A common data model to assess cardiovascular hospitalization and mortality in atrial fibrillation patients using administrative claims and medical records.

PURPOSE: Atrial fibrillation/flutter (AF) is frequently associated with cardiovascular comorbidities. Observational health care databases are commonly used for research purposes in studies of quality of care, health economics, outcomes research, drug safety, and epidemiology. This retrospective cohort study applied a common data model to administrative claims data (Truven Health Analytics MarketScan(®) claims databases [MS-Claims]) and electronic medical records data (Geisinger Health System's MedMining electronic medical record database [MG-EMR]) to examine the risk of cardiovascular hospitalization and all-cause mortality in relation to clinical risk factors in recent-onset AF and to assess the consistency of analyses for each data source. METHODS: Cohorts of patients with newly diagnosed AF (n=105,262 [MS-Claims] and n=3,919 [MG-EMR]) and demographically similar patients without AF (n=105,262 [MS-Claims] and n=3,872 [MG-EMR]) were followed from the qualifying AF diagnosis until cardiovascular hospitalization, death, database disenrollment, or study completion. A common data model standardized the data in structure, format, content, and nomenclature to allow for systematic assessment and comparison of outcomes from two disparate data sets. RESULTS: In both databases, AF patients had greater overall baseline comorbidity and higher incidence rates of cardiovascular hospitalization (threefold higher) and all-cause mortality (46% higher) than non-AF patients. For AF patients, incidence rates of cardiovascular hospitalization and all-cause mortality were increased by the concomitant presence of coronary disease, chronic obstructive pulmonary disease, and stroke at baseline. Overall, the pattern of cardiovascular hospitalization in the MS-Claims database was similar to that in the MG-EMR database. Compared with the MS-Claims database, the use of cardiovascular medications and the capture of certain comorbidities among AF patients appeared to be higher in the MG-EMR data set. CONCLUSION: Similar standardized analyses across EMR and Claims databases were consistent in the association of AF with acute morbidity and an increased risk of all-cause mortality. Areas of inconsistency were due to differences in underlying population demographics and cardiovascular risks and completeness of certain data fields.

CHADS2 and CHA2DS2-VASc risk factors to predict first cardiovascular hospitalization among atrial fibrillation/atrial flutter patients.

Limited data exist concerning risk factors for cardiovascular (CV) hospitalization in patients with atrial fibrillation (AF) or atrial flutter (AFL). The aim of this retrospective cohort evaluation was to assess whether patient characteristics and risk factors, including CHADS(2) (congestive heart failure, hypertension, age ≥75 years, type 2 diabetes, and previous stroke or transient ischemic attack [doubled]) and CHA(2)DS(2)-VASc (congestive heart failure; hypertension; age ≥75 years [doubled]; type 2 diabetes; previous stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 75 years; and sex category) scores, identified patients with AF or AFL at risk for CV hospitalization. Claims data (January 2003 to June 2009) were evaluated to identify patients aged ≥40 years with ≥1 inpatient or ≥2 (within 30 days of each other) outpatient diagnoses of AF or AFL and an absence of diagnosis codes related to cardiac surgery within 30 days of AF or AFL diagnosis. Risk factors for first CV hospitalization in the 2-year period after diagnosis were assessed using univariate and multivariate analyses. Overall, 377,808 patients (mean age 73.9 ± 12.1 years) were identified, of whom 128,048 had CV hospitalizations. CHADS(2) and CHA(2)DS(2)-VASc scores were the top 2 predictors of first CV hospitalization after AF or AFL diagnosis. Hospitalization risk was increased 2.3- to 2.7-fold in patients with CHADS(2) scores of 6 and approximately 3.0-fold in patients with CHA(2)DS(2)-VASc scores of 9 compared to patients with a score of 0. These increases were maintained essentially unchanged throughout the 2-year follow-up period. In conclusion, CHADS(2) and CHA(2)DS(2)-VASc scores were predictive of first CV hospitalization in patients with AF or AFL and may be helpful in identifying "at-risk" patients and guiding therapy.

Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an economic evaluation.

BACKGROUND: The development of low-molecular-weight heparins (LMWHs) has made it possible to shift treatment of deep vein thrombosis (DVT) from inpatient to outpatient settings, thereby saving costs and improving patient quality of life. OBJECTIVE: To quantify the economic benefits of early discharge of patients treated for DVT with LMWH using data pooled from multiple healthcare plans. METHODS: Data sources were integrated medical and pharmacy claims paid by 37 US health plans (the PharMetrics Integrated Outcomes Database, PharMetrics, Inc., Watertown, MA). Hospitalized patients discharged with a diagnosis of DVT were selected and grouped according to the anticoagulation therapy they received after discharge. Outcomes and costs of DVT treatment were assessed over a 1-year period. RESULTS: Patients discharged on the LMWH enoxaparin and warfarin spent 2.6 fewer days in the hospital than those discharged on warfarin alone (P< .0001), resulting in cost savings of $1911 per patient. Mean costs of outpatient management of DVT, including pharmacy and medical services, were $901 higher in the enoxaparin/warfarin cohort, but rate of readmission was lower (6.7% versus 9.0%; P < .05) and hence subsequent inpatient costs were reduced by $140 per patient. Total cost savings in the enoxaparin/warfarin cohort, net of higher outpatient costs, were $1151 per patient. CONCLUSIONS: Outpatient anticoagulation therapy for DVT with enoxaparin and warfarin is associated with earlier hospital discharge, fewer readmissions, and lower total DVT-related costs compared with warfarin monotherapy.

Use of managed care claims data in the risk assessment of venous thromboembolism in outpatients.

BACKGROUND: Deep vein thrombosis (DVT) is a complication of immobilizing illness in both inpatient and outpatient settings and can lead to serious complications such as pulmonary embolism (PE). DVT and PE are collectively referred to as venous thromboembolism. OBJECTIVE: To develop DVT and PE risk assessment models that can be used in office-based practice and for population-based disease management efforts. METHODS: Data were culled from integrated medical and pharmacy claims paid by 37 health plans in the United States (the PharMetrics Integrated Outcomes Database, PharMetrics Inc., Watertown, MA), and included information on adult plan members enrolled during 1998 and 1999. Patients hospitalized for DVT or PE in 1999 were identified, and potential risk factors were assessed by reviewing claims for the entire study population in 1998 to document prior DVT or immobilizing illness. The contribution of each potential risk factor to the probability of the occurrence of DVT or PE was determined by means of multiple logistic regression analysis. A risk-scoring algorithm based on regression coefficients was then developed. RESULTS: Fifty-two percent of the study population of 2.8 million plan members were women. DVT or PE occurred in 1330 of those 2.8 million individuals (47 per 100,000). Logistic regression results confirmed the role of risk factors previously reported in the literature and revealed additional risk factors that have not been reported previously, including diabetes, renal failure, rheumatoid arthritis, cellulitis, use of warfarin, use of systemic corticosteroids, and use of potassium chloride. When risk scores were applied to the study population, the 1% identified as being at highest risk had a probability for the development of venous thromboembolism that was 10 times greater than that of the population average. CONCLUSIONS: This study confirms the feasibility of using managed care claims data to develop a risk assessment tool for venous thromboembolism that can be used in office-based practice and for population-based disease management.

The special cervix clinic - abstract

The purpose of this study is to present the cumulation of experience in the organization, co-ordination, and value of a cervix clinic from its inception in 1966 to the end of 1971. The record sheets of the clinic have been reviewed in combination with other records such as cytology smears and in-patient records of the relevant patients. A description of the target the design, techniques and personnel is an essential preliminary to the results. To date more than 400 patients with positive cervical smears have been referred to the clinic for investigation and treatment. About 5 percent of these have had invasive cancer diagnosed at first biopsy. The vast majority, approximately 60 percent have been patients with cervical dysplasia diagnosed at cytology smear. Histologic samples taken as outpatients have confirmed the diagnosis in 45 percent. Outpatient treatment has been accompanied by a returned to normal smears in 40 percent. The remaining 5 percent have been proven to have a more advanced state and have had to be admitted for further investigation and treatment. Of the cases not confirmed and treated, there has been a small percentage in which subsequent smears have been normal. Another percentage fall into the category of spontaneous cures. The remainder, approximately 10 percent out of the original 60 percent, are still under investigation. In an area where invasive cervical cancer is statistically proven and clinically known to be a frequent cause of death, preventive programmes must, if possible, be instituted, The specific preventive programme shown by worldwide experience to be of value is based on cervical cytology. Cytology screening programmes will identify, especially in the early years, large numbers of women with cervical disease ranging from incidental and minor to death-dealing. It is of tremendous importance that provision be made for the further investigation and treatment of these women. The special cervix clinic is currently emerging as the most valuable way of doing this (AU)

Social and psychological factors associated with teenage pregnancy - abstract

At the Queen Elizabeth Hospital in Barbados at least 300 teenage girls have their first baby in her teens. The impact of teenage pregnancy upon the demographic data and also upon the social and economic furture of the girl are indicated. Significant factors associated with the phenomenon are indicated and some steps to avoid it are suggested (AU)

Insertion of lippes loop by nurse-midwives and doctors

Follow-up studies of 7 to 19 months of two groups of 500 women each in Barbados, in one of which a Lippes loop had been inserted by a doctor and in the other by a nurse-midwife, showed a slightly higher incidence of pregnancy and expulsion of the loop in the second group, though the difference was not statistically significant. The insertion of loops by paramedical personnel when this is an economic necessity is thought not to be contraindicated, but adequate training is essential.(AU)

An island-wide screening program for cervical neoplasia in Barbados

In an attempt to develop a cervical cancer screening program applicable to nonindustrialized nations, an island wide project was undertaken in Barbados, West Indies, utilizing paramedical personnel and existing health facilities. Among the first 5,000 women screened, 0.5 percent were found to have invasive carcinoma, 0.8 percent carcinoma in situ, and 4.2 percent dysplasia. The results of this project suggest that directing a screening program at those women who are undergoing a reproductive event is an efficient, effective, and relatively inexpensive method of detecting cervical neoplasia. (AU)

Knowledge and use of birth control in Barbados

Based on material collected in Barbados in 1964, this paper examines knowledge and use of birth control in terms of 3 types of family union - married, common law, and visiting. Analysis of knowledge of birth control is dealt with for the sample at large, for educational attainment, and for the average number of methods known by each woman. The relative importance of the different methods known is also treated by family type and education. The extent to which women in the sample make use of birth control is discussed from 4 aspects. First, the growing use of the different methods among younger-age cohorts is made evident from tabulations of methods-last used. Second, information on the agencies and individuals recommending the use of different contraceptives emphasizes the degree to which the partner's influence is responsible for resort to birth control. Third, the proportions of users in religious groups show that religion is not a barrier to the use of any method. Fourth, the material is treated from the standpoint of age cohorts, since there is, in many cases, a vagueness as to the age at which use began, although women are able to identify the inter-pregnancy period when use began

Population control in Barbados

Barbados, a small island in the Eastern Caribbean, has one of the higest population densities in the world. A family planning service was started in May, 1955, expanded in 1958, and extended further in 1961. An attempt is made to demonstrate the acceptance of the program, and to evaluate its effectiveness on population control. New registrations rose from 662 in 1956 to 2,055 in 1961-1962, while total attendances also increased from 1,656 to 5,574 for the same years. Recent trends in the population growth show that there has been a decline in the birth rate from 33.4 in 1955 to 29.6 in 1962. It seems that a fertility control program operating with limited resources will be most effective if specifically directed toward married and common-law unions (AU)

Bacteriuria, prematurity, and the hypertensive disorders of pregnancy

The occurrance of prematurity and the hypertensive disorders of pregnancy in bacteriuric and in non-bacteriuric women has been compared. In all age and parity groups the occurrance of prematurity and the hypertensive disorders of pregnancy was higher in bacteriurics than in non-bacteriurics. Prevalence rates for the emergence of the hypertensive disorders of pregnancy rose particularly rapidly with increasing age parity in bacteriuric subjects. The predictive value of bacteriuria as an index of subsequent clinical pyelonephritis has been confirmed. The possible implications of these observations are discussed. It is suggested that some of the perinatal mortality and morbidity associated with hypertension and prematurity may be preventable. (Summary)

Population control in Barbados

Since May 1955 an effort has been made in Barbados to control population growth by setting up family planning clinics. New registrations and attendances have increased steadily each year reaching a total of 2,055 new registrations and 5,574 attendances for the year April 1961 to March 1962. An attempt was made to evaluate the effect of this programme on birth rate (AU)

Carcinoma of the uterine cervix: some epidemiological data from a hospital in Jamaica

Epidemiological data collected at the University College Hospital of the West Indies have been examined in an attempt to determine the cause of cervical cancer. The risk of contracting the disease has been demonstrated to be high over a much wider range of ages than in a British population. Some deductions from the observed data lead to the conclusion that the predisposing factor is probably related to childbearing but not necessarily to the first pregnancy (Summary)

Caesarean section for eclampsia

The literature concerning Caesarean section for eclampsia has been reviewed. A small series of cases treated single-handed by an experienced practitioner in an isolated country hospital has been reviewed. The results recorded are encouraging. Some conclusions are drawn, leading to a suggestion that the method be given a further trial. (AU)