Classifying Polypharmacy According to Pharmacotherapeutic and Clinical Risks in Older Adults: A Latent Class Analysis in Quebec, Canada.

INTRODUCTION: The simplistic definition of polypharmacy, often designated as the concomitant use of five medications or more, does not distinguish appropriate from inappropriate polypharmacy. Classifying polypharmacy according to varying levels of health risk would help optimise medication use. OBJECTIVE: We aimed to characterise different types of polypharmacy among older adults and evaluate their association with mortality and institutionalisation. METHODS: Using healthcare databases from the Quebec Integrated Chronic Disease Surveillance System, we selected a community-based random sample of the population ≥ 66 years old covered by the public drug plan. Categorical indicators used to describe polypharmacy included number of medications, potentially inappropriate medications (PIMs), drug-drug interactions, enhanced surveillance medications, complex route of administration medications, anticholinergic cognitive burden (ACB) score and use of blister cards. We used a latent class analysis to subdivide participants into distinct groups of polypharmacy. Their association with 3-year mortality and institutionalisation was assessed with adjusted Cox models. RESULTS: In total, 93,516 individuals were included. A four-class model was selected with groups described as (1) no polypharmacy (46% of our sample), (2) high-medium number of medications, low risk (33%), (3) medium number of medications, PIM use with or without high ACB score (8%) and (4) hyperpolypharmacy, complex use, high risk (13%). Using the class without polypharmacy as the reference, all polypharmacy classes were associated with 3-year mortality and institutionalisation, with the most complex/inappropriate classes denoting the highest risk (hazard ratio [HR] [95% confidence interval]: class 3, 70-year-old point estimate for mortality 1.52 [1.30-1.78] and institutionalisation 1.86 [1.52-2.29]; class 4, 70-year-old point estimate for mortality 2.74 [2.44-3.08] and institutionalisation 3.11 [2.60-3.70]). CONCLUSIONS: We distinguished three types of polypharmacy with varying pharmacotherapeutic and clinical appropriateness. Our results highlight the value of looking beyond the number of medications to assess polypharmacy.

A real-world risk analysis of biological treatment (adalimumab and etanercept) in a country with a high prevalence of tuberculosis and chronic liver disease: a nationwide population-based study.

OBJECTIVES: Few studies on tumour necrosis factor (TNF) inhibitor-associated tuberculosis (TB) and hepatic events have been performed in regions where these risks are elevated. This study aimed to provide a direct comparison between adalimumab and etanercept in a high-risk population and to address the implications for physicians working with patients in such an environment. METHOD: Data collected from the National Health Insurance Research Database (NHIRD) in Taiwan between 2007 and 2011 were analysed retrospectively for incidences of eight adverse events associated with TNF-α inhibitors. Hazard ratios (HRs) of adalimumab vs. etanercept were calculated using a Cox proportional hazards model. RESULTS: During this 5-year period, 86 events of TB were reported after 5317 person-years of exposure to adalimumab (1.62 events per 100 person-years), compared to 44 events after 7690 person-years of exposure to etanercept (0.57 events per 100 person-years). For serious hepatic events that led to hospitalization, 0.75 events were reported per 100 person-years of exposure to adalimumab compared to 0.39 events per 100 person-years of exposure to etanercept. Adjusted HRs for TB [aHR 3.06, 95% confidence interval (CI) 2.09-4.49, p < 0.0001], hospitalization due to a hepatic event (aHR 2.05, 95% CI 1.27-3.30, p = 0.0035), and serious infection (aHR 1.48, 95% CI 1.19-1.84, p = 0.0005) attained significance. CONCLUSIONS: TNF-α-targeting therapies with the monoclonal antibody adalimumab confers significant added risk of TB and serious hepatic events compared to therapies with the soluble fusion protein etanercept. Tailored strategies to attenuate these risks are warranted in high-risk regions such as Taiwan.

Medical costs incurred by organ damage caused by active disease, comorbidities and side effect of treatments in systemic lupus erythematosus patients: a Taiwan nationwide population-based study.

This study aims to systematically investigate the medial expenditures incurred by systemic lupus erythematosus (SLE)-associated organ damages in order to assess the economic impact of damage accrual by active disease, comorbidities and side effect of treatments. In total, 22,258 SLE cases were identified from the National Health Insurance Research Database, and organ damages assessed were according to the list from Systemic Lupus International Collaborative Clinic/American Rheumatology damage index system. Medical expenditures incurred by organ damages in the first as well as the subsequent year were obtained from the database. Our data reflected that organ damages caused by active disease and comorbidities, such those of renal, neuropsychiatric, pulmonary and cardiovascular systems are among the highest costing of all damage items. This study also shows that significant medical expenditures are incurred by damage items such as those occurring in ocular and musculoskeletal systems, which are typically caused by side effect of treatments such as corticosteroids. The medical expenditure in subsequent year still causes substantial economic burden. This systematic and continuous survey provided important reference of disease burden of SLE.

Study of heavy metal poisoning in frequent users of Chinese medicines in Hong Kong and Macau.

This study is a direct assessment of blood heavy metal concentrations of frequent users of Chinese medicines (CM), who had been taking prescribed CM at least 6 days per week for not less than 3 months, to determine whether their intake of CM could cause an increased load of toxic heavy metals in the body. From November 2009 to June 2010, 85 subjects were recruited with informed consent, and their blood samples were collected for measurement of arsenic, cadmium, lead and mercury concentrations. Results showed that blood concentrations of four heavy metals of nearly all 85 subjects were within reference ranges. Only one subject who had consumed plentiful seafood was found to have transiently increased blood arsenic concentration (29% higher than the upper limit of the reference range). However, after refraining from eating seafood for 1 month, his blood arsenic concentration returned to normal. Eighty commonly prescribed CM in both raw medicine and powder concentrate supplied by local distributors were also tested for the four heavy metals. Twelve out of the 80 raw medicines were found to contain one or more of the heavy metals that exceeded the respective maximum permitted content. Cadmium was most frequently found in the contaminated samples. None of the powder concentrates had heavy metal content exceeding their respective maximum permitted level.

Nationwide population-based epidemiologic study of rheumatoid arthritis in Taiwan.

OBJECTIVES: Epidemiological studies of rheumatoid arthritis in Asia are rare. The aim of this research was to study the epidemiology and associated medical expenses of rheumatoid arthritis in Taiwan. METHODS: Cases of rheumatoid arthritis, based on the 1987 American College of Rheumatology criteria, were retrieved from the National Health Insurance Research Database with corresponding International Classification of Diseases, Ninth Revision code (ICD-9) 714.0 from January 2000 to December 2007, and limited to those 16 years and older. Age- and sex-specific incidences were estimated by dividing the incidence number by population data obtained from the Department of Statistics, Ministry of the Interior. RESULTS: There were a total of 40,995 cases. The average age-adjusted annual incidence rate was 15.8 per 100,000. The adjusted incidence rates were very stable at 20.9-25.2/100,000/year and 7.0-8.2/100,000/year for females and males, respectively, during the study period. The adjusted average incidence ratio of females/males was 3.1. The age-specific incidence peaked in the 60-64 and 70-74 year age groups for females and males, respectively. The adjusted prevalence rate increased steadily during the study period from 57.7/100,000 in 2000 to 99.6/100,000 in 2007. The average total yearly expense per patient increased from 1,155 United States Dollars (USD) in 2000 to 1,821 USD in 2007. Sicca syndrome (ICD-9 code 710.2) was the most common co-existing ICD-9 code. CONCLUSIONS: This is the first incidence study based on the 1987 American College of Rheumatology criteria in Asia. The prevalence rate based on these criteria was lower than in previous Asia studies. The medical expenses increased continuously.

Nationwide population-based epidemiologic study of systemic lupus erythematosus in Taiwan.

The purpose of the study was to investigate the epidemiology and medical costs of systemic lupus erythematosus (SLE) in Taiwan. Cases of SLE were identified from the National Health Insurance Research Database with corresponding International Classification of Diseases, Ninth Revision (ICD-9) code 710.0 from January 2000 to December 2007. Age and sex-specific incidences were estimated by dividing the incidence number by population data obtained from the Department of Statistics, Ministry of the Interior. During the study period, 22,182 cases were identified. The average annual incidence rate was 8.1 per 100,000. The incidence was especially high in women of 20-54 years. The female:male incidence ratio increased with age to a peak in the age group of 40-44, and then declined. The prevalence increased steadily during the study period from 42.2/100,000 in 2000 to 67.4/100,000 in 2007, while the incidence decreased steadily from 9.9/100,000/year in 2001 to 6.8/100,000/year in 2007. The average cost was US$71.5 for each outpatient service and US$1922.3 for each hospitalization. This is the first epidemiologic study of both pediatric and adult SLE in Taiwan. The incidence and prevalence were higher than in most reports on Whites. The sex ratio was similar to that of Whites, with a marked female predominance, especially during reproductive age. There was a probable lower survival rate for male patients.

Mothers' parenting self-appraisals: the contribution of perceived infant temperament.

To learn how a mother's perception of her infant's temperament contributes to her appraisal of her parenting and of her problem-solving competence during the first 3 months postpartum, we explored a conceptual model, including infant gender and maternal attributes (education and parity) and the personal and social context of the parenting experience (infant centrality and life change), in a sample of 117 mothers. The set of temperament variables contributed to the variance in both parenting evaluation and problem-solving competence at 1 and 3 months. The pattern of infant temperament variables contributing to maternal self-appraisal variables at 1 and at 3 months suggests change in the temperament variables that are salient to mothers as the infants grow older.

Influences on mothers' use of clinician help in the infants' first three months.

Factors that influenced use of physician and nurse help were explored for 49 mothers of healthy, term-born infants for two study periods in the first three months. These factors were concepts pertinent to mothers' internal working models of help use, their resources, perceived problem-solving competence, and clinical evaluation of maternal competence in use of help. Variables contributing to the frequency with which help was used and to the ratio of that help to other communal help sources differed for nurse and physician help and for the time period. For physicians, the number of infant caretaking issues a mother identified contributed to the frequency of help use in both study periods. The problem-solving help nurses gave emerged as a critical help in the second study period. The ratio of help from nurses to that from other sources was higher when mothers identified reassurance from the nurse as a critical help and, in addition, as the infant grew older, when the nurse's evaluation of the mother's use of help was more positive. In contrast, throughout the first three months, the more infant care experience a mother had, the higher the proportion of help from physicians relative to communal sources of help. The findings suggest that nurses and physicians may have complementary functions when a mother uses help.