The metrics used to assess quality of care and pay for performance are increasingly important. Medicare established the Physician Quality Reporting System (PQRS) that allowed physicians to report performance measures for many conditions including osteoporosis and rheumatoid arthritis (RA). We described the frequency and nature of physician-reported reasons why recommended care for individual osteoporosis and RA patients was not provided.
Using national data on Medicare fee-for-service beneficiaries (2007-2009), we identified healthcare providers reporting on quality of care for any of 3 osteoporosis or 3 RA measures. PQRS reason codes allowed physicians to submit explanations why recommended care was not given.
In 2009, 1775 physicians reported on >= 1 osteoporosis PQRS measure, and 630 physicians reported on >= 1 RA measure. For patients for whom their physician reported via PQRS on lifetime DXA screening since age 60, 76% of older women had received such screening. Among patients with physician-diagnosed osteoporosis reported via PQRS, 82% received prescription osteoporosis medication in the preceding year. For RA medication use reported via PQRS, 89% of patients received a DMARD or a biologic. For the remaining 11-24% of osteoporosis and RA patients, their physicians reported medical, patient, system, or other reasons why care was considered but not provided.
A substantial fraction of Medicare enrollees who did not receive recommended osteoporosis or RA care had physician-documented reasons for why care was not provided. For Medicare and other health plans that implement penalties for apparent nonperformance (or delivery of suboptimal care), it will be important for allow physicians to provide reasons that care was considered medically inappropriate, refused, or otherwise not feasible.
osteoporosis; rheumatoid arthritis; quality; Medicare; DMARD
We compared the incidence of cancer following tumor necrosis factor alpha antagonists (TNF-I) therapy to that with commonly used alternative therapies across multiple immune mediated diseases.
The Safety Assessment of Biologic thERapy (SABER) study used data from national Medicaid & Medicare, Kaiser Permanente Northern California, TennCare, and pharmacy benefits plans for Medicare beneficiaries in New Jersey and Pennsylvania. Propensity score adjusted hazard ratios (HR) and 95% confidence intervals (CI) were computed to estimate the relative rates of cancer, comparing TNF-I users to alternative disease modifying therapies. The cancer finding algorithm had a positive predictive value ranging from 31% for any leukemia to 89% for female breast cancer.
We included 29,555 patients with rheumatoid arthritis (13,102 person-years), 6,357 patients with inflammatory bowel disease (1,508 person-years), 1,298 patients with psoriasis (371 person-years), and 2,498 patients with psoriatic arthritis (618 person-years). The incidence of any solid cancer was not elevated in rheumatoid arthritis (HR 0.80, CI 0.59-1.08), inflammatory bowel disease (HR 1.42, CI 0.47-4.26), psoriasis (HR 0.58, CI 0.10-3.31) or psoriatic arthritis (HR 0.74, CI 0.20-2.76) during TNF-I therapy compared to disease specific alternative therapy. Among patients with rheumatoid arthritis, the incidence of any of the ten most common cancers in the United States and nonmelanoma skin cancer was not increased with TNF-I therapy compared to methotrexate failure.
Short-term cancer risk was not elevated among patients treated with TNF-I therapy relative to commonly used therapies for immune mediated chronic inflammatory diseases in this study.
rheumatoid arthritis; inflammatory bowel disease; psoriasis; psoriatic arthritis; ankylosing spondylitis; tumor necrosis factor alpha
Herpes zoster (HZ) reactivation disproportionately affects patients
with rheumatoid arthritis (RA). It is unclear whether anti-tumor necrosis
factor (anti-TNF) therapy elevates HZ risk, and whether monoclonal
antibodies carry greater risk than etanercept.
To ascertain whether initiation of anti-TNF therapy compared with
non-biologic comparators is associated with increased HZ risk
Design, Setting, and Patients
We identified new users of anti-TNF therapy among cohorts of
rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and
psoriasis-psoriatic arthritis-ankylosing spondylitis (PsO-PsA-AS) patients
during 1998–2007 within a large US multi-institutional collaboration
combining data from Kaiser Permanente Northern California, Pharmaceutical
Assistance Contract for the Elderly, Tennessee Medicaid, and national
Medicaid/Medicare programs. We compared HZ incidence between new anti-TNF
users and patients initiating non-biologic disease modifying drugs (DMARDs)
within each inflammatory disease cohort (last participant follow-up Dec 31,
2007). Within these cohorts, we used Cox regression models to compare
propensity-score adjusted HZ incidence between new anti-TNF and non-biologic
DMARD users while controlling for baseline corticosteroid use.
Main Outcome Measure
Incidence of herpes zoster cases occurring after initiation of new
anti- TNF or non-biologic DMARD therapy
Among 32,208 new users of anti-TNF therapy, we identified 310 HZ
cases. Crude incidence rates among anti-TNF users for RA, IBD, and
PsO-PsA-AS were 12.1/1000 pt-yrs, (95% CI 10.7–13.6),
11.3/1000 (95% CI 7.7–16.7), and 4.4/1000 (95% CI
2.8–7.0) respectively. Baseline use of corticosteroids of >
10mg/day was associated with elevated risk [adjusted HR 2.13 (1.64,
2.75) compared with no baseline use. For RA patients, adjusted incidence
rates were similar between anti-TNF and nonbiologic DMARD initiators
[adjusted HR 1.00 (95% CI 0.77–1.29) and comparable
between all three anti-TNF therapies studied.
Conclusions and Relevance
Among patients with RA and other select inflammatory diseases, those
who initiated anti-TNF therapies were not at higher risk for HZ compared to
patients who initiated non-biologic treatment regimens.
shingles; zoster; herpes; biologic therapy; tumor necrosis factor-alpha; rheumatoid arthritis; adverse events; psoriasis
This study investigates the associations of a history of fracture, comorbid chronic conditions, and demographic characteristics with incident fractures among Medicare beneficiaries. The majority of fracture incidence studies have focused on the hip and on white females. This study examines a greater variety of fracture sites and more population subgroups than prior studies.
We used Medicare claims data to examine the incidence of fracture at six anatomic sites in a random 5% sample of Medicare beneficiaries during the time period 2000 through 2005.
For each type of incident fracture, women had a higher rate than men, and there was a positive association with age and an inverse association with income. Whites had a higher rate than nonwhites. Rates were lowest among African Americans for all sites except ankle and tibia/fibula, which were lowest among Asian Americans. Rates of hip and spine fracture were highest in the South, and fractures of other sites were highest in the Northeast. Fall-related conditions and depressive illnesses were associated with each type of incident fracture, conditions treated with glucocorticoids with hip and spine fractures and diabetes with ankle and humerus fractures. Histories of hip and spine fractures were associated positively with each site of incident fracture except ankle; histories of nonhip, nonspine fractures were associated with most types of incident fracture.
This study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.
epidemiology; fractures; osteoporosis; incidence; Medicare
Our objective was to evaluate adherence among new users of zoledronate and IV ibandronate among U.S. Medicare enrollees.
We used data from the Medicare 5% random sample to evaluate new users of IV zoledronate and IV ibandronate with continuous Part A+B fee-for-service coverage. The outcome was adherence as quantified by the proportion of days covered (PDC), measured continuously and dichotomously (>= 80%). Follow-up time extended from 18–27 months for all individuals. Factors associated with low adherence with zoledronate were evaluated with logistic regression.
We identified 775 new users of zoledronate and 846 new users of IV ibandronate. For both drugs, 30–48% of first infusions were given in an outpatient infusion center, not in a physician office. The mean PDC for zoledronate users was 82%, which was greater than the mean PDC for the IV Ibandronate users (58–62%, depending on time period, p < 0.0001). Approximately 30% of zoledronate users did not receive a second infusion. Factors associated with low adherence to zolendronate included older age and receipt of the first infusion in an outpatient infusion center rather than a physician’s office.
Less frequently dosed IV bisphosphonates have not resolved the problem of suboptimal adherence with prescription osteoporosis medications. Interventions continue to be warranted to improve long term adherence with osteoporosis treatments.
osteoporosis; adherence; persistence; zoledronate; ibandronate; bisphosphonates
Pragmatic clinical trials (PCTs) seek to improve the generalizability and increase the statistical power of traditional explanatory trials. They are a major tenet of comparative effectiveness research. While a powerful study design, PCTs have been limited by high cost, modest efficiency, and limited ability to fill relevant evidence gaps. Based on an American Reinvestment and Recovery Act (ARRA) supported meeting of national stakeholders, we propose several innovations and future research that could improve the efficiency and effectiveness of such studies focused in the U.S. Innovations discussed include optimizing the use of community based practices through partnership with Practice Based Research Networks (PBRNs), using information technology to simplify PCT subject recruitment, consent and randomization processes, and utilizing linkages to large administrative databases, such as Medicare, as a mechanism to capture outcomes and other important PCT variables with lower subject and research team burden. Testing and adaptation of such innovations to PCT are anticipated to improve the public health value of these increasingly important studies.
Pragmatic clinical trials; Large simple trials; Comparative effectiveness research; Practice Based Research Network
To determine relative rates of incident malignancy among children with juvenile idiopathic arthritis (JIA) with respect to treatment compared to children without JIA
Using national U.S. Medicaid data from 2000 through 2005, we identified cohorts of children with JIA and without JIA using physician diagnosis codes and dispensed medication prescriptions. Study follow-up began after a 6 month lag period to exclude prevalent and misdiagnosed malignancies. Treatment with methotrexate and TNF inhibitors was categorized as ever or never exposed. Malignancy outcomes were identified using an adapted version of a previously validated algorithm. Incident malignancies were categorized as possible, probable, or highly probable based on a comprehensive review of all claims. Malignancy rates were standardized to the age, sex, and race distribution of the overall JIA cohort. Standardized incidence ratios (SIR) were calculated using children without JIA (N=321,821) as the referent group.
The JIA cohort included 7,812 children with a total follow-up time of 12,614 person-years, of whom 1,484 children contributed 2,922 person-years of TNF inhibitor exposure. For all children with JIA versus children without JIA, the SIR was 4.4 (1.8–9.0) for probable and highly probable malignancies. For methotrexate users without TNF inhibitor use, the SIR was 3.9 (0.4–14). Following any use of TNF inhibitors, no probable or highly probable malignancies were identified (SIR 0 (0–9.7)).
Children with JIA appeared to have an increased rate of incident malignancy compared to children without JIA. JIA treatment, including TNF inhibitors, did not appear significantly associated with the development of malignancy.
Gout is a common and disabling cause of arthritis in middle-aged and elderly populations, with its main predisposing factor being hyperuricemia (serum urate > 6.8 mg/dL). Options for treatment of chronic gout until 2008 were allopurinol, a xanthine oxidase inhibitor, and the group of drugs known as uricosurics that stimulate the renal excretion of uric acid. A proportion of patients, including some with chronic kidney disease and solid organ transplantations, could not be treated with the those therapies because of intolerance, drug interactions, or adverse events. Febuxostat is a nonpurine xanthine oxidase inhibitor, recently approved in Europe and the United States for the treatment of chronic gout.
To review the clinical evidence (phase II and III studies) of the effectiveness and safety of febuxostat for treatment of hyperuricemia and gout.
Febuxostat, at doses ranging from 40 to 240 mg/day, is efficacious in reducing serum urate in patients with hyperuricemia and gout, comparing favorably with fixed doses of allopurinol in that respect. Early safety signals with respect to liver test abnormalities and cardiovascular outcomes have not been confirmed in recent large prospective trials but need to be further monitored.
Given its low cost and extensive clinical experience, allopurinol will likely remain the first-line drug for management of hyperuricemia and gout. Febuxostat may provide an important option in patients unable to use allopurinol, those with very high serum urate levels, or in the presence of refractory tophi.
febuxostat; gout; hyperuricemia; evidence
Although the Bone Mass Measurement Act outlines the indications for central dual energy x-ray absorptiometry (DXA) testing for U.S. Medicare beneficiaries, the specifics regarding the appropriate ICD-9 codes to use for covered indications have not been specified by Medicare and are sometimes ambiguous. We describe the extent to which DXA reimbursement was denied by gender and age of beneficiary, ICD-9 code submitted, time since previous DXA, whether the scan was performed in the physician’s office and local Medicare carrier.
Using Medicare administrative claims data from 1999–2005, we studied a 5% national sample of beneficiaries age ≥ 65 with part A+B coverage who were not HMO enrollees. We identified central DXA claims and evaluated the relationship between the factors listed above and reimbursement for central DXA (CPT code 76075). Multivariable logistic regression was used to evaluate the independent relationship between DXA reimbursement, ICD-9 diagnosis code and Medicare carrier.
For persons that had no DXA in 1999 or 2000 and who had one in 2001 or 2002, the proportion of DXA claims denied was 5.3% for women and 9.1% for men. For repeat DXAs performed within 23 months, the proportion denied was approximately 19% and did not differ by sex. Reimbursement varied by more than 6-fold according to the ICD-9 diagnosis code submitted. For repeat DXAs performed at < 23 months, the proportion of claims denied ranged from 2% to 43%, depending on Medicare carrier.
Denial of Medicare reimbursement for DXA varies significantly by sex, time since previous DXA, ICD-9 diagnosis code submitted, place of service (office versus facility) and local Medicare carrier. Greater guidance and transparency in coding policies are needed to ensure that DXA as a covered service is reimbursed for Medicare beneficiaries with the appropriate indications.
osteoporosis; bone mineral density; epidemiology; dual energy xray absorptiometry; reimbursement
Although tumor necrosis factor alpha (TNF-α) antagonists are increasingly used in place of non-biologic comparator medications, their safety profile remains incomplete.
To determine whether initiation of TNF-α antagonists compared with non-biologic comparators is associated with an increased risk of serious infections.
Design, setting and patients
Within a US multi-institutional collaboration, we assembled retrospective cohorts (1998–2007) of patients with rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and psoriasis, psoriatic arthritis or ankylosing spondylitis (PsO-PsA-AS) combining data from Kaiser Permanente Northern California, New Jersey and Pennsylvania Pharmaceutical Assistance programs, Tennessee Medicaid and National Medicaid/Medicare. TNF-α antagonists and non-biologic regimens were compared in disease specific-propensity score (PS) matched cohorts using Cox regression models with non-biologics as reference. Baseline glucocorticoid use was evaluated as a separate covariate.
Main outcome measure
Infections requiring hospitalization (serious infections) during the first 12 months after initiation of TNF-α antagonists or non-biologic regimens.
Study cohorts included 10484 RA, 2323 IBD and 3213 PsO-PsA-AS PS-matched pairs using TNF-α antagonists and comparator medications. Overall, we identified 1171 serious infections, most of which (53%) were pneumonia and skin and soft tissue infections. Among RA patients, serious infection hospitalization rates were 8.16 (TNF-α antagonists) and 7.78 (comparator regimens) per 100 person-years (adjusted hazard ratio [aHR]: 1.07 (95% CI: 0.93–1.23)). Among IBD patients, rates were 10.91 and 9.60 per 100 person-years (aHR: 1.13, (0.85–1.50)). Among PsO-PsA-AS patients, rates were 5.41 and 5.19 per 100 person-years (aHR: 1.10, (0.80–1.53)). Among RA patients, infliximab was associated with a significant increase in serious infections compared with etanercept and adalimumab (aHRs: 1.27 (1.08–1.49) and 1.23 (1.02–1.48)). Baseline glucocorticoid use was associated with a dose-dependent increase in infections.
Among patients with autoimmune diseases, compared to treatment with non-biologic regimens, initiation of TNF-α antagonists was not associated with an increased risk of hospitalizations for serious infections.
Rheumatoid arthritis; inflammatory bowel disease; psoriasis; psoriatic arthritis; ankylosing spondylitis; infliximab; etanercept; adalimumab; safety; infection
Whether the link between gout and mortality is causal or confounded by lifestyle factors or comorbidities remains unclear. Studies in Asia are warranted due to the rapid modernisation of the locale and ageing of the population.
The association between gout and mortality was examined in a prospective cohort, the Singapore Chinese Health Study, comprising 63 257 Singapore Chinese individuals, aged 45–74 years during the enrolment period of 1993–8. All enrollees were interviewed in person on lifestyle factors, current diet and medical histories. All surviving cohort members were contacted by telephone during 1999–2004 to update selected exposure and medical histories (follow-up I interview), including the history of physician-diagnosed gout. Cause-specific mortality in the cohort was identified via record linkage with the nationwide death registry, up to 31 December 2009.
Out of 52 322 participants in the follow-up I interview, 2117 (4.1%) self-reported a history of physician-diagnosed gout, with a mean age at diagnosis of 54.7 years. After a mean follow-up period of 8.1 years, there were 6660 deaths. Relative to non-gout subjects, subjects with gout had a higher risk of death (HR 1.18; 95% CI 1.06 to 1.32), and specifi cally from death due to coronary heart disease (CHD) (HR 1.38, 95% CI 1.10 to 1.73) and kidney disease (HR 5.81, 95% CI 3.61 to 9.37). All gout–mortality risk associations were present in both genders but the risk estimates appeared higher for women.
Gout is an independent risk factor for mortality, and specifically for death due to CHD and kidney disease.
Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.
Findings that African-American race/ethnicity is associated with higher concentrations of serum urate have not been adjusted for possible confounding factors or have not explored this question as a primary outcome. We tested this hypothesis in a bi-racial cohort of younger African-American and white men and women.
Data from 5,049 participants at the Coronary Artery Risk Development in Young Adults (CARDIA) cohort baseline (1985 to1986) and follow-up for up to 20 years of individuals without hyperuricemia (defined as a serum urate of 6.8 mg/dL or more) at baseline were utilized. We determined associations between race, serum urate and the development of hyperuricemia in sex-specific cross-sectional and longitudinal analyses. Confounding factors examined included: age at enrollment, body mass index, development of hypertension, glomerular filtration rate, medication use, diet and alcohol intake and menopausal symptoms in women.
Referent to whites, African-American men and women had significantly lower concentrations of serum urate at baseline. African-American men had an essentially equal risk of developing incident hyperuricemia during follow-up compared with white men (multivariable adjusted HR = 1.12 (0.88 to1.40)). African-American women developed a significantly increased risk of hyperuricemia when compared to white women (HR = 2.31 (1.34 to 3.99)).
Young African-American men and women had lower concentrations of serum urate than whites. During longitudinal follow-up, African-American women had a significantly increased risk of developing hyperuricemia when compared with white women, a difference that was not observed in men. Differences in production of serum urate or a more rapid decline in fractional excretion of serum urate are potential, albeit still unproven, explanations for these findings in African-American women.
Under-treatment of osteoporosis is common, even for high risk patients. Among the reasons for under-treatment may be a clinician’s perception of a lack of treatment benefit, particularly in light of patients’ expected future mortality. Among U.S. Medicare beneficiaries, we evaluated the risk for second fracture vs. death in the five years following a hip, clinical vertebral, and wrist/forearm fracture.
Using data from 1999–2006 for a random 5% sample of U.S. Medicare beneficiaries, we identified individuals who experienced an incident hip, clinical vertebral, or wrist/forearm fracture in 2000 or 2001. We evaluated the risk for a second incident fracture versus death in the following five years. Results were stratified by age, gender, race/ethnicity, and medical comorbidities. In light of the competing mortality risk, and assuming 30% efficacy of an osteoporosis medication to prevent a second fracture, we calculated the number of individuals needed to treat (NNT) for 5 years after first fracture to prevent one additional subsequent fracture.
We identified 18,853, 12,751, and 7,635 persons with an incident hip, clinical vertebral, and wrist/forearm fracture, respectively. While the 5-year risk of death usually exceeded the risk for second fracture across age, gender, racial groups, and primary fracture type (median ratio of death to second fracture = 1.4, inter-quartile range 0.9, 2.0), the 5-year risk for second fracture was high, varying from a low of 13% to a high of 43%. Across demographic groups, the NNT to prevent a second fracture was low, ranging from 8 to 46.
Among older persons with hip, clinical vertebral, or wrist/forearm fracture, while the risk for death was usually greater than the risk for a second fracture, both were high. The relatively low NNT to prevent one additional subsequent fracture fell within a range generally considered acceptable for secondary prevention strategies.
hip fracture; vertebral fracture; wrist fracture; epidemiology; mortality; osteoporosis
It is unclear whether anti-tumour necrosis factor alpha and biological agents with different mechanisms of action have similar safety. This study evaluated the incidence of hospitalised infections among rheumatoid arthritis (RA) patients starting or switching various biological agents.
Using a database from a large US healthcare organisation from January 2005 to August 2009, the authors identified enrollees with RA and their treatment episodes entailing the new use of a biological agent, stratified by no biological use in the previous year (‘biological-free’) or switching from a different biological agent (‘switchers’). Outcomes were hospitalised infections identified using previously validated algorithms. Proportional hazards models estimated the hazard ratio of hospitalised infections, comparing each biological agent with infliximab.
Among 7847 biological treatment episodes, 63% were for biological-free patients and 37% for switchers. There were 364 hospitalised infections. Rates of hospitalised infection among biological-free patients and switchers were 4.6 and 7.0 per 100 person-years, respectively (p<0.0001). After multivariable adjustment controlling for biological-free/switcher status and other infection-related factors and compared with infliximab, users of abatacept (HR 0.68, 95% CI 0.48 to 0.96), adalimumab (HR 0.52, 0.39 to 0.71), etanercept (HR 0.64, 0.49 to 0.84) and rituximab (HR 0.81, 0.55 to 1.20) had lower rates of hospitalised infection. Patient risk factors contributed more to the risk of infection than did the risk associated with specific biological therapies.
The rate of hospitalised infections among RA patients was highest for infliximab. Most of the variability in patients’ risk of infection was driven by factors other than biological agent exposure.
Patients' receipt of prescription therapies are significantly influenced by their physician's prescribing patterns. If physicians in the same practice setting influence one another's prescribing, evidence implementation interventions must consider targeting the practice as well as individual physicians to achieve maximal success.
We examined receipt of osteoporosis treatment (OP Rx) from two prior evidence implementation studies: long term glucocorticoid (GC) users and 2) nursing home (NH) residents with prior fracture or osteoporosis. Common practice setting was defined as doctors practicing at the same address or in the same nursing home. Alternating logistic regression evaluated the relationship between OP Rx, common practice setting and individual physician treatment patterns.
Among 6281 GC users in 1296 practices, the proportion receiving OP Rx in each practice was 6–100%. Among 779 NH residents in 66 nursing homes, the proportion in each NH receiving OP Rx was 0–100%. In both, there was no significant relationship between receipt of OP Rx and common practice setting after accounting for treatment pattern of individual physicians.
Physicians practicing together were not more alike in prescribing osteoporosis medications than those in different practices. Osteoporosis quality improvement may be able to ignore common practice settings and maximize statistical power by targeting individual physicians.
osteoporosis; glucocorticoid; fracture; nursing home; group randomized trial; alternating logistic regression
Analyses of osteoporosis-related fractures that use administrative data often exclude pathologic fractures (ICD-9 733.1x) due to concern that these are caused by cancer. We examined “pathologic” fractures of the vertebrae and hip to evaluate their contribution to fracture incidence and assessed the evidence for a malignancy.
We studied U.S. Medicare beneficiaries age ≥ 65 with new fractures identified using ICD-9 diagnosis codes 733.13 (pathologic vert), 805.0, 805.2, 805.4, 805.8 (non-pathologic vert); and 733.14 (pathologic hip), 820.0, 820.2 820.8 (non-pathologic hip). We further examined the proportion of cases with a diagnosis of a malignancy proximate to the fracture.
We identified 44,120 individuals with a vertebral fracture and 60,354 with a hip fracture. Approximately 50% of vertebral fractures and 3% of hip fractures were coded as pathologic. For only approximately 25% of persons with a “pathologic” vertebral fracture ICD-9 code, but 66% of persons with a “pathologic” hip fracture, there was evidence of a possible cancer diagnosis.
Among U.S. Medicare beneficiaries, one-fourth of pathologic vertebral fracture and two-thirds of pathologic hip fracture cases had evidence for a malignancy. Particularly for vertebral fractures, excluding persons with pathologic fractures in epidemiologic analyses that utilize administrative claims data substantially underestimates the burden of fractures due to osteoporosis.
hip fracture; vertebral fracture; pathologic fracture; epidemiology
Medicare reimbursement for DXAs performed in non-facility settings (e.g. physician offices) decreased in 2007. With declining reimbursement, some DXA providers may cease providing this service, which would increase travel distance for some people. The impact of travel distance on access to DXA is unclear.
Using national Medicare data, we identified claims for DXA to evaluate trends in the number and locations of DXAs performed. Travel distance was the distance from beneficiaries’ residence and the nearest DXA provider. Binomial regression evaluated the relationship between travel distance and receipt of DXA.
In 2006, 2.9 million DXAs were performed, a 103% increase since 1999. In 2005–2006, 8.0% of persons were tested at non-facility sites versus 4.2% at facility sites. The remainder (88%) had no DXA. Persons traveling 5–9, 10–24, 25–39, and 40–54, and ≥ 55 miles were less likely to receive DXA (adjusted risk ratios = 0.92, 0.79, 0.43, 0.32, and 0.26, respectively, <5 miles referent). Rural residents were more dependent than urban residents on the availability of DXA from non-facility providers.
Approximately two-thirds of DXAs in 2005–2006 were performed in non-facility settings (e.g. as physician offices). Rural residents would have preferentially reduced access to DXA if there were fewer non-facility sites.
bone mineral density; dual-energy xray absorptiometry (DXA); travel distance; osteoporosis
Undertreatment of osteoporosis has been recognized as a common problem in selected patient subgroups. However, primary prevention has been hampered by limited risk assessment tools that can be applied to large populations.
Using clinical risk factors with a new tool from the World Health Organization (FRAX) and recommendations from the National Osteoporosis Foundation (NOF), we evaluated fracture risk and osteoporosis treatment in a US cohort.
African Americans and Caucasians recruited from 2003–7 across the US as part of a longitudinal study.
The number of persons receiving prescription osteoporosis medications was assessed by race, sex, and fracture risk. Multivariable logistic regression evaluated the association between receipt of osteoporosis medications and fracture risk after controlling for potential confounders.
Among 24,783 participants, estimated fracture risk was highest for Caucasian women. After multivariable adjustment for fracture-related risk factors, the likelihood of receipt of osteoporosis medications among African Americans was lower than among Caucasians [odds ratio (OR) = 0.44, 95% confidence interval (CI) 0.37, 0.53] and for men compared to women (OR = 0.08, 95% CI 0.06–0.10). Even for the highest risk group, Caucasian women with 10-year hip fracture risk ≥3% (n = 3,025, 39.7%), only 26% were receiving treatment.
A substantial gap exists between 2008 NOF treatment guidelines based on fracture risk and the receipt of prescription osteoporosis medications. This gap was particularly notable for African Americans and men. FRAX is likely to be useful to assess risk at a population level and identify high-risk persons in need of additional evaluation.
osteoporosis; fracture; African American; Caucasian; epidemiology; FRAX; bisphosphonate
Previous research suggests patients with rheumatoid arthritis (RA) may receive suboptimal care with respect to preventive tests and services. We evaluated the proportion of older Americans with RA, psoriatic arthritis (PsA), and osteoarthritis (OA) receiving these services and the specialty of the providers delivering this care.
Using data from 1999 to 2006 from the Medicare Chronic Conditions Warehouse, we identified persons age >/= 65 in the national 5% sample. Over the required five-year observation period, we identified tests and services recommended for older adults and the associated healthcare provider. Services of interest included dual energy x-ray absorptiometry (DXA), influenza and pneumococcal vaccination, hyperlipidemia lab testing, mammography and colonoscopy.
After accounting for the sampling fraction, we identified 141,140 RA, 6,300 PsA, and 770,520 OA patients eligible for analysis. Over five years, a majority of RA, PsA, and OA patients were tested for hyperlipidemia (84%, 89% and 87% respectively) and received DXA (69%, 75%, and 52%). Only approximately one-third of arthritis patients received pneumococcal vaccination; 19% to 22% received influenza vaccination each year. Approximately 20% to 35% of arthritis patients never underwent mammography and colonoscopy over five years. Concomitant care from both a rheumatologist and a primary care physician was significantly associated with a greater likelihood of receiving almost all preventive tests and services.
Among older Americans on Medicare, the absolute proportion of persons with arthritis receiving various recommended preventive services and screening tests was substantially less than 100%. Improved co-management between primary care and arthritis physicians may in part improve the delivery of preventive care for arthritis patients, but novel systematic interventions in this area are needed.
Bisphosphonates differ in their in vitro potency, avidity for bone, and rapidity of onset in clinical trials. To address potential differences between bisphosphonates in comparative effectiveness, we compared new users of alendronate and risedronate to determine if there were differences in the risk of clinical fractures at 1 year and beyond.
Using claims data from a U.S. health care organization, we identified new, adherent users of weekly alendronate or risedronate and assessed subsequent fractures. We calculated fracture incidence rate differences and ratios between the two agents.
There were no significant differences in fracture rates between alendronate users (n=12,956) and risedronate users (n=6,107) at 1 year. Using all available data, the rate of hip fracture was higher among risedronate users compared to alendronate users (absolute rate difference approximately 5 per 1000 person-years). Risedronate users had a higher relative rate [RR] of hip fracture (RR = 1.77, 95% CI 1.15 – 2.74) and similar rates of clinical vertebral and nonvertebral fractures compared to alendronate users.
The absolute rate of clinical fractures among alendronate and risedronate users was similar both at one year and beyond, suggesting comparable effectiveness between agents.
bisphosphonate; alendronate; risedronate; fracture; osteoporosis
In the past decade, we have witnessed a revolution in osteoporosis diagnosis and therapeutics. This includes enhanced understanding of basic bone biology, recognizing the severe consequences of fractures in terms of morbidity and short-term re-fracture and mortality risk and case finding based on clinical risks, bone mineral density, new imaging approaches, and contributors to secondary osteoporosis. Medical interventions that reduce fracture risk include sufficient calcium and vitamin D together with a wide spectrum of drug therapies (with antiresorptive, anabolic, or mixed effects). Emerging therapeutic options that target molecules of bone metabolism indicate that the next decade should offer even greater promise for further improving our diagnostic and treatment approaches.
To evaluate diagnostic properties of International Classification of Diseases, Version 9 (ICD-9) diagnosis codes and infection criteria to identify bacterial infections among rheumatoid arthritis (RA) patients.
Study Design and Setting
We performed a cross- sectional study of RA patients with and without ICD-9 codes for bacterial infections. Sixteen bacterial infection criteria were developed. Diagnostic properties of comprehensive and restrictive sets of ICD-9 codes and the infection criteria were tested against an adjudicated review of medical records.
Records on 162 RA patients with and 50 without purported bacterial infections were reviewed. Positive (PPV) and negative predictive values (NPVs) of ICD-9 codes ranged from 54% – 85% and 84% – 100%, respectively. PPVs of the medical records-based criteria were: 84% and 89% for “definite” and “definite or empirically treated” infections, respectively. PPV of infection criteria increased by 50% as disease prevalence increased using ICD-9 codes to enhance infection likelihood.
ICD-9 codes alone may misclassify bacterial infections in hospitalized RA patients. Misclassification varies with the specificity of the codes used and strength of evidence required to confirm infections. Combining ICD-9 codes with infection criteria identified infections with greatest accuracy. Novel infection criteria may limit the requirement to review medical records.
Bacterial Infections; Diagnostic coding; Administrative claims data; Rheumatoid Arthritis; Bacterial infection classification criteria; Validation study
Administrative claims data have a limited ability to identify persons with high compliance to oral bisphosphonates. We tested whether adding information on compliance with other drugs used to treat chronic, asymptomatic conditions would improve the predictive ability of administrative data to identify adherent individuals.
Using data from a large, U.S. healthcare organization, we identified new bisphosphonate users and their 1 year compliance to oral bisphosphonates, quantified by the Medication Possession Ratio (MPR). Multivariable logistic regression models evaluated the relationship between high bisphosphonate compliance (MPR >= 80%) and patient demographics, comorbidities, and health services utilization. To these logistic regression models, we evaluated the incremental change in the area under the receiver operator curve (AUC) after adding information regarding compliance with other drug classes. These included anti-hyperlipidemics (statins), anti-hypertensives, anti-depressants, oral diabetes agents, and glaucoma medications. Results from the logistic regression models were evaluated in parallel using recursive partitioning trees with 10-fold cross-validation.
Among 101,038 new bisphosphonate users, administrative data identified numerous non-medication factors (e.g. age, gender, use of preventive services) significantly associated with high bisphosphonate compliance at 1 year. However, all these factors in aggregate had low discriminant ability to identify persons highly adherent with bisphosphonates (AUC = 0.62). For persons who were new users of ≥ 1 of the other asymptomatic condition drugs, MPR data on the other drugs substantially improved the prediction of high bisphosphonate compliance. The impact on prediction was largest for concomitant statin users (AUC = 0.70).
Information on compliance with drugs used to treat chronic asymptomatic conditions improves the prediction of compliance with oral bisphosphonates. This information may help identify persons who should receive targeted interventions to promote compliance to osteoporosis medications.
bisphosphonate; adherence; compliance; osteoporosis