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1.
J Am Heart Assoc ; 9(5): e014940, 2020 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-32079480

RESUMO

Background Noninvasive cardiac tests, including exercise treadmill tests (ETTs), are commonly utilized in the evaluation of patients in the emergency department with suspected acute coronary syndrome. However, there are ongoing debates on their clinical utility and cost-effectiveness. It is important to be able to use ETT results for research, but manual review is prohibitively time-consuming for large studies. We developed and validated an automated method to interpret ETT results from electronic health records. To demonstrate the algorithm's utility, we tested the associations between ETT results with 30-day patient outcomes in a large population. Methods and Results A retrospective analysis of adult emergency department encounters resulting in an ETT within 30 days was performed. A set of randomly selected reports were double-blind reviewed by 2 physicians to validate a natural language processing algorithm designed to categorize ETT results into normal, ischemic, nondiagnostic, and equivocal categories. Natural language processing then searched and categorized results of 5214 ETT reports. The natural language processing algorithm achieved 96.4% sensitivity and 94.8% specificity in identifying normal versus all other categories. The rates of 30-day death or acute myocardial infarction varied (P<0.001) by categories for normal (0.08%), ischemic (1.9%), nondiagnostic (0.77%), and equivocal (0.58%) groups achieving good discrimination (C-statistic, 0.81; 95% CI, 0.7-0.92). Conclusions Natural language processing is an accurate and efficient strategy to facilitate large-scale outcome studies of noninvasive cardiac tests. We found that most patients are at low risk and have normal ETT results, while those with abnormal, nondiagnostic, or equivocal results have slightly higher risks and warrant future investigation.

2.
Clin Genitourin Cancer ; 18(2): e91-e102, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31917174

RESUMO

BACKGROUND: Disparities in bladder cancer survival by race/ethnicity and gender are likely related to differences in diagnosis. We assessed disparities in stage at diagnosis and potential contributing factors within a large, integrated delivery system. PATIENTS AND METHODS: We conducted a retrospective cohort study of 7244 patients with bladder cancer age ≥ 21 years diagnosed from January 2001 to June 2015 within Kaiser Permanente Southern California. Bivariate analyses compared stage at diagnosis - as well as comorbidities, health plan membership length, and health care utilization prior to diagnosis - by race/ethnicity, gender, and age. Multivariable generalized linear mixed models with urologist as a random effect were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for diagnosis of muscle-invasive bladder cancer (MIBC) versus non-muscle-invasive bladder cancer. RESULTS: In multivariable analyses, stage at diagnosis varied significantly by race/ethnicity (P < .001). Non-Hispanic black patients had significantly higher odds of being diagnosed with MIBC than non-Hispanic white patients (OR, 1.33; 95% CI, 1.05-1.67), whereas Asian patients had significantly lower odds (OR, 0.67; 95% CI, 0.49-0.91). Women were significantly more likely to be diagnosed with MIBC than men (OR, 1.40; 95% CI, 1.22-1.61). Non-Hispanic black women had the highest proportion (39%) of MIBC diagnoses. Among Hispanic and Asian patients, a greater proportion of diagnoses occurred at younger ages. CONCLUSIONS: Health care coverage within an equal-access system did not eliminate disparities in stage at diagnosis by race/ethnicity or gender. Studies are needed to identify etiologic factors and aspects of care delivery (eg, patient-physician interactions) that may affect the diagnostic process to inform efforts to improve health equity.

3.
Urology ; 131: 93-103, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31129191

RESUMO

OBJECTIVES: To examine treatment variability, disparities, and quality among newly diagnosed nonmuscle invasive bladder cancer (NMIBC) patients, and to identify factors associated with treatment use in a large, diverse integrated delivery system. METHODS: Retrospective cohort study of 5386 NMIBC patients diagnosed between January 2001 and June 2015 within Kaiser Permanente Southern California. Electronic health data were used to identify treatment outcomes and patient, provider, and tumor characteristics. Outcomes were use of (1) postoperative intravesical chemotherapy, (2) induction Bacille Calmette-Guérin (BCG) immunotherapy, and (3) any intravesical therapy. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using generalized linear mixed models with a binary outcome and urologist as a random effect. RESULTS: From 2001 to 2015, 41% of newly diagnosed NMIBC patients were treated with intravesical therapy. Postoperative chemotherapy use increased significantly over this period (OR per-year = 1.16, 95% CI: 1.07-1.25). BCG use was strongly associated with tumor characteristics: patients with high-grade or carcinoma in situ tumors were more likely to receive BCG (OR = 10.10, 95% CI: 8.39-12.16). Few treatment differences were found by sex or race/ethnicity, but were observed by age. Wide treatment variability across urologists was observed, with some urologists never using intravesical therapy as part of initial treatment while others almost always used it. Differences across urologists accounted for more variability in postoperative chemotherapy (intraclass correlation coefficient = 0.52) than BCG immunotherapy (intraclass correlation coefficient = 0.11) use. CONCLUSION: Substantial variability in initial treatment of NMIBC was observed across urologists, accounting for tumor, patient, and provider characteristics. Results suggest a considerable opportunity for quality improvement programs to reduce unwanted treatment variability and improve care for patients.


Assuntos
Adjuvantes Imunológicos/administração & dosagem , Antineoplásicos/administração & dosagem , Vacina BCG/administração & dosagem , Qualidade da Assistência à Saúde , Neoplasias da Bexiga Urinária/tratamento farmacológico , Administração Intravesical , Idoso , Idoso de 80 Anos ou mais , California , Estudos de Coortes , Prestação Integrada de Cuidados de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Neoplasias da Bexiga Urinária/patologia
4.
Ann Emerg Med ; 74(2): 216-223, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30955986

RESUMO

STUDY OBJECTIVE: Professional guidelines recommend 72-hour cardiac stress testing after an emergency department (ED) evaluation for possible acute coronary syndrome. There are limited data on actual compliance rates and effect on patient outcomes. Our aim is to describe rates of completion of noninvasive cardiac stress testing and associated 30-day major adverse cardiac events. METHODS: We conducted a retrospective analysis of ED encounters from June 2015 to June 2017 across 13 community EDs within an integrated health system in Southern California. The study population included all adults with a chest pain diagnosis, troponin value, and discharge with an order for an outpatient cardiac stress test. The primary outcome was the proportion of patients who completed an outpatient stress test within the recommended 3 days, 4 to 30 days, or not at all. Secondary analysis described the 30-day incidence of major adverse cardiac events. RESULTS: During the study period, 24,459 patients presented with a chest pain evaluation requiring troponin analysis and stress test ordering from the ED. Of these, we studied the 7,988 patients who were discharged home to complete diagnostic testing, having been deemed appropriate by the treating clinicians for an outpatient stress test. The stress test completion rate was 31.3% within 3 days and 58.7% between 4 and 30 days, and 10.0% of patients did not complete the ordered test. The 30-day rates of major adverse cardiac events were low (death 0.0%, acute myocardial infarction 0.7%, and revascularization 0.3%). Rapid receipt of stress testing was not associated with improved 30-day major adverse cardiac events (odds ratio 0.92; 95% confidence interval 0.55 to 1.54). CONCLUSION: Less than one third of patients completed outpatient stress testing within the guideline-recommended 3 days after initial evaluation. More important, the low adverse event rates suggest that selective outpatient stress testing is safe. In this cohort of patients selected for outpatient cardiac stress testing in a well-integrated health system, there does not appear to be any associated benefit of stress testing within 3 days, nor within 30 days, compared with those who never received testing at all. The lack of benefit of obtaining timely testing, in combination with low rates of objective adverse events, may warrant reassessment of the current guidelines.

5.
Rheumatol Int ; 39(3): 541-549, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30656412

RESUMO

The study objective was to estimate secular trends in the overall incidence rate (IR) and prevalence rate (PR) of rheumatoid arthritis (RA); and subgroup-specific IR and PR by race, ethnicity, and sex in a multi-ethnic population of a large integrated health care delivery system. An ecological study was conducted within the adult population of Kaiser Permanente Southern California health plan. From January 1995 up to and including December 2014, annual IR and PR were calculated separately by race, ethnicity, sex and pooled overall. Depending on the stationarity of each ecological series, annual percentage change in IR and PR was evaluated using auto-regressive integrated moving average models. Average overall IR was 53 [95% confidence interval (CI) 46, 61] per 100,000 person-years. The overall as well as subgroup-specific annual IR of RA were unchanged from 1995 to 2014. In 1995, the overall PR of RA was 59 (44, 74) per 100,000 person-years which increased by 14% (7%, 21%) annually thereafter. The increase in PR in Caucasians was lower as compared to African American, Asian and other race (13% vs 15%, 15%, and 18%, respectively). Compared to non-Hispanic ethnicity, the increase in PR among Hispanic was higher (17% vs 14%). Over the past 2 decades, while the incidence of RA was unchanged, the prevalence had increased significantly overall as well as within every subgroup of race, ethnicity, and sex.


Assuntos
Artrite Reumatoide/epidemiologia , Adulto , Afro-Americanos , Artrite Reumatoide/etnologia , Americanos Asiáticos , Prestação Integrada de Cuidados de Saúde , Grupo com Ancestrais do Continente Europeu , Feminino , Hispano-Americanos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência
6.
Perm J ; 22: 17-132, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30028673

RESUMO

CONTEXT: Many patients with ductal carcinoma in situ (DCIS) receive treatment that is too extensive. OBJECTIVE: To take a holistic approach in comparing the effectiveness in cancer prevention between mastectomy and breast-conserving surgery (BCS) for patients with DCIS. DESIGN: Female Kaiser Permanente Southern California members who underwent surgery for treatment of single primary DCIS from 2004 to 2014 were identified by the Kaiser Permanente Southern California cancer registry and HealthConnect database. METHOD: Two-stage residual inclusion with the surgeon's preference of surgical procedure type as the instrumental variable was used to examine the effect of surgical choice on DCIS recurrence, breast cancer progression, and other cancer progression. Traditional Cox proportional hazards models were used for comparison. RESULTS: Of qualified subjects, 72.2% underwent BCS and 27.8% underwent mastectomy. Patients were likelier to receive BCS if their surgeon preferred to perform BCS in the past 5 years (odds ratio = 1.02, 95% confidence interval = 1.02-1.03). Although traditional Cox proportional hazards models suggested an association between BCS and higher risk of DCIS recurrence, no significant effect was observed when we adjusted for endogeneity. Neither model showed significant differences between mastectomy and BCS in progression of any cancer. CONCLUSION: No significant benefit was observed with a more aggressive surgical procedure in preventing DCIS recurrence or cancer progression in a diverse population. Many patients with DCIS could benefit from BCS with preservation of their body image. Breast conservation followed-up with cancer surveillance is a rational approach to ensure affordable, effective care for patients with DCIS.


Assuntos
Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Pesquisa Comparativa da Efetividade , Feminino , Humanos , Mastectomia , Mastectomia Segmentar , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Resultado do Tratamento
7.
J Allergy Clin Immunol Pract ; 6(3): 944-954.e5, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29153881

RESUMO

BACKGROUND: Eosinophilic airway inflammation characterizes a chronic obstructive pulmonary disease (COPD) phenotype that requires more study. OBJECTIVE: To investigate the relationship of blood eosinophil count to exacerbations in COPD. METHODS: Using administrative pharmacy and health care utilization data from 2009 to 2012, we retrospectively identified patients 40 years or older with a COPD diagnosis, postbronchodilator FEV1/forced vital capacity ratio of less than 0.7, and a blood eosinophil count (N = 7,245). COPD exacerbations were defined as hospitalizations or emergency department visits with a primary diagnosis of COPD, or outpatient visits with systemic corticosteroid dispensing within ±14 days associated with an encounter code consistent with a COPD exacerbation. The relationship between the index blood eosinophil count and the rate of COPD exacerbations in the follow-up year was determined by multivariable analyses. RESULTS: Patients with COPD were predominantly male (57.1%), white (71.8%), often current or past smokers (75.4%), and had frequent comorbidities; 19.0% had eosinophil counts of greater than or equal to 300 cells/mm3, 76.1% were classified as moderate to very severe by lung function, and the COPD exacerbation rate was 0.38 per year (95% CI, 0.37-0.40). After adjustment for potential confounders, COPD exacerbations during 1-year follow-up were significantly greater for patients with blood eosinophil counts of greater than or equal to 300 cells/mm3 (rate ratio [RR], 1.25; 95% CI, 1.10-1.43), greater than or equal to 400 cells/mm3 (RR, 1.48; 95% CI, 1.26-1.75), and greater than or equal to 500 cells/mm3 (RR, 1.76; 95% CI, 1.45-2.14), respectively, compared with patients with eosinophils lower than the cutoffs. CONCLUSIONS: In this study, high blood eosinophil counts were an independent risk factor for future exacerbations in patients with COPD, a phenotype that might benefit from therapy directed at eosinophilic-driven disease and inflammation.


Assuntos
Eosinofilia/diagnóstico , Eosinófilos/imunologia , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Progressão da Doença , Serviço Hospitalar de Emergência , Feminino , Hospitalização , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
9.
Support Care Cancer ; 25(9): 2787-2795, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28397022

RESUMO

PURPOSE: The study objective was to evaluate chemotherapy treatment patterns and incidence, cost, and resource utilization of febrile neutropenia-related hospitalization (FNH) in patients with breast cancer, lung cancer, and non-Hodgkin's lymphoma (NHL) from Kaiser Permanente Southern California (KPSC), a large integrated delivery system. METHODS: Adults ≥18 years with any stage breast cancer, lung cancer, or NHL who initiated myelosuppressive chemotherapy from 01/01/2006 to 12/31/2009 were included. Chemotherapy dose delays ≥7 days, relative dose intensity (RDI), regimen switching, FNH and all-cause mortality, granulocyte colony-stimulating factor (G-CSF) and antibiotic use, and healthcare utilization/cost were evaluated by cancer type, regimen, and/or cycle. RESULTS: Among 3314 breast cancer patients, 25.3% received an RDI ≤85%, 13.9% experienced FNH with an all-cause mortality rate of 2.0%, and 20.2% received primary prophylaxis with G-CSF. Among those with FNH, mean hospital length of stay (LOS) was 4.1 days, and mean total costs were $20,462. Among 1443 lung cancer patients, 17.9% had an RDI ≤85%, 8.0% experienced FNH with an all-cause mortality rate of 25.2%, and 4.5% received primary prophylaxis with G-CSF. Among those with FNH, mean LOS was 6.8 days, and mean total costs were $32,964. Among 581 NHL patients, 27.9% had an RDI ≤85% and 22.4% experienced FNH with an all-cause mortality rate of 13%. Among those with FNH, mean LOS was 7.9 days, and mean total costs were $37,555. CONCLUSIONS: Marked variability was observed among different cancer types and chemotherapy regimens. Given the variability, detailed insight into incidence, management, and burden of FN can help inform clinical decision making.


Assuntos
Neutropenia Febril/economia , Programas de Assistência Gerenciada/normas , Neutropenia Febril/prevenção & controle , Neutropenia Febril/terapia , Feminino , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
10.
J Allergy Clin Immunol Pract ; 5(1): 144-153.e8, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27665383

RESUMO

BACKGROUND: Severe uncontrolled asthma (SUA) is associated with increased asthma exacerbations. Whether high blood eosinophil counts are related to this burden is uncertain. OBJECTIVES: To determine the relationship of blood eosinophil counts to asthma exacerbations, utilization, and cost in patients with SUA. METHODS: Patients with persistent asthma (age ≥ 12 years) were identified administratively with SUA in phase I by evidencing (1) 2 or more asthma exacerbations; (2) 6 or more medium- or high-dose dispensed canisters of inhaled corticosteroid (ICS) as monotherapy or with long-acting ß2-agonist; and (3) 3 or more dispensed non-ICS controllers. Of the 541 patients with SUA invited to participate in the prospective phase II follow-up study, 261 (48.2%) had blood tests (index date) to determine eosinophil count and other atopic biomarkers. The relationship of blood eosinophil cutoff points to asthma exacerbations and direct costs 1 year after the index date were determined by multivariable regression. RESULTS: A blood eosinophil cutoff point of greater than or equal to 400 cells/mm3 compared with less than 400 cells/mm3, but not 150 cells/mm3 or 300 cells/mm3, was a risk factor in the outcome year in adjusted analyses for 2 or more asthma exacerbations (risk ratio, 1.55; 95% CI, 1.02-2.35; P =.04) and any asthma emergency department visit or hospitalization (risk ratio, 2.29; 95% CI, 1.16-4.55; P =.02), but not for rate of asthma exacerbations or incremental total direct asthma costs per patient ($202; 95% CI, -286 to 691). CONCLUSIONS: A high blood eosinophil count was an independent risk factor for 2 or more asthma exacerbations or any asthma emergency department visit or hospitalization, but not direct costs in patients with SUA, possibly constrained by limited power.


Assuntos
Asma/diagnóstico , Células Sanguíneas/patologia , Eosinófilos/patologia , Adulto , Idoso , Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Biomarcadores , Contagem de Células , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Resultado do Tratamento
11.
J Allergy Clin Immunol Pract ; 4(1): 120-9.e3, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26439182

RESUMO

BACKGROUND: Clinical and economic burden of patients with severe uncontrolled asthma (SUA) in a real-world managed-care setting required further documentation. OBJECTIVE: The objective of this study was to determine the characteristics, clinical, and economic burden of SUA in a managed-care setting. METHODS: This observational study identified patients with persistent asthma aged 12 years or more (N = 25,935) using the International Classification of Diseases, 9th Revision asthma codes and Healthcare Effectiveness Data and Information Set administrative criteria. An SUA subgroup was identified when all of the following 3 criteria were met in 2012: (1) 2 or more asthma exacerbations; (2) 6 or more medium- or high-dose dispensed canisters of inhaled corticosteroid (ICS) as monotherapy or with long-acting ß2-agonist; and (3) 3 or more dispensed non-ICS controllers. Health care utilization and direct costs (all-cause and asthma-related) in 2013 were compared between SUA and non-SUA subgroups using multivariable regression. RESULTS: Compared with the non-SUA subgroup (N = 25,350, 97.7%), the SUA subgroup (N = 585, 2.3%) at baseline was significantly older and had more comorbidities, asthma specialist care, controller medication dispensed, and asthma exacerbations. During follow-up, patients with SUA exhibited significantly more asthma exacerbations and short-acting ß2-agonist use, and higher all-cause and asthma-related costs than patients with non-SUA. The adjusted asthma-related average direct cost per patient at follow-up was significantly higher for SUA (mean ± SE) ($2325 ± $75) than non-SUA ($1261 ± $9) with an incremental cost of $1056 (95% CI, $907-$1205). Asthma drugs accounted for the major difference (incremental cost of $848/patient; 95% CI, $737-$959). CONCLUSION: Increases and disparities in health care utilization and direct cost by SUA status suggest that patients with SUA require more intensive therapy, greater attention to adherence and comorbidities, more specialist care, and, possibly, personalized treatment approaches including novel biologic treatments.


Assuntos
Agonistas de Receptores Adrenérgicos beta 2/economia , Asma/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Agonistas de Receptores Adrenérgicos beta 2/uso terapêutico , Adulto , Asma/diagnóstico , Asma/tratamento farmacológico , Progressão da Doença , Humanos , Classificação Internacional de Doenças , Programas de Assistência Gerenciada , Recidiva , Estados Unidos , Adulto Jovem
12.
Ann Epidemiol ; 25(11): 844-8, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26475981

RESUMO

PURPOSE: To estimate the association between hydroxymethylglutaryl-CoA inhibitor (statin) use and hip fracture. METHODS: We conducted a population-based case-control study. Cases were 6774 male enrollees in a large managed care organization, aged 45 or more years, with an incident hip fracture from 1997 to 2006. Controls without fracture (n = 6774) were matched to cases on age, race, and medical center. Electronic information on pharmaceutical use was used to identify the dispensing of statins from 1991 forward. RESULTS: Overall, 1884 (27.8%) cases and 2150 controls (31.7%) used a statin before index date (matched odds ratio [mOR] = 0.81, 95% confidence interval [CI] = 0.74-0.87). Adjustment for comorbidity burden strengthened the magnitude of the overall association (mOR = 0.68, CI = 0.62-0.74). The adjusted association was similar across age groups but was strongest among men aged 80 years or more (mOR = 0.62, CI = 0.54-0.71) and was most pronounced in African Americans (mOR = 0.43, CI = 0.28-0.64). Greater duration of statin use did not alter the odds ratios. CONCLUSIONS: These data add to the growing evidence of a potential protective effect of statin use on bone health. However, these results need to be replicated in a prospective study that can account for confounding by indication which may explain these findings.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Grupos Étnicos/estatística & dados numéricos , Fraturas do Quadril/epidemiologia , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , California/epidemiologia , Estudos de Casos e Controles , Comorbidade , Relação Dose-Resposta a Droga , Comportamentos Relacionados com a Saúde , Fraturas do Quadril/prevenção & controle , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Incidência , Masculino , Adesão à Medicação/etnologia , Pessoa de Meia-Idade , Razão de Chances , Vigilância da População , Risco
13.
Clin Ther ; 37(3): 660-666.e8, 2015 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-25618317

RESUMO

PURPOSE: The objectives of this study were to assess medication adherence rate and attrition rate in first-time adalimumab (ADA) or etanercept (ETA) users in rheumatoid arthritis (RA) patients. This study also identified the risk factors associated with nonadherence and treatment abandonment. METHODS: This was a retrospective study with a 2-year follow-up. A total 2151 adult RA patients (18 years of age and older) who initiated ADA or ETA treatment in the Kaiser Permanente Southern California health plan between 2002 and 2009 were identified. Among those on treatment in the first year, continuous treatment receipt was determined by having at least 1 medication refill in the second year; otherwise treatment was considered as abandoned. Medication adherence was measured through proportion of days covered (PDC) and compared between patients continuously on treatment and those abandoning treatment. Risk factors of nonadherence (PDC <80%) and treatment abandonment were estimated by a multinomial logistic regression model. FINDINGS: Patients who abandoned treatment had significantly lower PDC (37.3%) and lower average number of refills (5.1) than adherers (PDC = 88.8%; average number of refills = 12.4) and nonadherers (PDC = 53.3%; average refills = 8.2). Age, African Americans (odds ratio [OR], 1.49; 95% CI, 1.03-2.17), corticosteroids use (OR, 0.80; 95% CI, 0.63-0.98), and history of physical/occupational therapy (OR = 0.66; 95% CI, 0.46-0.93) were associated with nonadherence, whereas having a comorbidity (OR, 1.24; 95% CI, 1.01-1.57) was associated with treatment abandonment. The difference in PDC between ADA and ETA was no longer statistically significant after excluding the treatment abandonment group. A higher proportion of ADA users abandoned treatment than ETA users (42.9% vs 32.2%). IMPLICATIONS: Taking into account treatment abandonment when measuring medication adherence in ADA and ETA use in RA patients can provide a fair and clinically meaningful view of patients' medication-taking behavior.


Assuntos
Adalimumab/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Etanercepte/uso terapêutico , Adesão à Medicação , Adolescente , Adulto , Idoso , Antirreumáticos/uso terapêutico , California , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Adulto Jovem
14.
J Gastrointestin Liver Dis ; 23(4): 379-86, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25531995

RESUMO

BACKGROUND AND AIMS: Diverticulitis is often diagnosed in outpatients, yet little evidence exists on diagnostic evidence and demographic/clinical features in various practice settings. We assessed variation in clinical characteristics and diagnostic evidence in inpatients, outpatients, and emergency department cases and effects of demographic and clinical variables on presentation features. METHODS: In a retrospective cohort study of 1749 patients in an integrated health care system, we compared presenting features and computed tomography findings by practice setting and assessed independent effects of demographic and clinical factors on presenting features. RESULTS: Inpatients were older and more often underweight/normal weight and lacked a diverticulitis past history and had more comorbidities than other patients. Outpatients were most often Hispanic/Latino. The classical triad (abdominal pain, fever, leukocytosis) occurred in 78 (38.6%) inpatients, 29 (5.2%) outpatients and 34 (10.7%) emergency department cases. Computed tomography was performed on 196 (94.4%) inpatients, 110 (9.2%) outpatients and 296 (87.6%) emergency department cases and was diagnostic in 153 (78.6%) inpatients, 62 (56.4%) outpatients and 243 (82.1%) emergency department cases. Multiple variables affected presenting features. Notably, female sex had lower odds for the presence of the triad features (odds ratio [95% CI], 0.65 [0.45-0.94], P<0.05) and increased odds of vomiting (1.78 [1.26-2.53], P<0.01). Patients in age group 56 to 65 and 66 or older had decreased odds of fever (0.67 [0.46-0.98], P<0.05) and 0.46 [0.26-0.81], P<0.01), respectively, while > / =1 co-morbidity increased the odds of observing the triad (1.88 [1.26-2.81], P<0.01). CONCLUSION: There was little objective evidence for physician-diagnosed diverticulitis in most outpatients. Demographic and clinical characteristics vary among settings and independently affect presenting features.


Assuntos
Assistência Ambulatorial , Doença Diverticular do Colo/diagnóstico , Doença Diverticular do Colo/epidemiologia , Serviço Hospitalar de Emergência , Pacientes Internados , Pacientes Ambulatoriais , Dor Abdominal/diagnóstico , Dor Abdominal/epidemiologia , Doença Aguda , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , California/epidemiologia , Comorbidade , Grupos de Populações Continentais , Prestação Integrada de Cuidados de Saúde , Feminino , Febre/diagnóstico , Febre/epidemiologia , Humanos , Leucocitose/diagnóstico , Leucocitose/epidemiologia , Modelos Logísticos , Masculino , Programas de Assistência Gerenciada , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Tomografia Computadorizada por Raios X , Adulto Jovem
15.
Value Health ; 17(6): 661-8, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25236989

RESUMO

OBJECTIVE: To estimate the health resource use (HRU) and expenditure of adult patients with attention deficit/hyperactivity disorder (ADHD) subsequently diagnosed with one or more mental health (MH) comorbidities. METHODS: Using Kaiser Permanente Southern California electronic medical records (January 1, 2006, to December 31, 2009), we identified adults with at least one ADHD diagnosis and at least two subsequent prescriptions fills for ADHD medication. The date of first MH comorbidity diagnosis after the index ADHD diagnosis was defined as the index transition date. Continuous eligibility 12 months before and after the index transition date was required. For patients with multiple transitions (≥2), the post-transition period reflected the 12 months after the second transition. HRU for all-cause inpatient, outpatient, emergency department, behavioral therapy, overall prescription fill counts, and ADHD-specific prescription fill counts and mean patient expenditure (2010 US $) were estimated. Generalized estimating equations were used to evaluate differences in HRU and expenditure between the pre- and post-transition periods, respectively. RESULTS: Of the 3809 patients with ADHD identified, 989 (26%) had at least one transition (n = 357 single and n = 632 multiple). From the pre- to the post-transition period, for single transition cohort, all HRU increased significantly except for behavioral therapy. In the multiple transition cohort, all HRU increased significantly. Total expenditure increased by mean ± SE of $1822 ± $306 and $4432 ± $301 (both P < 0.0001) in the single and multiple transition cohorts, respectively. CONCLUSIONS: Twenty-six percent of patients with ADHD transitioned to MH comorbid diagnoses. Increased HRU and expenditure were associated with MH transitions. Identifying of patients with ADHD at risk for MH comorbidities may help to improve their outcomes.


Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/economia , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Gastos em Saúde , Programas de Assistência Gerenciada/economia , Saúde Mental/economia , Aceitação pelo Paciente de Cuidados de Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtorno do Deficit de Atenção com Hiperatividade/psicologia , California/epidemiologia , Estudos de Coortes , Comorbidade , Feminino , Gastos em Saúde/tendências , Humanos , Masculino , Programas de Assistência Gerenciada/tendências , Saúde Mental/tendências , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Vigilância da População/métodos , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
16.
Arthritis Care Res (Hoboken) ; 66(3): 364-70, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23982942

RESUMO

OBJECTIVE: To compare survey response rates and preferences for 3 modes of survey administration in rheumatoid arthritis (RA) patients. METHODS: Adult RA patients were identified from Kaiser Permanente Southern California's electronic medical records. One hundred patients each were randomly assigned to telephone, mail with followup letter, and mail with followup telephone call as modes of survey administration. Respondents completed a 7-page survey (in English or Spanish) that included the Health Assessment Questionnaire disability index and pain scale, EuroQol 5-dimensions, and generic questions on preferences and sociodemographics. Response rates were based on the number of completed surveys received from the total number of patients contacted (n = 295; 5 were ineligible). RESULTS: The mean ± SD age of the cohort was 61 ± 12.3 years, with the majority being women (141 [85%] of 166). Of the 3 modes of survey administration, telephone (63 [64%] of 99) had the highest response rate, followed by mail with followup telephone call (55 [56%] of 98) and mail with followup letter (48 [49%] of 98). When asked about preference over administration mode, 57% (95 of 166) preferred to complete the survey by mail, followed by telephone (27 [16%] of 166) and internet (17 [10%] of 166). CONCLUSION: When asked about their choice of survey administration mode for reporting their health status, the majority of RA patients in this study had a strong preference for a mail survey as compared to a telephone interview. However, the response rate in the telephone administration mode of survey was the highest between the 3 modes of administration that were compared. Future studies in RA can achieve better response using telephone over mail-in surveys.


Assuntos
Artrite Reumatoide/psicologia , Coleta de Dados/métodos , Autorrelato , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Preferência do Paciente/estatística & dados numéricos
17.
Arthritis Care Res (Hoboken) ; 65(2): 299-303, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22807272

RESUMO

OBJECTIVE: To assess racial/ethnic differences in the use of biologic disease-modifying antirheumatic drugs (DMARDs) among California Medicaid (Medi-Cal) rheumatoid arthritis (RA) patients. METHODS: Medi-Cal patient level data for 5,385 DMARD recipients between ages 18 and 100 years with at least 1 diagnosis of RA (International Classification of Disease, Ninth Revision, Clinical Modification code 714.xx) and the use of 1 DMARD between January 1, 1998 and December 31, 2005 were collected. The outcome of interest was the choice of either standard DMARDs (methotrexate, lefluonomide, hydroxychloroquine, and sulfasalazine) or biologic DMARDs (adalimumab, etanercept, anakinra, and infliximab). A univariate analysis and logistic regression model were applied to examine the association of the choice of DMARD among different racial/ethnic groups. RESULTS: In the univariate analysis, biologic DMARD use was significantly associated with race/ethnicity (P < 0.001). In the multivariate logistic regression model, after adjusting for age, sex, insurance coverage, 12 comorbid conditions, RA-related drug prescription, RA-related inpatient stay, and rehabilitation visits, African Americans had 53% lower odds of receiving biologic DMARDs as compared to whites, whereas Hispanics had 36% increased odds of receiving biologic DMARDs as compared to whites. CONCLUSION: In this Medi-Cal population, with its racial diversity and relatively homogenous socioeconomic status and health care benefits, racial/ethnic differences were found in RA patients receiving biologic DMARDs.


Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Artrite Reumatoide/etnologia , California/epidemiologia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
18.
Health Econ ; 22(7): 807-23, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22718267

RESUMO

In health care, decision makers are generally interested in simultaneous comparisons among multiple treatments or interventions available as treatment choices in real-world clinical setting. The lack of random assignment to treatment in real-world clinical settings leads to selection-bias issues when evaluating the marginal benefits of treatment. The application of instrumental variables (IV) estimation to mitigate selection bias has traditionally been limited to comparing only two treatments/interventions concurrently. Using the case of biologic treatment in rheumatoid arthritis, we describe a generalized method of moments (GMM)-based panel data IV (IV-GMM) framework, to simultaneously estimate multiple treatment effects in the presence of time-varying selection bias and time-invariant heterogeneity. To satisfy the order and rank conditions for identification with multiple endogeneity, we propose lagged values of each treatment as excluded instruments. We evaluate the validity of the IV estimation assumptions on instrument relevance and exogeneity. Results indicate that the IV-GMM model offers enhanced control over selection bias and heterogeneity, and more importantly the panel data framework can provide valid excluded instruments that satisfy the order and rank conditions for identification when dealing with multiple endogenous variables. The approach outlined in this article has broad application for comparative effectiveness and health technology assessment involving multiple treatments/interventions using real-world nonexperimental data.


Assuntos
Antirreumáticos/economia , Artrite Reumatoide/economia , Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Análise Custo-Benefício , Custos de Medicamentos/estatística & dados numéricos , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Fatores de Tempo , Resultado do Tratamento
19.
Arthritis Care Res (Hoboken) ; 64(11): 1649-56, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22674912

RESUMO

OBJECTIVE: To quantify the incremental direct medical expenditure associated with rheumatoid arthritis (RA) in the US population from a payer's perspective. METHODS: A probability-weighted sample of adult respondents from the Medical Expenditure Panel Survey (2008) was used to identify a cohort of patients with RA and compared to a control cohort without RA. Annual expenditure outcomes, including total expenditure and subgroups related to pharmacy, office-based visits, emergency department visits, hospital inpatient stays, and residual expenditures were estimated. Differences between the RA and control cohort were adjusted for sociodemographic factors, employment status, insurance coverage, health behavior, and health status using a generalized linear model with log link and gamma distribution. Statistical inferences on difference in expenditures between RA and non-RA controls were based on nonparametric cluster bootstrapping using percentiles. RESULTS: The adjusted average annual total expenditure of the RA cohort in 2008 US dollars (USD) was $13,012 (95% confidence interval [95% CI] $1,737-$47,081), while that of the control cohort was $4,950 (95% CI $567-$17,425). The incremental total expenditure of the RA patients as compared to non-RA controls was $2,085 (95% CI $250-$7,822). RA patients also had a significantly higher pharmacy expenditure of $5,825 (95% CI $446-$30,998) that was on average $1,380 (95% CI $94-$7,492) higher as compared to the controls. The summated total incremental expenditure of all RA patients in the US was $22.3 billion (2008 USD). CONCLUSION: RA exerts considerable incremental economic burden on US health care, which is primarily driven by the incremental pharmacy expenditure.


Assuntos
Artrite Reumatoide/economia , Artrite Reumatoide/epidemiologia , Gastos em Saúde/estatística & dados numéricos , Adolescente , Adulto , Idoso , Estudos de Coortes , Comorbidade , Coleta de Dados , Farmacoeconomia/estatística & dados numéricos , Serviço Hospitalar de Emergência/economia , Feminino , Agências de Assistência Domiciliar/economia , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Visita a Consultório Médico/economia , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Adulto Jovem
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