Opioid prescribing among new users for non-cancer pain in the USA, Canada, UK, and Taiwan: A population-based cohort study.

BACKGROUND: The opioid epidemic in North America has been driven by an increase in the use and potency of prescription opioids, with ensuing excessive opioid-related deaths. Internationally, there are lower rates of opioid-related mortality, possibly because of differences in prescribing and health system policies. Our aim was to compare opioid prescribing rates in patients without cancer, across 5 centers in 4 countries. In addition, we evaluated differences in the type, strength, and starting dose of medication and whether these characteristics changed over time. METHODS AND FINDINGS: We conducted a retrospective multicenter cohort study of adults who are new users of opioids without prior cancer. Electronic health records and administrative health records from Boston (United States), Quebec and Alberta (Canada), United Kingdom, and Taiwan were used to identify patients between 2006 and 2015. Standard dosages in morphine milligram equivalents (MMEs) were calculated according to The Centers for Disease Control and Prevention. Age- and sex-standardized opioid prescribing rates were calculated for each jurisdiction. Of the 2,542,890 patients included, 44,690 were from Boston (US), 1,420,136 Alberta, 26,871 Quebec (Canada), 1,012,939 UK, and 38,254 Taiwan. The highest standardized opioid prescribing rates in 2014 were observed in Alberta at 66/1,000 persons compared to 52, 51, and 18/1,000 in the UK, US, and Quebec, respectively. The median MME/day (IQR) at initiation was highest in Boston at 38 (20 to 45); followed by Quebec, 27 (18 to 43); Alberta, 23 (9 to 38); UK, 12 (7 to 20); and Taiwan, 8 (4 to 11). Oxycodone was the first prescribed opioid in 65% of patients in the US cohort compared to 14% in Quebec, 4% in Alberta, 0.1% in the UK, and none in Taiwan. One of the limitations was that data were not available from all centers for the entirety of the 10-year period. CONCLUSIONS: In this study, we observed substantial differences in opioid prescribing practices for non-cancer pain between jurisdictions. The preference to start patients on higher MME/day and more potent opioids in North America may be a contributing cause to the opioid epidemic.

Informing Primary Care Changes in Alberta: Continuity and Potential Impacts on Acute Care.

Health systems across Canada are embarking on initiatives to enhance access to primary care services, with the intent of improving patient outcomes and mitigating escalating healthcare costs. However, it is important that such initiatives be carefully weighed with the evidence that the changes will indeed have the desired impact. In Alberta, part of the informative process involved an analysis to examine links between continuity with primary care and utilization of acute care services. The findings provide information regarding expectations for outcomes and potentially useful (and not so useful) measures for monitoring progress and performance.

Diet impacts mortality from cancer: results from the multiethnic cohort study.

PURPOSE: Cancer is the second leading cause of death in the United States and mortality varies by ethnicity. The objective of this study was to examine the association between cancer mortality and dietary intake among a large multiethnic population. METHODS: A prospective cohort design was used to examine cancer mortality among 146,389 participants. Multiethnic cohort study participants represent five ethnic groups: African American, Native Hawaiian, Japanese American, Latino, and Caucasian. Hazard ratios for cancer mortality by intake levels of five food groups and discretionary fat were calculated using Cox proportional hazards models stratified by sex and ethnicity. RESULTS: There were a total of 2,028 male and 1,464 female fatal cancer cases at the end of follow-up. Among Japanese American men only, there was a significant protective effect seen in those reporting a high grain intake (HR = 0.49, 95 % CI 0.35-0.69); there was no effect of grain consumption in any other ethnic-sex group. There was no evidence that ethnicity modified associations between fruit, vegetable, meat, dairy, or discretionary fat intake and cancer mortality among men. Associations between food group consumption and risk for cancer mortality among women were similar across ethnic groups. CONCLUSIONS: The considerable reduction in cancer risk associated with high grain consumption among a specific ethnic-sex group, Japanese American men, warrants further investigation. Additional research is needed to validate this observation and determine whether this was a chance finding, or possibly due to differential intake of specific grain subtypes, and/or related to a sex-specific cancer type.

Impact of diet on mortality from stroke: results from the U.S. multiethnic cohort study.

OBJECTIVES: Stroke is the fourth leading cause of death in the United States and stroke mortality rates vary by ethnicity. The purpose of this study was to examine the associations between food group consumption and risk of death from stroke among 5 ethnic groups in the United States. METHODS: The Multiethnic Cohort includes >215,000 participants, the majority of whom are African American, Native Hawaiian, Japanese American, Latino, and Caucasian men and women recruited by mail survey in Hawaii and Los Angeles in 1993-1996. Deaths from stroke were identified by linkage to the state death files and the U.S. National Death Index. Diet was assessed using a validated food frequency questionnaire. Associations were examined using multivariable Cox proportional hazards models, stratified by ethnicity and gender. RESULTS: A total of 860 deaths from stroke were identified among the cohort participants. Vegetable intake was associated with a significant reduction in risk for fatal stroke among African American women (relative risk [RR]=0.60; 95% CI: 0.36-0.99). Among Japanese American women only, high fruit intake was significantly associated with a risk reduction for stroke mortality (RR=0.43; 95% confidence interval [CI]: 0.22-0.85), whereas meat intake increased risk (RR=2.36; 95% CI: 1.31-4.26). Among men, a significant reduction in stroke mortality was observed among Native Hawaiians (RR=0.26; 95% CI: 0.07-0.95). After pooling the data for the ethnic groups, the findings support an elevated risk for high meat intake among women overall (RR=1.56; 95% CI: 1.12-2.16); no significant effects of dietary intake on risk for fatal stroke were observed among men. CONCLUSIONS: Although some variations were observed for the associations between diet and stroke mortality among ethnic groups, the findings suggest that these differences are not substantial and may be due to dietary intake of specific food subgroups. Additional investigations including dietary subgroups and nutrients sources are needed to clarify these findings.

Breaking the 80:20 rule in health research using large administrative data sets.

Objective: To explore the application of online analytic processing (OLAP) to improve the efficiency of analytics using large administrative health data sets. Methods: 18 years of administrative health data (1994/95 to 2012/13) were obtained from the Alberta Ministry of Health in Canada. The data sets included hospitalization, ambulatory care and practitioner claims data. Reference files were obtained that provided information including patient demographics, resident postal code, facility, and provider details. Population counts and projections for each year, sex, age were included for rate calculations. These sources were used to develop a data cube using OLAP tools. Results: Time required for analyses was reduced to 5% of that required when comparing run-time for simple queries that did not require linkage of data sets. The data cube negated the need for many intermediary steps for data extraction and analyses for research activities. Conventional methods required over 250 GB of server space for multiple analytic subsets, compared to only 10.3 GB for the data cube. Conclusions: Cross-training in information technology and health analytics is recommended to provide capacity to better leverage OLAP tools which are available with many common applications.

Factors associated with pharmacologic treatment of osteoporosis in an older home care population.

BACKGROUND: A number of studies have shown low rates of osteoporosis treatment. Few, if any, have assessed a comprehensive range of functional and clinical correlates of treatment coverage. Our objective was to examine which sociodemographic, clinical, and functional characteristics are associated with pharmacotherapy for osteoporosis among community-based seniors. METHODS: The study sample included 48,689 home care clients aged >/= 65 years in Ontario, Canada. Treatment coverage (calcium and vitamin D and/or anti-osteoporotic drugs) was assessed in two subgroups, clients with a diagnosis of osteoporosis (without fracture) and those with a prevalent fracture. Sociodemographic, health, and functional measures available from the Resident Assessment Instrument for Home Care (RAI-HC) were assessed as correlates of treatment in multivariable logistic regression analyses. RESULTS: Approximately 59% of clients with a diagnosis of osteoporosis were receiving pharmacotherapy, compared with 27% of those with a prevalent fracture. For both subgroups, treatment coverage was significantly lower among clients with at least three chronic conditions, health instability, fewer than nine medications, functional impairment, and depressive symptoms and among those clients who were widowed. Among clients with a diagnosis of osteoporosis, treatment was positively associated with cognitive impairment and negatively associated with confinement to a wheelchair or bed. Men with a prevalent fracture were significantly less likely to receive treatment, particularly in the absence of an osteoporosis diagnosis. CONCLUSIONS: Many older adults with presumed osteoporosis in our study were not receiving drug therapy for this condition. Indicators of clinical instability and functional decline appear to represent influential factors in treatment decisions. Despite a lower likelihood of treatment among men with a prevalent fracture, this sex difference in treatment largely disappeared in the presence of an osteoporosis diagnosis.

Medication nonadherence and subsequent risk of hospitalisation and mortality among older adults.

BACKGROUND: Despite a higher risk for medication nonadherence among older adults residing in the community, few prospective studies have investigated the health outcomes associated with nonadherence in this population or the possible variations in risk in urban versus rural residents. OBJECTIVES: The primary objective of this study was to examine, in a prospective manner, the risk for hospitalisation (including an emergency department visit) and/or mortality associated with medication nonadherence in older, at-risk adults residing in the community. A secondary objective was to examine differences in the prevalence, determinants and consequences of medication nonadherence between rural and urban home care clients. METHODS: Data were derived from a 1-year prospective study of home care clients aged > or =65 years (n = 319) randomly selected from urban and rural settings in southern Alberta, Canada. Trained nurses conducted in-home assessments including a comprehensive medication review, self-report measures of adherence and the Minimum Data Set for Home Care (MDS-HC) tool. Hospitalisation and mortality data during 12-month follow-up were obtained via linkages with regional administrative and vital statistics databases. RESULTS: Nonadherent clients showed an increased but nonsignificant risk for an adverse health outcome (hospitalisation, emergency department visit or death) during follow-up (hazard ratio [adjusted for relevant covariates] = 1.24, 95% CI 0.93, 1.65). Subgroup analyses suggested this risk may be higher for unintentional nonadherence (unadjusted hazard ratio = 1.55, 95% CI 0.97, 2.48). The prevalence of nonadherence was similar among rural (38.2%) and urban (38.9%) clients and was associated with the presence of vision problems, a history of smoking, depressive symptoms, a high drug regimen complexity score, residence in a private home (vs assisted-living setting) and absence of assistance with medication administration. In both settings, approximately 20% of clients received one or more inappropriate medications. CONCLUSIONS: Although not associated with rural/urban residence, medication nonadherence was common in our study population, particularly among those with depressive symptoms and complex medication regimens. The absence of a significant association between overall medication nonadherence and health outcomes may reflect study limitations and/or the need to differentiate among types of nonadherent behaviours.

Treatment of osteoporosis in an older home care population.

BACKGROUND: Previous research indicates that many patients with fractures indicative of underlying osteoporosis are not receiving appropriate diagnostic follow-up and therapy. We assessed osteoporosis treatment coverage in older home care clients with a diagnosis of osteoporosis and/or prevalent fracture. METHODS: Subjects included 330 home care clients, aged 65+, participating in a longitudinal study of medication adherence and health-related outcomes. Data on clients' demographic, health and functional status and service utilization patterns were collected using the Minimum Data Set for Home Care (MDS-HC). A medication review included prescribed and over-the-counter medications taken in the past 7 days. Criteria for indications for osteoporosis therapy included diagnosis of osteoporosis or a recent fracture. Coverage for treatment was examined for anti-osteoporotic therapies approved for use in 2000. RESULTS: Of the 330 home care clients, 78 (24%) had a diagnosis of osteoporosis (n = 47) and/or had sustained a recent fracture (n = 34). Drug data were available for 77/78 subjects. Among the subjects with osteoporosis or a recent fracture, 45.5% were receiving treatment for osteoporosis; 14% were receiving only calcium and vitamin D, and an additional 31% were receiving drug therapy (bisphosphonate or hormone replacement therapy). The remaining 54.5% of subjects were not receiving any approved osteoporosis therapy. CONCLUSIONS: The high prevalence of undertreatment among a population of older adults with relatively high access to health care services raises concern regarding the adequacy of diagnosis and treatment of osteoporosis in the community.

Measurement, correlates, and health outcomes of medication adherence among seniors.

OBJECTIVE: To provide a comprehensive review of the literature on the measurement, correlates, and health outcomes of medication adherence among community-dwelling older adults. DATA SOURCES: Searches of MEDLINE, PubMed, and International Pharmaceutical Abstracts databases for English-language literature (1966-December 2002) were conducted using one or more of the following terms: elderly, adherence/nonadherence, compliance/noncompliance, medication/drug, methodology/measurement, and hospitalization. STUDY SELECTION AND DATA EXTRACTION: From the above search, studies of medication adherence in community-dwelling seniors were selected for review along with relevant publications from the reference lists of articles identified in the initial database search. DATA SYNTHESIS: Although several methods are available for the assessment of adherence, accurate measurement continues to be difficult. The available evidence suggests that polypharmacy and poor patient-healthcare provider relationships (including the use of multiple providers) may be major determinants of nonadherence among older persons, with the impact of most sociodemographic factors being negligible. There is little consensus regarding other determinants of nonadherence. Relatively few high-quality investigations have examined the associations between nonadherence and subsequent health outcomes. Available data provide some support for increased health risks with nonadherence. However, interventions to improve adherence have seldom demonstrated positive effects on health outcomes. CONCLUSIONS: There are few empirical data to support a simple systematic descriptor of the nonadherent patient. The inconsistencies across studies may be attributable, in part, to the inherent difficulties involved in the measurement of a behavioral risk factor such as nonadherence. Future research in this area would be strengthened by incorporation of detailed assessments of patient-reported reasons for nonadherence, the appropriateness of drug regimens, and the effect of nonadherence on health outcomes.