Group-Based Trajectory Modeling to Identify Patterns of Antipsychotic-Associated Weight Gain Among Children and Adolescents.

PURPOSE/BACKGROUND: Antipsychotic-associated weight gain (AAWG) is a common adverse effect of second-generation antipsychotic (SGA) medications among children and adolescents. This study applied group-based trajectory modeling to identify latent trajectories of AAWG among children and adolescents and associated risk factors. PROCEDURES: This was a retrospective analysis of the IQVIA Ambulatory EMR-US database from 2016 to 2021. The cohort consisted of patients aged 6 to 19 years who were SGA naive and received at least 90 days of continuous SGA prescriptions. Group-based trajectory modeling was used to identify latent trajectories of AAWG development during a 24-month period since SGA initiation, and multinomial logistic regression analysis was conducted to examine the risk factors associated with the identified AAWG trajectories. FINDINGS/RESULTS: A total of 16,262 patients were included. Group-based trajectory modeling identified the following 4 distinctive AAWG trajectories: persistent severe weight gain (4.2%), persistent moderate weight gain (20.1%), minor weight change (69.6%), and gradual weight loss (6.1%). Compared with the minor weight change group, younger age (12-17 vs 5-11: odds ratio [OR], 0.634; 95% confidence interval [CI], 0.521-0.771), lower baseline body mass index z -score (OR, 0.216; 95% CI, 0.198-0.236), and receiving olanzapine as the initial SGA (olanzapine vs aripiprazole: OR, 1.686; 95% CI, 1.673-1.699) were more likely to follow severe weight gain trajectories. The area under the receiver operating characteristic curves for comparing severe weight gain versus minor weight change groups and moderate weight vs minor weight change groups in the multinomial regression model were 0.91 and 0.8, respectively. IMPLICATIONS/CONCLUSIONS: A quarter of pediatric SGA recipients experienced persistent weight gain during the SGA treatment. The risk of having persistent AAWG can be predicted using patient characteristics collected before SGA initiation and the initial SGA agent.

Immunomodulator adherence in multiple myeloma patients with lower socioeconomic status: a retrospective study.

OBJECTIVE: Poor adherence to oral chemotherapy adversely impacts clinical outcomes and escalates overall healthcare costs. Despite barriers to medication adherence, a significant gap remains in assessing adherence to oral chemotherapy among multiple myeloma (MM) patients with lower socioeconomic status. Hence, our study aims to evaluate immunomodulator adherence in MM patients at a county hospital, primarily serving underrepresented and indigent individuals with low socioeconomic status across the greater Houston area. METHODS: Inclusion criteria composed of patients diagnosed with MM, aged at least 18 years, and treated with lenalidomide or pomalidomide-two widely used immunomodulators-for a minimum of 2 months or having two or more records of dispensation between May 2019 and May 2021. Adherence was gauged using an adjusted version of the medication possession ratio (MPR). RESULTS: Sixty-two patients were enrolled, yielding a mean MPR value of 88% (SD, ± 18.9). Of these, 43 patients (69.3%) demonstrated adherence with an MPR of ≥ 0.90. A significant difference was found in treatment duration between the adherent (mean 8.8 months; SD, ± 7.2) and non-adherent (mean 13.4 months; SD, ± 7.9) groups (p = 0.027). Notably, race/ethnicity demonstrated a significant difference (p = 0.048), driven by disparities in African American and Hispanic representation across adherence levels. CONCLUSION: In summary, our findings highlight race and treatment duration to be predictors of immunomodulator adherence among MM patients with lower socioeconomic status. Further research is imperative to devise and test innovative interventions aimed at enhancing medication adherence, thereby contributing to improved survival and healthcare quality in this population.

Overall survival associated with CDK4/6 inhibitors in patients with HR+/HER2- metastatic breast cancer in the United States: A SEER-Medicare population-based study.

BACKGROUND: Evidence on overall survival (OS) with cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors is generally limited to data from clinical trials or a few observational studies with limited generalizability to Medicare population. The aim of this study was to determine OS benefits associated with CDK4/6 inhibitors in older Medicare patients with hormone receptor (HR)-positive and human epidermal growth factor receptor-2 overexpressing (HER2-) metastatic breast cancer (MBC). METHODS: In a retrospective cohort design, female patients aged ≥65 years with diagnosis of HR+/HER2- MBC from 2015 to 2017 who initiated first-line systemic therapy within 12 months of MBC diagnosis were selected from the Survey Epidemiology and End Results-Medicare database. The effect of treatment type (endocrine therapy [ET]+CDK4/6 inhibitor vs. ET alone) on OS was analyzed using Kaplan-Meier methods and multivariable Cox regression models. Adjusted hazard ratio (aHR) and 95% CIs were estimated. RESULTS: A total of 630 eligible patients were identified (169 patients treated with ET+CDK4/6 inhibitor and 461 patients treated with ET alone). In the Kaplan-Meier analysis, OS rate at 3 years after first-line treatment initiation was 73.0% for ET+CDK4/6 inhibitor versus 49.1% for ET alone (log-rank p < .0001). In Cox regression analysis, first-line ET+CDK4/6 inhibitor therapy was associated with 41% lower rate of mortality versus ET alone (aHR, 0.590; 95% CI, 0.423-0.823). CONCLUSIONS: The findings of this real-world study demonstrate significant OS benefit associated with ET+CDK4/6 inhibitor therapy over ET alone in an older Medicare population of patients with HR+/HER2- MBC, largely consistent with the evidence from clinical trials.

Impact of CDK4/6 inhibitors on chemotherapy utilization in earlier therapy lines for HR+/HER2- metastatic breast cancer in the United States.

PURPOSE: Delaying chemotherapy remains a vital goal in therapeutic management of HR+/HER2- metastatic breast cancer (MBC). However, recent reports continue to highlight substantially high chemotherapy utilization in earlier therapy lines. In this study, we explored the impact of cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor therapy class, introduced in 2015, on early chemotherapy utilization in an older population of patients with HR+/HER2- MBC in the United States (US). METHODS: Using an interrupted time series design, patients with a confirmed diagnosis of MBC aged ≥ 65 years initiating systemic therapy during 2010-2019 were selected from the SEER-Medicare database. The proportion of chemotherapy use was summarized quarterly based on the date of treatment initiation separately in the first, second, and third lines. Segmented regression models adjusted for autocorrelation over time were fitted to estimate trends before and after the availability of CDK4/6 inhibitors in the first quarter of 2015. RESULTS: Of the 3244 eligible women (median age at diagnosis: 74 years), all initiated first-line therapy; 47.9% (n = 1581) initiated second-line therapy, and 50.1% (n = 792) initiated third-line therapy. Overall utilization of chemotherapy (alone or in combination) during the study period was 15.7% for the first line, 19.6% for the second line, and 24.8% for the third line. Chemotherapy utilization in the period immediately after introduction of CDK4/6 inhibitor therapy decline by estimated 2.5% in the first line (P = 0.408), 15.5% in the second line (P = 0.005), and 16.3% in the third line (P = 0.003). CONCLUSIONS: This population-based study illustrates that chemotherapy utilization in earlier therapy lines for HR+/HER2- MBC declined steadily between 2010 and 2019. These declines were significantly accelerated by the introduction of CDK4/6 therapy class in 2015, notably in the second- and third-line settings.

Dose-dependent relation between metformin and the risk of hormone receptor-positive, her2-negative breast cancer among postmenopausal women with type-2 diabetes.

PURPOSE: Metformin has demonstrated a chemoprotective effect in breast cancer but there is limited evidence on the effect of cumulative exposure to metformin and the risk of hormone receptor-positive and human epidermal growth factor receptor 2-negative (HR + /HER2-) breast cancer. This study assessed this risk with dose and intensity of metformin in postmenopausal women with type-2 diabetes mellitus (T2DM). METHODS: This nested case-control study used the Surveillance, Epidemiology, and End Results-Medicare data (2008-2015). Cohort entry was the date of incident T2DM diagnosis. Cases were those diagnosed with HR + /HER2- breast cancer (event date) as their first/only cancer. Non-cancer T2DM controls were matched using variable-ratio-matching. Cumulative dose and average intensity of metformin were measured during the 1-year lookback period. Dose(mg) was categorized as: (1)0, (2)0-30,000, (3)30,001-136,000, (4)136,001-293,000, and (5) > 293,000, and intensity(mg/day) as: 0, 1-500, and > 500. Covariates were conceptualized using the Andersen Behavioral Model. Conditional logistic regression was used to assess the risk of HR + /HER2- breast cancer with metformin-use. RESULTS: There were 690 cases and 2747 controls. The median duration of T2DM was 1178 days in controls and 1180 days in cases. Higher cumulative dose categories: 4 (adjusted odds ratio(aOR) = 0.72, 95% CI 0.55-0.95,p = 0.02), and 5 (OR = 0.60, 95% CI 0.42-0.85,p < 0.01) had significantly lower odds of HR + /HER2- breast cancer compared to category 0. The highest intensity category of metformin had 39% lower odds of HR + /HER2- breast cancer (OR = 0.61, 95% CI 0.46-0.82,p < 0.01) compared to the 0 mg/day group. CONCLUSIONS: Higher metformin exposure was associated with reduced risk of HR + /HER2- breast cancer, adding to the evidence supporting metformin's chemoprotective effect.

Barriers and Facilitators to DATA Waivered Providers Prescribing Buprenorphine: A Qualitative Analysis Applying the Theory of Planned Behavior.

Background: Provider beliefs about the treatment of people with addiction may influence their prescribing behavior. Objective: This study applied the Theory of Planned Behavior (TPB), to identify the salient beliefs of Drug Addiction Treatment Act of 2000 (DATA 2000) waivered providers, concerning prescribing buprenorphine to patients with Opioid Use Disorder (OUD). Methods: Texas buprenorphine providers participated in one of four online focus group discussions conducted in fall 2019. The focus group discussion were audio recorded and the total length was between 60-90 minutes. Thematic analysis was conducted to identify emerging themes and to categorize the behavioral, normative, and control beliefs related to buprenorphine prescribing. Results: Of the 14 total participants, 57% of the participants were male and annually treated between zero to sixty patients with buprenorphine. The codes generated were represented in thematic maps, specifying the positive or negative aspects of buprenorphine prescribing. Results indicate that providers' primary motivation to prescribe buprenorphine was, implementation of a whole-patient approach through collaboration with behavioral health providers, in the provision of medications for opioid use disorder (MOUD). Providers primary normative belief was the recognition of key members of the medical community and patients' families and friends as influential groups. Providers' control beliefs focused on their ability to use buprenorphine in different practice settings. Conclusion: These results indicate that buprenorphine access may be expanded by increasing support for DATA waivered providers from other parts of the healthcare system such as behavioral health providers and pharmacists. Implications for clinical practice and future research will be discussed.

Adherence to concomitant diabetes, hypertension, and hyperlipidemia treatments among older patients.

BACKGROUND: Diabetes, hypertension, and hyperlipidemia have been identified as common modifiable risk factors of cardiovascular disease, frequently occurring together, especially among older people. Medication adherence to concomitant triple therapy is of vital importance among this population. OBJECTIVES: The objective of the current study was to examine adherence to concurrent oral antidiabetics, renin-angiotensin system antagonists, and statins (triple therapy) among older patients and further evaluate the predictors associated with adherence to concurrent triple therapy among older patients. METHODS: Patients on concurrent triple therapy were identified using a Texas Medicare Advantage dataset. Patients had to have an overlap of 30 days of triple therapy and a second prescription of each component of triple therapy within the identification period. Medication adherence was measured using Proportion of Days Covered during the 1-year follow-up period to determine different adherence groups. A multinomial logistic regression was further conducted to determine various demographic and clinical factors associated with each adherence group. RESULTS: The final patient cohort comprised 7847 patients. Of these, 68.05% were adherent to triple therapy, 21.43% were adherent to double therapy, and 10.51% were adherent to monotherapy or none. Compared with the triple therapy adherent group, females had a higher likelihood of being in the triple therapy nonadherent groups, while a refill of 90 days or more and prevalent use of triple therapy was associated with a lower likelihood of being in the triple therapy nonadherent groups. Finally, predictors associated with the adherent to monotherapy or none group included older age and a higher number of total other medications. CONCLUSION: Adherence to triple therapy among older patients was 68.05%, and several demographic and clinical factors were associated with the different adherence groups.

Using group-based trajectory modeling to characterize the association of past ACEIs/ARBs adherence with subsequent statin adherence patterns among new statin users.

BACKGROUND: Despite well-documented benefits, statin adherence remains suboptimal. Studies have suggested that previous adherence to other chronic medications is a strong predictor of future adherence to newly initiated statins. Group-based trajectory modeling (GBTM) has been applied as a method to longitudinally depict the dynamic nature of adherence. OBJECTIVES: This study aimed to examine the association between patients' adherence patterns to newly initiated statins and previous adherence trajectories of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) using GBTM. METHODS: This retrospective cohort study was conducted among continuously enrolled statin initiators using claims data. Patients were included if they had ACEI/ARB use within 1 year before statin initiation (preindex period). Monthly adherence to ACEIs/ARBs was calculated during the preindex period and monthly adherence to statins was assessed 1 year after statin initiation using proportion of days covered (PDC). The monthly PDCs were modeled as a longitudinal response in a logistic GBTM to provide distinct patterns of adherence for ACEIs/ARBs and statins, separately. A multinomial logistic regression was conducted to determine an association between ACEI/ARB adherence trajectories and future statin trajectories, controlling for patient characteristics. RESULTS: A total of 1078 patients were categorized into 4 distinct statin adherence trajectories: adherent (40.8%), gradual decline (37.4%), gaps in adherence (13.9%), and rapid decline (7.9%). Patients were further categorized into 4 groups on the basis of their distinct past ACEIs/ARBs trajectories: adherent (43%), gaps in adherence (29%), delayed nonadherence (15.2%), and gradual decline (12.8%). In the multinomial logistic regression, patients in the gaps in adherence or gradual decline groups were more likely to follow similar trajectories for future statin use than the adherent trajectory. CONCLUSION: Previous adherence trajectories of ACEIs/ARBs may predict future adherence patterns for newly initiated statins. Knowledge of past medication-taking behavior could provide valuable information for developing tailored interventions to improve adherence.

Switching pharmacies leads to gaps in medication possession in individuals treated with buprenorphine.

BACKGROUND: Not all pharmacies stock and dispense buprenorphine, potentially complicating continuous access to care for patients with opioid use disorder (OUD). This may become problematic if a patient's primary pharmacy can no longer provide buprenorphine, and the patient cannot locate a new pharmacy. OBJECTIVES: To identify how often patients treated with buprenorphine for OUD switch pharmacies and to estimate the association between switching pharmacies and a clinically significant gap in therapy of 7 days or longer. METHODS: A retrospective repeated measures longitudinal cohort design was used. Patients initiating treatment with a buprenorphine product indicated for OUD were identified from the 2016-2018 Texas Prescription Monitoring Program. The predictor of interest-switching pharmacies-was defined by comparing the dispensaries used between subsequent prescriptions. The outcome of interest was defined as a gap in medication possession of 7 days or longer on the basis of the National Quality Forum's definition of continuity of pharmacotherapy for OUD. A generalized estimating equation approach was used to estimate a repeated measures logistic regression measuring the association between switching pharmacies and a gap in therapy. RESULTS: Of 13,375 eligible patients, 29.6% switched pharmacies at least once during treatment, and 51.6% of these did so more than once. The median time to initial switch was 30 days (interquartile range: 13-66 days). When patients switched pharmacies, they were significantly more likely to have a gap in therapy of between 7 and 29 days (adjusted odds ratio 1.67 [95% CI 1.57-1.78]). CONCLUSION: Patients receiving buprenorphine switch pharmacies early and frequently in treatment, which leads to clinically significant gaps in therapy. Although qualitative explanatory work is needed to understand why patients switch pharmacies so often, pharmacists and prescribers must ensure that patients have reliable access to a convenient source of buprenorphine to prevent gaps in therapy.

Patient-reported barriers to statin adherence: Excerpts from a motivational interviewing intervention in older adults.

OBJECTIVE: Despite a known benefit in the reduction of cardiovascular risk, adherence to statins remains suboptimal. A qualitative analysis was conducted within an intervention that identified trajectories of statin adherence in patients and used motivational interviewing (MoI) to improve adherence. The objective of this qualitative study was to evaluate transcripts of an MoI telephonic intervention to identify potential, past, and current barriers to statin adherence and barriers specific to distinct adherence trajectories. METHODS: The MoI intervention was customized by past 1-year adherence trajectories (rapid discontinuation, gradual decline, and gaps in adherence). Two authors independently extracted and documented barriers from phone transcripts. Themes were derived from literature a priori and by cataloging recurring themes from the transcripts. RESULTS: The transcripts of calls made to 157 patients were reviewed of which 25.2% did not communicate a specific adherence barrier despite falling into a low-adherence trajectory when examining refill data. The most commonly reported barriers to statin adherence included adverse effects (40.1%), forgetfulness (30.0%), and lack of skills or knowledge pertaining to statins (25%). More patients in the rapid discontinuation group perceived medication as unnecessary, whereas more patients in the gaps in adherence group reported a communication barrier with their health care provider. Several barriers among patients who fell into low-adherence trajectories were reported. Some patients did not report any barriers, which may have indicated denial. MoI phone calls were useful in providing knowledge, clarifying medication regimens, and reinforcing the need to take statins. CONCLUSION: This study identified patient-reported barriers to statin adherence elicited during an MoI telephonic intervention conducted by student pharmacists. There were differences in barriers reported by patients from each trajectory, which emphasize the need for additional tailored interventions to improve patient adherence.

Evaluating trajectories of statin adherence after a motivational interviewing intervention.

OBJECTIVE: The objective of the current study was to compare postintervention adherence trajectories with preintervention trajectories for those receiving a telephonic motivational interviewing (MoI) intervention to determine predictors associated with each distinct postintervention trajectory and any association between pre- and postintervention trajectories. DESIGN: Retrospective study design using group-based trajectory modeling. SETTINGS AND PARTICIPANTS: A telephonic MoI intervention was conducted by trained student pharmacists to improve statin adherence in a Medicare Advantage plan. Four preintervention adherence trajectories were previously identified: rapid decline (RD), gradual decline (GD), gaps in adherence (GA), and adherent and were used to customize the MoI intervention. Patients from the 3 nonadherent preintervention trajectories were randomized to control or intervention groups and were followed for 6 months from the date of MoI intervention. OUTCOME MEASURES: Group-based trajectory modeling was performed to identify 3 relevant postintervention trajectories. Descriptive statistics were used to assess differences in pre- and postintervention adherence trajectories. Multinomial logistic regression was conducted to determine predictors associated with each identified postintervention trajectory. RESULTS: There were 152 intervention patients and 304 randomly selected controls. The prominent postintervention trajectories that were identified differed from the preintervention trajectories and were (1) GD (17.2%), (2) adherent (61.9%), and (3) discontinuation (20.9%). Among the intervention group, more patients in the GA preintervention trajectory (58.65%) moved to the adherent trajectory postintervention than those in the RD and GD preintervention trajectories. Furthermore, the predictors associated with the postintervention trajectories included MoI intervention, prescriber specialty, presence of diabetes, presence of congestive heart failure, Centers for Medicare & Medicaid Services risk score, and preintervention trajectories. CONCLUSION: The postintervention adherence trajectory patterns differed from the preintervention trajectory patterns with many patients moving into an adherent trajectory especially among those receiving the intervention.

Identifying adherence barriers to oral endocrine therapy among breast cancer survivors.

PURPOSE: Approximately 70-80% of breast cancers are hormone receptor-positive (HR+). OET, including tamoxifen and aromatase inhibitors, is considered standard adjuvant therapy for HR+ breast cancer. Despite demonstrated benefits, nearly half of patients are non-adherent and over two-thirds discontinue therapy before the recommended 5 years. Our objective was to identify and summarize literature-reported barriers associated with non-adherence/non-persistence to OET among breast cancer survivors. METHODS: A PUBMED literature search was conducted using the following terms: 'breast cancer,' 'oral endocrine therapy' or 'Tamoxifen' or 'Aromatase Inhibitors,' 'adherence,' or 'barriers.' The search was restricted to past six years. The abstracts of each result were reviewed and categorized as either patient-reported or physician-reported. All patient- and physician-reported factors that affected adherence and persistence were listed and grouped together into the three main categories: Socio-demographic and medical parameters, general psychosocial parameters, and psychosocial parameters related to OET. RESULTS: A total of 320 articles were identified, of which 19 met inclusion criteria. Adverse drug reactions were the most commonly reported barrier but were generally underreported among physicians. Among patient-reported barriers, common social-demographic and medical parameters were age, comorbidity, and financial status. General psychosocial variables were lack of patient-provider communication, depressive symptoms, and lack of perceived self-efficacy. Treatment toxicity was the most commonly reported psychosocial parameter related to OET. CONCLUSION: The determinants of non-adherence and non-persistence are multi-dimensional and influenced by several factors. The three categories of adherence barriers should be evaluated and considered when designing future interventions to enhance OET adherence for a tailored approach.

Neratinib in HER2-Positive Breast Cancer Patients.

OBJECTIVE: To review the chemistry, pharmacology, pharmacokinetics, safety, and efficacy of neratinib in human epidermal growth factor receptor (HER2)+ breast cancer (BC). DATA SOURCES: A PubMed search was performed using the term neratinib between September 12, 2018, and November 21, 2018. References of published articles and reviews were also assessed for additional information. STUDY SELECTION AND DATA EXTRACTION: English-language preclinical and clinical studies on the chemistry, pharmacology, pharmacokinetics, safety, and efficacy of neratinib were evaluated. DATA SYNTHESIS: Neratinib, an irreversible inhibitor of HER1, HER2, and HER4, is Food and Drug Administration approved for the extended adjuvant treatment of stage I-III HER2+ BC to follow trastuzumab-based therapy. A phase III study has demonstrated statistically significant improvement in 5-year disease-free survival rate (90.2 vs 87.7; hazard ratio = 0.73, 95% CI = 0.57-0.92, P = 0.0083). Its most common adverse effect is diarrhea, observed in more than 90% of patients. The incidence of grade 3/4 diarrhea (~40%) is reduced by half with loperamide prophylaxis, which is recommended for the first 8 weeks of neratinib therapy. Other common adverse reactions are nausea and fatigue. The patients need to be monitored for liver function tests and drug interactions with acid-reducing agents, CYP3A4 inhibitors/inducers, and P-glycoprotein substrates with narrow therapeutic window. Relevance to Patient Care and Clinical Practice: American Society of Clinical Oncology and National Comprehensive Cancer Network clinical guidelines suggest the use of neratinib for extended adjuvant therapy following 1-year trastuzumab in stage I to III HER2+ BC. Diarrhea remains a clinically significant but manageable adverse event. CONCLUSION: Neratinib significantly improves treatment outcomes and has manageable toxicity in stage I to III HER2+ BC patients.

Comparison of Suicide Attempts/Behaviors Following Smoking Cessation Treatments Among Schizophrenic Smokers.

BACKGROUND: Smoking cessation may lead to depression in some smokers and result in increased risk of suicide. OBJECTIVE: To compare the risk of suicide attempts/behaviors associated with different smoking cessation medications among schizophrenic patients. METHODS: A retrospective cohort study was conducted using General Electric (GE) medical record database (1995-2011). The first day of being prescribed a smoking cessation medication defined as index date. Patients were followed up to one year from index date. Patients' suicide behaviors or attempts were identified through ICD-9 codes and E-codes. Cox proportional hazards model was applied to examine the association between smoking cessation medication and suicidal/self-injurious behaviors. RESULTS: Our cohort consisted of 3925 patients with diagnosis of schizophrenia or schizoaffective disorder who initiated cessation medication. Among them, 104 (2.65%) had suicide attempts or behavior within one-year follow up. However, statistically significant difference in the risk of suicide attempts/behaviors was not detected across cessation regimens in the Cox proportional hazard analysis. Only comorbidity index was found to be associated with suicide, which showed that higher Charlson comorbidity index was associated with higher risks of suicide behaviors within one year (HR=1.15, 95% CI=1.04-1.27). CONCLUSION: There were no significant differences in suicide attempts/behaviors with different cessation medications.

Intention to quit water pipe smoking among Arab Americans: Application of the theory of planned behavior.

In this study, we examined the effect of theory of planned behavior (TPB) constructs on the intention to quit water pipe smoking by using an observational, survey-based, cross-sectional study design with a convenient sample of Arab American adults in Houston, Texas. Multivariate logistic regression models were used to determine predictors of intention to quit water pipe smoking in the next year. A total of 340 participants completed the survey. Behavioral evaluation, normative beliefs, and motivation to comply were significant predictors of an intention to quit water pipe smoking adjusting for age, gender, income, marital status, and education. Interventions and strategies that include these constructs will assist water pipe smokers in quitting.

Comparative Effectiveness of Smoking Cessation Medications to Attenuate Weight Gain Following Cessation.

OBJECTIVE: To compare the postcessation weight gain following the use of different FDA-approved smoking cessation medications among obese smokers. METHODS: A retrospective cohort study was conducted using the General Electric (GE) electronic medical record database (2006-2011). The cohort consisted of obese adult smokers newly initiating use of an FDA-approved smoking cessation medication (i.e., bupropion vs. varenicline). The outcome variable was weight change at 3, 6, or 12 months following the first prescription. Descriptive analyses and t-tests were conducted to assess the frequency distribution of sample characteristics and their association with the postcessation weight change. Multivariate linear regression models were carried out to compare the weight change among the FDA-approved smoking cessation medications and to identify predictors of weight change at 3, 6, and 12 months after assessing the model assumptions. RESULTS: The mean weight gain was 1.14 pounds (±17.26), 2.06 pounds (±18.46), and 3.06 pounds (±20.78) at 3-, 6-, and 12-month, respectively. Obese smokers who were prescribed varenicline had a mean weight gain of 1.18 pounds (±16.75), 2.14 pounds (±18.14), and 3.12 pounds (±20.89) for each follow up, while those who were prescribed bupropion had a mean weight gain of 0.23 pounds (±25.90), 0.22 pounds (±25.32), and 1.47 pounds (±17.50), respectively. Descriptive analysis showed that obese smokers taking bupropion had less weight gain than those taking varenicline at each follow up; however, this association was not statistically significant after accounting for all covariates. CONCLUSIONS: While patients using bupropion gained slightly less weight compared to those using varenicline, type of smoking cessation medication was not a significant predictor of weight change in the multivariate linear regression model.

Comparison of Diabetes Risk Following Smoking Cessation Treatment Using Varenicline Versus Bupropion Among Obese Smokers.

BACKGROUND: Recent literature suggests an initial increased risk of diabetes following smoking cessation. OBJECTIVES: To compare the risk of developing diabetes among obese smokers who tried to quit smoking using bupropion versus varenicline. METHODS: A population-based retrospective cohort study was conducted using the General Electric (GE) electronic medical record database (2006-2011). The cohort consisted of obese adult smokers without a diabetes diagnosis at baseline and newly initiating use of either bupropion or varenicline. This cohort was then followed for 1 year to observe the risk of developing diabetes. The relative risk of bupropion versus varenicline on developing diabetes was assessed using Cox Proportional Hazards regression model after controlling for covariates. RESULTS: The sample comprised of 78,002 obese smokers of which 1,937 (2.36%) developed diabetes during 1 year follow-up. Diabetes incidence rate was relatively comparable who used varenicline and bupropion (23.50 versus 25.80 per 1,000 person-years). Obese smokers who were prescribed bupropion had a statistically significant higher risk of developing diabetes during 1 year following cessation treatment than those who were prescribed varenicline. ([HR]: 1.58, 95% CI: 1.09-2.27) in the multivariate model. CONCLUSIONS/IMPORTANCE: Obese smokers who were prescribed bupropion might have a higher risk of developing diabetes during 1 year follow up compared to those who were prescribed varenicline. The clinical significance of the finding that bupropion had a higher risk of developing diabetes may need further investigation.

The Role of Socioeconomic Status and Health Care Access in Breast Cancer Screening Compliance Among Hispanics.

OBJECTIVES: Considerable disparities in breast cancer screening exist between Hispanic and non-Hispanic white (NHW) women. Identifying and quantifying the factors contributing to these racial-ethnic disparities can help shape interventions and policies aimed at reducing these disparities. This study, for the first time, identified and quantified individual-level sociodemographic and health-related factors that contribute to racial-ethnic disparities in breast cancer screening using the nonlinear Blinder-Oaxaca decomposition method. METHODS: Analysis of the retrospective pooled cross-sectional Medical Expenditure Panel Survey data from 2000 to 2010 was conducted. Women aged 40 years and older were included in the study. Logistic regressions were used to estimate racial-ethnic disparities in breast cancer screening. Nonlinear Blinder-Oaxaca decomposition method was used to identify and quantify the contribution of each individual-level factor toward racial-ethnic disparities. RESULTS: Based on the unadjusted analyses, Hispanic women had lower odds of receiving mammogram screening (MS) (odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.69-0.80) and breast cancer screening (OR: 0.75; 95% CI: 0.70-0.81) as compared with NHW women. However, the relationship reversed in adjusted analyses, such that Hispanic women had higher odds of receiving MS (OR: 1.27; 95% CI: 1.16-1.40) and breast cancer screening (OR: 1.28; 95% CI: 1.17-1.40) as compared with NHW women. The Blinder-Oaxaca decomposition estimated that improving insurance status, access to care, education, and income will considerably increase screening rates among Hispanic women. CONCLUSIONS: The study projects that improving health care access and health education will considerably increase breast cancer screening compliance among Hispanic women. Policies like the Affordable Care Act, and patient navigation and health education interventions, might considerably reduce screening disparities in the Hispanic population.

Predictors of smoking cessation medication use among nonobese and obese smokers.

The objective of this study was to identify and compare the predictors of smoking cessation medication use among obese and nonobese adult smokers. A retrospective cross-sectional study was conducted using the Medical Expenditure Panel Survey (MEPS) data (2008-2009). The study participants included smokers aged 18 years and older who self-reported their smoking status as smoker. The outcome variable was utilization of any Food and Drug Administration approved smoking cessation medication (varenicline, bupropion, and nicotine replacement therapy). Multivariable logistic regression analyses were conducted. A total of 82.20 million (weighted sample size for two years) adult smokers were included; of which nearly 30% were obese-smokers. The use of smoking cessation medication was 2.66% and 5.17% among nonobese and obese smokers, respectively. Multivariable logistic regression results showed that race/ethnicity, health insurance coverage, prescription insurance coverage, usual source of health care, urban residence, region, Charlson comorbidity index, and instrumental activities of daily living (IADL), were significant predictors of using smoking cessation medications. The overall smoking cessation medication use rate was low implying limited compliance to guideline. Predictors identified in this study should be taken into consideration in health promotion programs that are designed to optimize the utilization of these smoking cessation medications.

Predictors of adherence to direct oral anticoagulants after cardiovascular or bleeding events in Medicare Advantage Plan enrollees with atrial fibrillation.

BACKGROUND: Direct oral anticoagulants (DOACs) are recommended for patients with atrial fibrillation (AF) given their improved safety profile. Suboptimal adherence to DOACs remains a significant concern among individuals with AF. However, the extent of adherence to DOACs following a cardiovascular or bleeding event has not been fully evaluated. OBJECTIVE: To evaluate the pattern of adherence trajectories of DOACs after a cardiovascular or bleeding event and to investigate the sociodemographic and clinical predictors associated with each adherence trajectory by using claims-based data. METHODS: This retrospective study was conducted among patients with AF prescribed with DOACs (dabigatran/apixaban/rivaroxaban) between July 2016 and December 2017 and who were continuously enrolled in the Texas-based Medicare Advantage Plan. Patients who experienced a cardiovascular or bleeding event while using the DOACs were further included in the analysis. The sample was limited to patients who experienced a clinical event such as a cardiovascular or bleeding event while using the DOACs. The clinical events considered in this study were cardiovascular (stroke, congestive heart failure, myocardial infarction, systemic embolism) and bleeding events. To assess adherence patterns, each patient with a DOAC prescription was followed up for a year after experiencing a clinical event. The monthly adherence to DOACs after these events was evaluated using the proportion of days covered (PDC). A group-based trajectory model incorporated the monthly PDC to classify groups of patients based on their distinct patterns of adherence. Predictors associated with each trajectory were assessed using a multinomial logistic regression model, with the adherent trajectory serving as the reference group in the outcome variable. RESULTS: Among the 694 patients with AF who experienced clinical events after the initiation of DOACs, 3 distinct adherence trajectories were identified: intermediate nonadherent (30.50%), adherent (37.7%), and low adherent (31.8%); the mean PDC was 0.47 for the intermediate nonadherent trajectory, 0.93 for the adherent trajectory, and 0.01 for low adherent trajectory. The low-income subsidy was significantly associated with lower adherence trajectories (odds ratio [OR] = 4.81; 95% CI = 3.07-7.51) and with intermediate nonadherent trajectories (OR = 1.57; 95% CI = 1.06-2.34). Also, nonsteroidal anti-inflammatory drug use was significantly associated with lower adherence trajectories (OR = 5.10; 95% CI = 1.95-13.36) and intermediate nonadherent trajectories (OR = 3.17; 95% CI = 1.26-7.93). Other predictors significantly associated with both nonadherent trajectories are type of DOACs (OR = 0.53; 95% CI = 0.35-0.79), presence of coronary artery disease (OR = 1.89; 95% CI = 1.01-3.55), and having 2 or more clinical events (OR = 1.65; 95% CI = 1.09-2.50). CONCLUSIONS: Predictors identified provide valuable insights into the suboptimal adherence of DOACs among Medicare Advantage Plan enrollees with AF, which can guide the development of targeted interventions to enhance adherence in this high-risk patient population.