Antihypertensive Medication and Dementia Risk in Older Adult African Americans with Hypertension: A Prospective Cohort Study.

BACKGROUND: African Americans are especially at risk of hypertension and dementia. Antihypertensive medications reduce the risk of cardiovascular events, but may also reduce the risk of dementia. OBJECTIVE: To assess the longitudinal effects of antihypertensive medications and blood pressure on the onset of incident dementia in a cohort of African Americans. DESIGN: Prospective cohort. PARTICIPANTS: 1236 community-dwelling patients from an inner-city public health care system, aged 65 years and older, with a history of hypertension but no history of dementia, and who had at least three primary care visits and a prescription filled for any medication. MAIN MEASURES: Blood pressure was the average of three seated measurements. Dementia was diagnosed using a two-stage design, with a screening evaluation every 2 to 3 years followed by a comprehensive in-home clinical evaluation for those with a positive screen. Laboratory, inpatient and outpatient encounter data, coded diagnoses and procedures, and medication records were derived from a health information exchange. KEY RESULTS: Of the 1236 hypertensive participants without dementia at baseline, 114 (9%) developed incident dementia during follow-up. Individuals prescribed any antihypertensive medication (n = 816) were found to have a significantly reduced risk of dementia (HR = 0.57, 95% CI 0.37-0.88, p = 0.0114) compared to untreated hypertensive participants (n = 420). When this analysis was repeated including a variable indicating suboptimally treated blood pressure (> 140 mmHg systolic or >90 mmHg diastolic), the effect of antihypertensive medication was no longer statistically significant (HR = 0.65, 95% CI 0.32-1.30, p = 0.2217). CONCLUSIONS: Control of blood pressure in older adult African American patients with hypertension is a key intervention for preventing dementia, with similar benefits from most of the commonly available antihypertensive medications.

Changes of glucose levels precede dementia in African-Americans with diabetes but not in Caucasians.

INTRODUCTION: Changes in glucose levels may represent a powerful metabolic indicator of dementia in African-Americans with diabetes. It is unclear whether these changes also occur in Caucasians. METHODS: A secondary data analysis using electronic medical records from 5228 African-Americans and Caucasians aged ≥65 years was carried out. Mixed effects models with repeated serum glucose measurements were used to compare changes in glucose levels between African-Americans and Caucasian patients with and without incident dementia. RESULTS: African-Americans and Caucasians with diabetes had significantly different changes in glucose levels by dementia status (P < .0001). African-Americans experienced a significant decline in glucose levels before the dementia diagnosis (estimated glucose decline 1.3421 mg/dL per year, P < .0001) than those who did not develop dementia. Caucasians with and without dementia showed stable glucose levels over time (P = .3071). DISCUSSION: Significant changes in glucose levels precede dementia in African-American patients with diabetes but not in Caucasians.

Glucose level decline precedes dementia in elderly African Americans with diabetes.

INTRODUCTION: High blood glucose levels may be responsible for the increased risk for dementia in diabetic patients. METHODS: A secondary data analysis merging electronic medical records (EMRs) with data collected from the Indianapolis-Ibadan Dementia project (IIDP). Of the enrolled 4105 African Americans, 3778 were identified in the EMR. Study endpoints were dementia, mild cognitive impairment (MCI), or normal cognition. Repeated serum glucose measurements were used as the outcome variables. RESULTS: Diabetic participants who developed incident dementia had a significant decrease in serum glucose levels in the years preceding the diagnosis compared to the participants with normal cognition (P = .0002). They also had significantly higher glucose levels up to 9 years before the dementia diagnosis (P = .0367). DISCUSSION: High glucose levels followed by a decline occurring years before diagnosis in African American participants with diabetes may represent a powerful presymptomatic metabolic indicator of dementia.

Health outcomes and cost of care among older adults with schizophrenia: a 10-year study using medical records across the continuum of care.

OBJECTIVES: The population of older patients with schizophrenia is increasing. This study describes health outcomes, utilization, and costs over 10 years in a sample of older patients with schizophrenia compared with older patients without schizophrenia. METHODS: An observational cohort study of 31,588 older adults (mean age: 70.44 years) receiving care from an urban public health system, including a community mental health center, during 1999-2008. Of these, 1,635 (5.2%) were diagnosed with schizophrenia and 757 (2.4%) had this diagnosis confirmed in the community mental health center. Patients' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Dataset, and the Outcome and Assessment Information Set. Information on medication use was not available. MEASUREMENTS: Rates of comorbid conditions, healthcare utilization, costs, and mortality. RESULTS: Patients with schizophrenia had significantly higher rates of congestive heart failure (45.05% versus 38.84%), chronic obstructive pulmonary disease (52.71% versus 41.41%), and hypothyroidism (36.72% versus 26.73%) than the patients without schizophrenia (p <0.001). They had significantly lower rates of cancer (30.78% versus 43.18%) and significantly higher rates of dementia (64.46% versus 32.13%). The patients with schizophrenia had significantly higher mortality risk (hazard ratio: 1.25, 95% confidence interval: 1.07-1.47) than the patients without schizophrenia. They also had significantly higher rates of healthcare utilization. The mean costs for Medicare and Medicaid were significantly higher for the patients with schizophrenia than for the patients without schizophrenia. CONCLUSIONS: The management of older adult patients with schizophrenia is creating a serious burden for our healthcare system, requiring the development of integrated models of healthcare.

Risk of adverse gastrointestinal events from inhaled corticosteroids.

STUDY OBJECTIVE: To determine whether patients prescribed inhaled corticosteroids are at risk for adverse gastrointestinal effects. DESIGN: Retrospective cohort study. SETTING: Urban health center with an academic affiliation. PATIENTS: A total of 19,443 adults (mean age 31.8 yrs) with airways disease, defined as a diagnosis of asthma or chronic obstructive pulmonary disease, and who were prescribed both an inhaled corticosteroid and albuterol (7156 patients) or inhaled albuterol alone (12,287 patients) between November 1977 and February 2002. MEASUREMENTS AND MAIN RESULTS: The frequency of adverse gastrointestinal events in the patients who used inhaled corticosteroids and albuterol was compared with that in the patients who used albuterol alone. Adverse gastrointestinal outcomes included events such as gastritis, ulcers, and bleeding. Cox proportional hazards models were used to determine the risk of adverse events, controlling for possible confounders such as alcohol use or nonsteroidal antiinflammatory drug use. Adverse gastrointestinal events were observed in 461 (6.4%) patients using inhaled corticosteroids and albuterol and in 302 (2.5%) patients using only albuterol. After controlling for potential confounders, patients who used inhaled corticosteroids and albuterol had an increased risk for adverse gastrointestinal events compared with patients who used only inhaled albuterol (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.02-1.56). A prescription for a spacer device reduced this risk among patients using an inhaled corticosteroid (HR 0.26, 95% CI 0.20-0.34). CONCLUSION: Patients using inhaled corticosteroids appear to have a slight risk for adverse gastrointestinal events that is mitigated in patients who used a spacer device.

PATTERNS OF HEALTHCARE ENCOUNTERS EXPERIENCED BY PATIENTS WITH CHRONIC KIDNEY DISEASE.

BACKGROUND: Patterns of healthcare encounters by patients in each stage of chronic kidney disease (CKD) have not been fully described. OBJECTIVE: This study describes patterns of healthcare resource use by patients with CKD. DESIGN: A retrospective descriptive design was used. PARTICIPANTS: Patients with Stages 1-5 CKD were identified in five existing de-identified healthcare insurance claims databases in the United States using codes from the International Classification of Diseases (ICD-9-CM). MEASUREMENTS: The databases contained more than 23,660,000 claims records from over 11 million subscribers who were continuously enrolled in a single 2014 health plan. All CKD patients' 2014 claims were extracted, yielding 1,987 unique people with 110,594 healthcare encounters. RESULTS: Healthcare resources are used to manage the causes of CKD and its multiple effects on health, and thus the number of healthcare encounters among people with more advanced disease was, as expected, relatively higher. There were more hospitalisations, emergency department visits and specialist encounters in this group. Surprisingly, however, even people in earlier stages of kidney disease experienced a median of 14-17 healthcare encounters during a single calendar year. CONCLUSIONS: Understanding patterns of healthcare encounters provides important information about the transition experiences of patients with CKD. Exploring ways to reduce the risks associated with transitions in care may prevent problems with home medication management, frequent emergency department visits and potentially avoidable hospitalisations.

Age Differences in the Association Between Body Mass Index Class and Annualized Medicare Expenditures.

OBJECTIVE: The aim of the study is to assess the relationship between body mass index (BMI) class and Medicare claims among young-old (65-69), old (70-74), and old-old (75+) adults over a 10-year period. METHOD: We assessed costs by BMI class and age group among 9,300 respondents to the 1998 Health and Retirement Study (HRS) with linked 1998-2008 Medicare claims data. BMI was classified as normal (18.5-24.9), overweight (25-29.9), mild obesity (30-34.9), or severe obesity (35 or above). RESULTS: Annualized total Medicare claims adjusted for age, gender, ethnicity, education, and smoking history were 109% greater for severely obese young-old adults in comparison with normal weight young-old adults (US$9,751 vs. US$4,663). Total annualized claim differences between the normal weight and severely obese in the old and old-old groups were not statistically significant. DISCUSSION: Excess Medicare expenditures related to obesity may be concentrated among severely obese young-old adults. Preventing severe obesity among middle and older aged adults may have large cost implications for society.

Structure, functions, and activities of a research support informatics section.

The authors describe a research group that supports the needs of investigators seeking data from an electronic medical record system. Since its creation in 1972, the Regenstrief Medical Records System has captured and stored more than 350 million discrete coded observations on two million patients. This repository has become a central data source for prospective and retrospective research. It is accessed by six data analysts--working closely with the institutional review board--who provide investigators with timely and accurate data while protecting patient and provider privacy and confidentiality. From January 1, 1999, to July 31, 2002, data analysts tracked their activities involving 47,559 hours of work predominantly for physicians (54%). While data retrieval (36%) and analysis (25%) were primary activities, data analysts also actively collaborated with researchers. Primary objectives of data provided to investigators were to address disease-specific (35.4%) and drug-related (12.2%) questions, support guideline implementation (13.1%), and probe various aspects of clinical epidemiology (5.7%). Outcomes of these endeavors included 117 grants (including 300,000 US dollars per year salary support for data analysts) and 139 papers in peer-reviewed journals by investigators who rated the support provided by data analysts as extremely valuable.

Prenatal syphilis screening rates measured using medicaid claims and electronic medical records.

BACKGROUND: To prevent congenital syphilis, the Centers for Disease Control and Prevention and professional organizations recommend universal prenatal syphilis screening. State-level or larger-scale evaluations of adherence to these guidelines have relied on administrative data. We measured prenatal syphilis screening rates in Indiana women with prenatal Medicaid coverage and also used electronic medical records to examine the completeness of syphilis screening claims in Medicaid administrative data. METHODS: In statewide Indiana Medicaid claims data, diagnosis and procedure codes were used to identify women who delivered an infant between October 1, 1998, and September 30, 2002. Claims for prenatal (that is, during the 40 weeks before and including the delivery date) syphilis screens, including the "obstetric panel" of tests, and for prenatal visits were extracted. A subset of the study population received prenatal care in a large public hospital and its affiliated clinics served by an electronic medical records system. For these women, claims data were compared with laboratory reports. RESULTS: Among 74,188 women with one delivery in Medicaid claims data, 60% had at least 1 prenatal syphilis screening claim, and 15% had 2 or more. Women with continuous Medicaid enrollment during pregnancy or with at least one prenatal visit claim had higher rates. Among the 3960 women for whom Medicaid claims and laboratory data were available, 49.8% had at least one prenatal syphilis screen in Medicaid claims, but 99.3% had at least one laboratory report of a syphilis screen. CONCLUSIONS: Measurements made using Medicaid administrative data appear to substantially underestimate true prenatal syphilis screening rates.

An evaluation of educational outreach to improve evidence-based prescribing in Medicaid: a cautionary tale.

RATIONALE, AIMS AND OBJECTIVES: Evidence suggests that educational outreach ('academic detailing') improves evidence-based prescribing. We evaluated the impact of an academic detailing programme intended to increase new statin prescriptions. METHODS: In a 2 x 2 factorial design we evaluated the effect of an academic detailing programme with/without telephonic care management for patients. Eligible patients were continuously enrolled Medicaid members at high risk for cardiovascular disease utilization who were not receiving statin medication in the 18 months prior to the intervention. All primary care prescribers assigned to these patients were randomized by clinic to academic detailing. Two trained nurses provided the detailing to prescribers, including specific discussion about the use of statins in this high-risk patient population. Nurses left the prescribers with a summary of clinical practice guidelines, a one-page detailing sheet and a list of patients under the care of the prescriber who were candidates for statins. The primary outcome was the incidence of a new statin prescription claim during the 6-month intervention period and the subsequent 6 months. Logistic regression models were used to estimate main effects of the interventions and to adjust for potential confounding variables in the study. RESULTS: Forty-eight clinics were randomized, effectively randomizing a total of 284 patients and 128 prescribers. Among the 284 patients, 46 (16%) received a new statin claim during the evaluation period. Controlling for significant bivariate associations, the academic detailing intervention had no significant effect on new statin prescriptions compared with the control group (odds ratio = 0.8, 95% confidence interval: 0.4-1.6, P = 0.5). CONCLUSION: Among this Medicaid population at high risk for cardiovascular events, an academic detailing programme to increase statin prescriptions was not effective. To assist others to learn from our failed effort, we identify and discuss critical elements in the design and implementation of the programme that could account for these results.