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Biomedical subjects

J H Gurwitz

Publications and source records attributed to J H Gurwitz.

At least 19 recordsLinked to original sources
PubMed2001

Recent magnitude of and temporal trends (1994-1997) in the incidence and hospital death rates of cardiogenic shock complicating acute myocardial infarction: the second national registry of myocardial infarction.

BACKGROUND: Limited recent data are available to describe the magnitude of, and temporal trends in, the incidence and case-fatality rates associated with cardiogenic shock complicating acute myocardial infarction. The purpose of this study was to examine recent (1994-1997) trends in the incidence of, and hospital death rates from, cardiogenic shock complicating acute myocardial infarction from a large, multihospital national perspective. METHODS: An observational study was performed of 426,253 patients hospitalized with acute myocardial infarction in 1662 hospitals throughout the United States between 1994 and 1997. RESULTS: The incidence rates of cardiogenic shock averaged 6.2%. There was evidence for a slight decline in these rates between 1994 (6.6%) and 1997 (6.0%). Results of a multivariable regression analysis controlling for factors that might affect the risk of development of cardiogenic shock indicated that patients hospitalized in more recent years were at significantly lower risk for shock. Patients with shock had a markedly increased risk for dying during hospitalization compared with patients not having shock (74% vs 10%). Significant, albeit small, absolute differences were observed in the risk of dying after cardiogenic shock over time (76% dying in 1997, 72% dying in 1994). These improving trends were magnified, however, after potentially confounding prognostic factors were controlled: patients having shock in 1997 were at approximately one fifth lower risk of dying (odds ratio 0.79, 95% confidence interval 0.71-0.87) than those hospitalized in 1994. CONCLUSIONS: Our findings indicate a slight decline in the incidence rates of cardiogenic shock and improving trends in the hospital survival of patients with shock. Despite these trends, it remains of considerable importance to prevent this clinical syndrome, given its high lethality.

Aged↗
PubMed2000

Rate of heart failure and 1-year survival for older people receiving low-dose beta-blocker therapy after myocardial infarction.

BACKGROUND: Many older people do not receive beta-blocker therapy after myocardial infarction or receive doses lower than those tested in trials, perhaps because physicians fear that beta-blockers may precipitate heart failure. We examined the relation between use of beta-blockers, the dose used, and hospital admission for heart failure and 1-year survival in a cohort of all older patients surviving myocardial infarction in Ontario, Canada. METHODS: We collected data on a cohort of 13,623 patients aged 66 years or older who were discharged from hospital after a myocardial infarction and who did not receive beta-blocker therapy or received low, standard, or high doses. We used Cox's proportional-hazards models to study the association of dose with admission for heart failure and survival with adjustment for factors including age, sex, and comorbidity. FINDINGS: Among 8232 patients with no previous history of heart failure, dispensing of beta-blocker therapy was associated with a 43% reduction in subsequent admission for heart failure (adjusted risk ratio 0.57 [95% CI 0.48-0.69]) compared with patients not dispensed this therapy. Among the 4681 patients prescribed beta-blockers, the risk of admission was greater in the high-dose than in the low-dose group (1.53 [1.01-2.31]). Among all 13,623 patients in the cohort, 2326 (17.1%) died by 1 year. Compared with those not dispensed beta-blocker therapy, the adjusted risk ratio for mortality was lower for all three doses (low 0.40 [0.34-0.47], standard 0.36 [0.31-0.42], high 0.43 [0.33-0.56]). INTERPRETATION: Compared with high-dose beta-blocker therapy, low-dose treatment is associated with a lower rate of hospital admission for heart failure and has a similar 1-year survival benefit. Our findings support the need for a randomised controlled trial comparing doses of beta-blocker therapy in elderly patients.

Adrenergic beta-Antagonists↗
PubMed2000

Incidence and preventability of adverse drug events in nursing homes.

PURPOSE: Adverse drug events, especially those that may have been preventable, are among the most serious concerns about medication use in nursing homes. We studied the incidence and preventability of adverse drug events and potential adverse drug events in nursing homes. METHODS: We performed a cohort study of all long-term care residents of 18 community-based nursing homes in Massachusetts during a 12-month observation period. Potential drug-related incidents were detected by stimulated self-report by nursing home staff and by periodic review of the records of nursing home residents by trained nurse and pharmacist investigators. Each incident was classified by 2 independent physician-reviewers, using a structured implicit review process, by whether or not it constituted an adverse drug event or potential adverse drug event (those that may have caused harm, but did not because of chance or because they were detected), by the severity of the event (significant, serious, life-threatening, or fatal), and by whether it was preventable. Examples of significant events included nonurticarial rashes, falls without associated fracture, hemorrhage not requiring transfusion or hospitalization, and oversedation; examples of serious events included urticaria, falls with fracture, hemorrhage requiring transfusion or hospitalization, and delirium. RESULTS: During 28,839 nursing home resident-months of observation in the 18 participating nursing homes, 546 adverse drug events (1.89 per 100 resident-months) and 188 potential adverse drug events (0.65 per 100 resident-months) were identified. Of the adverse drug events, 1 was fatal, 31 (6%) were life-threatening, 206 (38%) were serious, and 308 (56%) were significant. Overall, 51% of the adverse drug events were judged to be preventable, including 171 (72%) of the 238 fatal, life-threatening, or serious events and 105 (34%) of the 308 significant events (P < 0.001). Errors resulting in preventable adverse drug events occurred most often at the stages of ordering and monitoring; errors in transcription, dispensing, and administration were less commonly identified. Psychoactive medications (antipsychotics, antidepressants, and sedatives/hypnotics) and anticoagulants were the most common medications associated with preventable adverse drug events. Neuropsychiatric events were the most common types of preventable adverse drug events. CONCLUSIONS: Adverse drug events are common and often preventable in nursing homes. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the ordering and monitoring stages of pharmaceutical care.

Accidental Falls↗
PubMed2000

Inhibitors of hydroxymethylglutaryl-coenzyme A reductase and risk of fracture among older women.

BACKGROUND: Inhibitors of hydroxymethylglutaryl-coenzyme A reductase (statins) increase new bone formation in rodents and in human cells in vitro. Statin use is associated with increased bone mineral density of the femoral neck. We undertook a population-based case-control study at six health-maintenance organisations in the USA to investigate further the relation between statin use and fracture risk among older women. METHODS: We investigated women aged 60 years or older. Exposure, outcome, and confounder information was obtained from automated claims and pharmacy data from October, 1994, to September, 1997. Cases had an incident diagnosis of non-pathological fracture of the hip, humerus, distal tibia, wrist, or vertebrae between October, 1996, and September, 1997. Controls had no fracture during this period. We excluded women with records of dispensing of drugs to treat osteoporosis. FINDINGS: There were 928 cases and 2747 controls. Compared with women who had no record of statin dispensing during the previous 2 years, women with 13 or more statin dispensings during this period had a decreased risk of non-pathological fracture (odds ratio 0.48 [95% CI 0.27-0.83]) after adjustment for age, number of hospital admissions during the previous year, chronic disease score, and use of non-statin lipid-lowering drugs. No association was found between fracture risk and fewer than 13 dispensings of statins or between fracture risk and use of non-statin lipid-lowering drugs. INTERPRETATION: Statins seem to be protective against non-pathological fracture among older women. These findings are compatible with the hypothesis that statins increase bone mineral density in human beings and thereby decrease the risk of osteoporotic fractures.

Age Factors↗
PubMed2000

Intracranial hemorrhage rates and effect of immediate beta-blocker use in patients with acute myocardial infarction treated with tissue plasminogen activator. Participants in the National Registry of Myocardial Infarction-2.

In acute myocardial infarction (AMI), immediate beta-blocker therapy reduces the incidence of reinfarction and recurrent chest pain in patients receiving tissue plasminogen activator (t-PA). Data from the Thrombolysis in Myocardial Infarction (TIMI)-2 trial also raises the possibility that such therapy may reduce the rate of intracranial hemorrhage (ICH). We reviewed data obtained from 60,329 patients treated with t-PA who were enrolled in the National Registry of Myocardial Infarction 2. Of the 60,329 in the study cohort, 23,749 patients (39.4%) were treated with immediate beta-blocker therapy and 542 patients (0.9%) developed an ICH. In a multivariate model that included all covariates known to be associated with the development of ICH, immediate beta-blocker therapy was associated with a 31% reduction in the ICH rate (odds ratio 0.69, 95% confidence intervals 0.57 to 0.84). Thus, in the present study, the use of immediate beta-blocker therapy in patients with AMI treated with t-PA was associated with a significant reduction in ICH. This finding supports the observations made in the TIMI 2 trial and serves to reinforce the recommendations made by the American College of Cardiology/American Heart Association task force that immediate beta-blocker therapy should be administered to all patients with AMI who do not have contraindications to this therapy.

Adrenergic beta-Antagonists↗
PubMed2000

Evaluating the predictive value of osteoarthritis diagnoses in an administrative database.

OBJECTIVE: To assess the positive and negative predictive values of osteoarthritis (OA) diagnoses contained in an administrative database. METHODS: We identified all members (> or =18 years of age) of a Massachusetts health maintenance organization with documentation of at least one health care encounter associated with an OA diagnosis during the period 1994-1996. From this population, we randomly selected 350 subjects. In addition, we randomly selected 250 enrollees (proportionally by the age and sex of the 350 subjects) who did not have a health care encounter associated with an OA diagnosis. Trained nurse reviewers abstracted OA-related clinical, laboratory, and radiologic data from the medical records of both study groups (all but 1 chart was available for review). Pairs of physician reviewers evaluated the abstracted information for both groups of subjects and rated the evidence for the presence of OA according to 3 levels: definite, possible, and unlikely. RESULTS: Among the group of patients with an administrative diagnosis of OA, 215 (62%) were rated as having definite OA, 36 (10%) possible OA, and 98 (28%) unlikely OA, according to information contained in the medical record. The positive predictive value of an OA diagnosis was 62%. In those without an administrative OA diagnosis, 44 (18%) were assigned a rating of definite OA. The negative predictive value of the absence of an administrative OA diagnosis was 78%. CONCLUSION: Use of administrative data in epidemiologic and health services research on OA may lead to both case misclassification and under ascertainment.

Aged↗
PubMed2000

Improving discussion of surgical treatment options for patients with breast cancer: local medical opinion leaders versus audit and performance feedback.

We studied whether a hospital intervention utilizing medical opinion leaders and performance feedback reduced the proportion of women who reported that surgeons did not discuss options prior to surgery for early stage breast cancer. Opinion leaders provided clinical education to their peers using a variety of strategies and were selected for their ability to influence their peers. Performance feedback involved distributing performance reports that contained data on the outcomes of interest as well as on other treatment patterns. Twenty-eight hospitals in Minnesota were randomized to the intervention or to a control group that received performance feedback only. The proportion of patients at intervention hospitals who said that their surgeon did not discuss options decreased significantly (p < 0.001) from 33% to 17%, but a similar decrease was observed among control hospitals. Using medical opinion leaders to intervene in hospitals appeared as effective as performance feedback.

Adult↗
PubMed2000

Evaluation of a formulary switch from conjugated to esterified estrogens in a managed care setting.

BACKGROUND: Formulary switches between agents in the same therapeutic class have become commonplace in the managed care setting as a strategy to reduce costs. OBJECTIVES: We evaluated the impact of a formulary switch from conjugated to esterified estrogen tablets at the Fallon Community Health Plan, a mixed-model health maintenance organization. DESIGN: A retrospective study was conducted with the use of the automated database of the health plan. SUBJECTS: Study subjects were members of the health plan during the period from May 1, 1995, to December 31, 1997, who were dispensed > or =1 estrogen replacement product. From this population, a cohort of users of conjugated estrogens during the period from May 1, 1995, to October 31, 1995, was selected. MEASURES: The cumulative incidence of switching from conjugated to esterified estrogen tablets and subsequent discontinuations of esterified estrogens was evaluated. The frequencies of ambulatory encounters during the 6 months before and after a switch or discontinuation were compared. RESULTS: During the period after promotion of the formulary switch, 2,149 of 2,984 patients (72%) originally dispensed conjugated estrogen tablets switched to esterified estrogen tablets. Among those patients switching to esterified estrogens, an excess of 20 office visits per 100 patients was noted in the postswitch period (P = 0.005). The risk of switching back to conjugated estrogen tablets was 15% by 2 years. CONCLUSIONS: The findings of this study suggest that plan efforts were successful in switching most users of conjugated estrogens to esterified estrogens. The switch was associated with an increase in utilization of health care services.

Adult↗
PubMed2000

Which patients are treated for glaucoma? An observational analysis.

PURPOSE: More than one million patients in the United States are treated for glaucoma, although little is known about the typical clinical characteristics of this group of patients and the type of therapy they receive. This study was conducted to describe the demographic and diagnostic characteristics of patients beginning long-term drug therapy for glaucoma. METHODS: This cross-sectional study included 544 patients beginning topical glaucoma medication regimens who received care at a group model health-maintenance organization (HMO) located in central Massachusetts. The primary medical records of 544 patients beginning topical glaucoma medication between 1987 and 1990 were reviewed to ascertain the presence of three clinical findings: intraocular pressure (IOP) > or = 22 mmHg; optic disc changes including cup-to-disc ratio > or = 0.8, cup-to-disc asymmetry > or = 0.2, or morphologic disc changes consistent with glaucomatous optic neuropathy; and visual field defect consistent with glaucoma. RESULTS: A majority of the 544 patients (86%) were diagnosed as having primary open-angle glaucoma (POAG) by their physicians. Almost half (44.7%) of these patients had only an elevation in IOP without other clinical findings, and 9% met none of the above criteria for glaucoma according to information in the medical record. CONCLUSION: In this setting, most patients who were prescribed drug therapy for POAG were treated for an elevation in IOP alone in the absence of other ophthalmologic characteristics of glaucoma.

Adrenergic beta-Antagonists↗
PubMed2000

Intracranial hemorrhage associated with thrombolytic therapy for elderly patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project.

BACKGROUND AND PURPOSE: Intracranial hemorrhage is a serious complication of thrombolytic therapy for acute myocardial infarction, especially among the elderly, but little information exists on estimating risk. Better estimation of risk in individual patients may allow for withholding or using alternate therapies among those at highest risk. METHODS: To quantify the risk and identify predictors of intracranial hemorrhage associated with thrombolytic therapy, we performed a retrospective cohort study using data from medical charts. The study involved nearly all acute-care hospitals in the United States. All Medicare patients discharged with a principal diagnosis of acute myocardial infarction during a 9-month period in 1994 to 1995 were included. The main outcome measure was intracranial hemorrhage among those treated with thrombolytic therapy. RESULTS: The rate of intracranial hemorrhage was 1.43% (455 of 31 732). In a logistic model, age > or =75 years, female, black race, prior stroke, blood pressure > or =160 mm Hg, tissue plasminogen activator (versus other thrombolytic agent), excessive anticoagulation (international normalized ratio > or =4 or prothrombin time > or =24), and below median weight (< or =65 kg for women; < or =80 kg for men) were independent predictors. A risk stratification scale was developed on the basis of these factors: with none or 1 of the factors (n=6651), the rate of intracranial hemorrhage was 0.69%; with 2 factors (n=10 509), 1.02%; with 3 factors (n=9074), 1.63%; with 4 factors (n=4298), 2.49%; and with > or =5 factors (n=1071), 4. 11% (Mantel-Haenszel; P<0.001). CONCLUSIONS: The rate of intracranial hemorrhage in older patients after treatment with thrombolytic therapy exceeds 1%. Readily available factors can identify elderly patients with acute myocardial infarction at high and low risk for intracranial hemorrhage associated with thrombolytic therapy.

Age Factors↗
PubMed1999

Use of beta-blocker therapy in older patients after acute myocardial infarction in Ontario.

BACKGROUND: Despite its proven efficacy, beta-blocker therapy remains underused in elderly patients after myocardial infarction (MI). The objectives of this study were to identify undertreated groups of seniors and to determine whether older and frailer patients are being selectively dispensed low-dose beta-blocker therapy. METHODS: From a comprehensive hospital discharge database, all people aged 66 years or more in Ontario who survived an acute MI between April 1993 and March 1995 were identified and classified into those who did not receive beta-blocker therapy and those dispensed low, standard or high doses of this agent. Logistic regression models were used to study the effect of age, sex, comorbidity, potential contraindications to beta-blocker therapy and residence in a long-term-care facility on the odds of not being dispensed a beta-blocker. Among beta-blocker users, the odds of being dispensed low relative to standard or high doses of this agent were evaluated. RESULTS: Of the 15,542 patients, 7549 (48.6%) were not dispensed a beta-blocker. Patients 85 years of age or more were at greater risk of not receiving beta-blocker therapy (adjusted odds ratio [OR] 2.8, 95% confidence interval [CI] 2.5-3.2) than were those 66 to 74 years. Having a Charlson comorbidity index of 3 or greater was associated with an increased risk of not receiving beta-blocker therapy (adjusted OR 1.5, 95% CI 1.3-1.8) compared with having lower comorbidity scores. Patients who resided in a long-term-care facility were at increased risk of not being prescribed beta-blocker therapy (adjusted OR 2.6, 95% CI 2.0-3.4). Among the 5453 patients with no identifiable contraindication to beta-blocker therapy, women were significantly less likely than men to receive this agent (p = 0.005). Of the 6074 patients who received beta-blockers, 2248 (37.0%) were dispensed low-dose therapy. Patients aged 85 years or more had an increased risk of being dispensed low-dose therapy (adjusted OR 1.6, 95% CI 1.3-2.0) compared with those aged 66 to 74 years. Compared with those who had the lowest comorbidity scores, patients with the highest comorbidity scores were more likely to be dispensed low-dose beta-blocker therapy (adjusted OR 1.3, 95% CI 1.0-1.8). INTERPRETATION: Almost half of Ontario patients aged 66 or more who survived an MI, particularly those who were older or frailer, did not receive beta-blocker therapy. Among those dispensed beta-blocker therapy, older and frailer patients were more frequently dispensed low-dose therapy.

Adrenergic Antagonists↗
PubMed1999

Duration of, and temporal trends (1994-1997) in, prehospital delay in patients with acute myocardial infarction: the second National Registry of Myocardial Infarction.

BACKGROUND: Extent of delay in seeking medical care in persons with acute myocardial infarction (AMI) is receiving increasing attention, given the time-dependent benefits associated with early administration of coronary reperfusion therapy. OBJECTIVE: To examine recent data, and temporal trends therein, about duration of prehospital delay in a large (N = 364,131) cross-sectional sample of patients included in the second National Registry of Myocardial Infarction. METHODS: The medical records of patients hospitalized with AMI in 1624 US hospitals from June 1, 1994, to October 31, 1997, were reviewed for information about duration of prehospital delay. RESULTS: There was evidence of a slight decline in average delay times in patients hospitalized in 1997 (5.5 hours) compared with those hospitalized in 1994 (5.7 hours). Median delay times (2.1 hours) did not change. Approximately 20% of patients presented to the hospital within 1 hour of acute symptom onset, and slightly more than two thirds presented within 4 hours. Delay times were more prolonged for older patients, women, nonwhite patients, and patients with a history of diabetes or hypertension vs respective comparison groups. Patients in cardiogenic shock exhibited shorter delay times than less severely ill patients. Patients with previous AMI or who had undergone previous coronary angioplasty presented to the hospital with shorter delay times, as did individuals hospitalized in the Mountain and Pacific regions. CONCLUSIONS: These results provide insights into recent delay times and into groups at risk for prolonged delay.

Aged↗
PubMed1999

Timeliness and quality of care for elderly patients with acute myocardial infarction under health maintenance organization vs fee-for-service insurance.

BACKGROUND: A commonly voiced concern is that health maintenance organizations (HMOs) may withhold or delay the provision of urgent, essential care, especially for vulnerable patients like the elderly. OBJECTIVE: To compare the quality of emergency care provided in Minnesota to elderly patients with acute myocardial infarction (AMI) who are covered by HMO vs fee-for-service (FFS) insurance. METHODS: We reviewed the medical records of 2304 elderly Medicare patients who were admitted with AMI to 20 urban community hospitals in Minnesota (representing 91% of beds in areas served by HMOs) from October 1992 through July 1993 and from July 1995 through April 1996. MAIN OUTCOME MEASURES: Use of emergency transportation and treatment delay (>6 hours from symptom onset); time to electrocardiogram; use of aspirin, thrombolytics, and beta-blockers among eligible patients; and time from hospital arrival to thrombolytic administration (door-to-needle time). RESULTS: Demographic characteristics, severity of symptoms, and comorbidity characteristics were almost identical among HMO (n = 612) and FFS (n = 1692) patients. A cardiologist was involved as a consultant or the attending physician in the care of 80% of HMO patients and 82% of FFS patients (P = .12). The treatment delay, time to electrocardiogram, use of thrombolytic agents, and door-to-needle times were almost identical. However, 56% of HMO patients and 51% of FFS patients used emergency transportation (P = .02); most of this difference was observed for patients with AMIs that occurred at night (60% vs 52%; P = .02). Health maintenance organization patients were somewhat more likely than FFS patients to receive aspirin therapy (88% vs 83%; P = .03) and beta-blocker therapy (73% vs 62%; P = .04); these differences were partly explained by a significantly larger proportion of younger physicians in HMOs who were more likely to order these drug therapies. All differences were consistent across the 3 largest HMOs (1 staff-group model and 2 network model HMOs). Logistic regression analyses controlling for demographic and clinical variables produced similar results, except that the differences in the use of beta-blockers became insignificant. CONCLUSIONS: No indicators of timeliness and quality of care for elderly patients with AMIs were lower under HMO vs FFS insurance coverage in Minnesota. However, two indicators of quality care were slightly but significantly higher in the HMO setting (use of emergency transportation and aspirin therapy). Further research is needed in other states, in different populations, and for different medical conditions.

Adrenergic beta-Antagonists↗
PubMed1999

Use of aspirin, beta-blockers, and lipid-lowering medications before recurrent acute myocardial infarction: missed opportunities for prevention?

BACKGROUND: For patients who have had a previous myocardial infarction (MI), the use of aspirin, beta-blockers, and lipid-lowering agents reduces the risk of recurrent MI and death. OBJECTIVE: To examine trends in and determinants of receipt of these 3 medications before hospitalization for recurrent acute MI (AMI). METHODS: The study population consisted of 1710 patients with a previous history of MI hospitalized with a validated recurrent AMI in all hospitals in Worcester, Mass, during 1986, 1988, 1990, 1991, 1993, and 1995. Logistic regression analyses were used to assess the effect of demographic, clinical, and temporal factors on the receipt of aspirin, beta-blockers, and lipid-lowering medications before hospital admission for recurrent AMI. RESULTS: More than 47% of patients in each study year were not receiving each medication before admission, although significant increases in use were noted over time for aspirin (from 13.5% to 52.6%), beta-blockers (from 33.2% to 44.4%), and lipid-lowering medications (from 0.8% to 11.7%). In multivariate analyses, advancing age was associated with not receiving aspirin (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.51-0.89), lipid-lowering medications (OR, 0.14; 95% CI, 0.08-0.25), and beta-blockers (OR, 0.75; 95% CI, 0.57-1.00), although this effect was of borderline significance for beta-blockers. Being a woman was associated with not receiving aspirin (OR, 0.78; 95% CI, 0.62-0.98) but was positively associated with receiving lipid-lowering medications (OR, 1.59; 95% CI, 1.04-2.43). Coexisting medical conditions and concurrent use of other cardiovascular medications were also associated with receipt of each medication. CONCLUSION: Despite encouraging increases over time, the low absolute levels of receipt of medications shown to be efficacious in the long-term treatment of patients after an MI, and their variation by age and sex, suggest that substantial opportunities may exist to prevent recurrent AMIs through the increased use of aspirin, beta-blockers, and lipid-lowering medications.

Adrenergic beta-Antagonists↗
PubMed1999

Agreement between drug treatment data and a discharge diagnosis of diabetes mellitus in the elderly.

The authors examined agreement between drug treatment data and a discharge diagnosis of diabetes, considered whether agreement was modified by demographic variables and measures of comorbidity, and evaluated construct validity through consideration of relations with subsequent mortality. The study sample comprised 81,700 residents of New Jersey aged 65-99 years who had prescription drug coverage either through Medicaid or that state's Pharmacy Assistance for the Aged and Disabled program and had at least one hospitalization between July 1, 1989, and June 30, 1991. In this population, 16.4% filled a prescription for insulin or an oral hypoglycemic agent during the 120 days before admission, and 16.3% had a discharge diagnosis of diabetes. Overall agreement between these two indicators was modest (kappa = 0.67, 95% confidence interval 0.66-0.67) and was weaker in those aged 85 years and above (kappa = 0.58, 95% confidence interval 0.56-0.60), those in nursing homes (kappa = 0.42, 95% confidence interval 0.39-0.44), and those with a high level of comorbidity (modified Charlson index > or =5; kappa = 0.59, 95% confidence interval 0.56-0.62). Presence of a diagnosis of diabetes was associated with an apparent 24% reduction in the risk of death during the study interval (p<0.001), while prior treatment for diabetes had little relation to mortality (p = 0.15). These paradoxical associations with mortality and the lower agreement between discharge diagnoses and drug treatments associated with older age, nursing home residence, and comorbidity suggest limitations in the use of claims data to identify diabetes in the elderly.

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