly between study arms (odds ratio 1.21; 95% confidence interval 0.78-1.88; P=.392). Few month 3 partial or nonresponders had a regimen change over the following 3 months; the study arms did not differ significantly (partial responders: 4.1% UC vs. 7.7% intervention; P=.429; nonresponders: 14.6% UC vs. 15.9% intervention; P=.888). CONCLUSIONS: Among depressed patients treated in primary care, little active management was observed. The lack of treatment modification for the majority of partial and nonresponders was notable.

Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.

PURPOSE: We assessed U.S. physicians' attitudes and perceptions regarding potential human papillomavirus (HPV) vaccination of males. METHODS: We surveyed a random sample of 2,714 pediatricians and family practitioners identified in administrative claims of a U.S. health plan as HPV vaccinators of females; 595 pediatricians and 499 family practitioners participated. RESULTS: Most physicians would recommend HPV vaccination to males aged 11-12 (63.9%), 13-18 (93.4%), and 19-26 (92.7%) years. Physicians agreed that males should be vaccinated to prevent them from getting genital and anal warts (52.9% strongly and 36.0% somewhat) and to protect females from cervical cancer (75.3% strongly and 20.8% somewhat). Physicians agreed that an HPV vaccine recommendation for males would increase opportunities to discuss sexual health with adolescent male patients (58.7% strongly, 35.3% somewhat). Most did not strongly agree (15.4% strongly, 45.4% somewhat) that parents of adolescent male patients would be interested in HPV vaccination for males, that a gender-neutral HPV vaccine recommendation would increase acceptance by adolescent females and their parents (19.6% strongly, 42.0% somewhat), or that a gender-neutral recommendation would improve current female vaccination rates (10.4% strongly, 26.0% somewhat). CONCLUSIONS: Physicians who currently vaccinate females against HPV supported the concept of vaccinating males for its benefits for both sexes. They agreed that a gender-neutral HPV vaccination recommendation would be appropriate with regard to public health and believed that it would increase opportunities for sexual health discussions, but were less sure that such a recommendation would change patient or parental attitudes toward HPV vaccination or improve current HPV vaccination efforts.

Predictors of gait speed in patients after hip fracture.

PURPOSE: Following hip fracture, patients demonstrate greatly reduced walking speeds 1 year later compared with age-matched elders. The purpose of our study was to examine the factors that relate to gait speed in patients after hip fracture. METHODS: Forty-two men and women (mean age 79 +/- 7.5 years) who sustained a hip fracture participated in this study. Linear regression analysis was used to determine a statistical model that best predicted gait speed, the dependent variable. Gait speed was measured with a computerized gait mat. The independent variables were age, sex, height, weight, time post-fracture, medications, mental status, depression, balance confidence, Medical Outcome Studies, Short Form (SF-36), balance, and lower extremity isometric force. All subjects were discharged from physical therapy services, and measurements were taken, on average, 17 weeks post-fracture. RESULTS: Using stepwise regression, 72% of the variance in gait speed was explained by summed lower extremity strength normalized by body weight, general health (SF-36), and balance confidence (Activities-specific Balance Confidence Scale). CONCLUSIONS: Impairments (summed lower extremity strength) and risk factors (perception of general health and balance confidence) are important predictors of gait speed in elders after hip fracture.

Assessment of asthma severity and asthma control in children.

National and international guidelines for asthma recommend the assessment and documentation of severity as the basis for patient management. However, studies show that there are problems with application of the severity assessment to children in clinical practice. More recently, asthma control has been introduced as a method to assess the adequacy of current treatment and inform asthma management. In this article we review the application and limitations of the severity assessment and the asthma-control tools that have been tested for use in children. A system of using asthma severity for disease assessment in the absence of treatment and using asthma-control assessment to guide management decisions while a child is receiving treatment appears to be a promising approach to tailor treatment to improve care and outcomes for children with asthma.

Agreement between administrative claims and the medical record in identifying patients with a diagnosis of hypertension.

OBJECTIVE: This study evaluated the accuracy of 2 administrative claims-based selection rules to identify patients with hypertension (HTN) using medical records as the gold standard. RESEARCH DESIGN: The claims database consisted of inpatient, outpatient, pharmacy, and eligibility claims for members of a single insurance company from January 2000 through March 2003. Medical records were abstracted for 258 matched patient pairs selected by Rule A (at least 1 HTN-related International Classification of Diseases, 9th Revision [ICD-9] claim) and 138 pairs selected by Rule B (at least 1 HTN-related ICD-9 and at least 1 HTN prescription claim) from 31 provider sites. Sensitivity and specificity of the 2 selection rules were computed using medical chart review as the gold standard for a diagnosis of HTN. SUBJECTS: Of patients selected by Rule A, chart review identified 281 patients with and 235 patients without HTN. Of patients selected by Rule B, chart review identified 172 patients with and 104 patients without HTN. RESULTS: The sensitivity and specificity was 70.8% and 74.9% for Rule A and 76.2% and 93.3% for Rule B. The kappa score was 0.45 for Rule A and 0.65 for Rule B. CONCLUSION: To identify patients with HTN, a selection rule using both a diagnosis and prescription claim has greater sensitivity and specificity than a rule using a diagnosis claim only.