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John Concato

Publications and source records attributed to John Concato.

At least 19 recordsLinked to original sources
PubMed2026

Enhancing Evidence Generation by Linking Randomized Clinical Trials to Real-World Data: The INVESTED-Medicare Linkage Study.

Real-world evidence (RWE) derived from real-world data (RWD) can complement randomized controlled trials (RCTs), yet the validity of RWD relative to RCT data remains insufficiently characterized. We obtained post hoc consent and linked individual participant data from the US-based INVESTED trial (2016-2019) with Medicare fee-for-service claims (2012-2020) to validate demographic factors, baseline characteristics (using 183-, 365-, and 730-day lookback periods) and outcomes, and to assess post-trial events. Among 5260 trial participants, 126 were enrolled and eligible for linkage. Among 115 participants with demographic information available from Medicare enrollment files, agreement between RCT- and RWD-based demographic factors was high: only one major age discrepancy, 100% agreement for sex, and an overall agreement of 0.89 for race. Participants with Medicare claims data (n = 65) were older and more likely to be White compared with the overall RCT population. For the 365-day lookback period, baseline comorbidities showed high sensitivity (median 0.80) and specificity (0.89), as did medication use (sensitivity 1.00, specificity 0.88). Lengthening the lookback period to 730 days increased sensitivity but decreased specificity, whereas shortening to 183 days decreased sensitivity but increased specificity. Clinical outcomes showed high specificity (0.88-0.94) but low sensitivity (0.18-0.50). Among those with Medicare coverage beyond the trial end date (n = 45), 22% experienced cardiopulmonary, 18% cardiovascular, and 7% heart failure (HF) hospitalizations, highlighting the value of RWD for extending RCT evidence. Proactive planning of future RCT-RWD linkage initiatives can improve the efficiency of linkage studies, leading to more actionable results.

Journal Article↗
PubMed2006

The effectiveness of screening for prostate cancer: a nested case-control study.

BACKGROUND: Screening for prostate cancer is done commonly in clinical practice, using prostate-specific antigen (PSA) tests or digital rectal examination (DRE). Evidence is lacking, however, to confirm a survival benefit among screened patients. We evaluated the effectiveness of PSA, with or without DRE, in reducing mortality. METHODS: We conducted a multicenter nested case-control study at 10 Veterans Affairs medical centers in New England. Among 71 661 patients receiving ambulatory care between 1989 and 1990, 501 case patients were identified as men who were diagnosed as having adenocarcinoma of the prostate from 1991 through 1995 and who died sometime between 1991 and 1999. Control patients were men who were alive at the time the corresponding case patient had died, matched (1:1 ratio) for age and Veterans Affairs facility. The exposure variable (determined blind to case-control status) was whether PSA testing or DRE was performed for screening prior to the diagnosis of prostate cancer among case patients, with the same time interval for control patients. The association of screening and overall or cause-specific (prostate cancer) mortality was adjusted for race and comorbidity. RESULTS: A benefit of screening was not found in our primary analysis assessing PSA screening and all-cause mortality (adjusted odds ratio, 1.08; 95% confidence interval, 0.71-1.64; P=.72), nor in a secondary analysis of PSA and/or DRE screening and cause-specific mortality (adjusted odds ratio, 1.13; 95% confidence interval, 0.63-2.06; P=.68). CONCLUSIONS: These results do not suggest that screening with PSA or DRE is effective in reducing mortality. Recommendations for obtaining "verbal informed consent" from men regarding such screening should continue.

Adenocarcinoma↗
PubMed2006

Long-term glycemic control and postoperative infectious complications.

HYPOTHESIS: Good preoperative glycemic control (hemoglobin A(1c) [HbA(1c)] levels <7%) is associated with decreased postoperative infections. DESIGN: Retrospective observational study using Veterans Affairs National Surgical Quality Improvement Program data from the Veterans Affairs Connecticut Healthcare System from January 1, 2000, through September 30, 2003. SETTING: Veterans Affairs Connecticut Healthcare System, a tertiary referral center and major university teaching site. PATIENTS: Six hundred forty-seven diabetic patients underwent major noncardiac surgery during the study period; 139 were excluded because the HbA(1c) levels were more than 180 days prior to surgery; 19 were excluded for other reasons; 490 diabetic patients were analyzed. The study patients were predominantly nonblack men with a median age of 71 years. MAIN OUTCOME MEASURES: Primary outcomes were infectious complications, including pneumonia, wound infection, urinary tract infection, or sepsis. Bivariate analysis was used first to determine the association of each independent variable (age, race, diabetic treatment, American Society of Anesthesiologists classification, Activities of Daily Living assessment, elective vs emergent procedure, wound classification, operation length, and HbA(1c) levels) with outcome. Factors significant at P<.05 were used in a multivariable logistic regression model. RESULTS: In the multivariable model, age, American Society of Anesthesiologists class, operation length, wound class, and HbA(1c) levels were significantly associated with postoperative infections. Emergency/urgent cases and dependence in Activities of Daily Living were significant in bivariate analysis but failed to reach statistical significance in the multivariable model. An HbA(1c) level of less than 7% was significantly associated with decreased infectious complications with an adjusted odds ratio of 2.13 (95% confidence interval, 1.23-3.70) and a P value of .007. CONCLUSION: Good preoperative glycemic control (HbA(1c) levels <7%) is associated with a decrease in infectious complications across a variety of surgical procedures.

Adult↗
PubMed2006

Prognostic implications of clinical practice guidelines among hemodialysis patients.

Although the National Kidney Foundation (NKF) has published clinical practice guidelines for the management of risk factors for cardiovascular disease, these guidelines have not been tested rigorously for their effectiveness. We conducted an observational study among patients with end-stage kidney disease to examine the prognostic impact of threshold levels recommended by the NKF for blood pressure, hemoglobin, calcium-phosphate product, parathyroid hormone, low-density lipoprotein, and glycosylated hemoglobin. The study population (N = 197) was assembled from a previously completed randomized trial examining arteriovenous graft thrombosis. Cox proportional hazard analysis was used to calculate hazard ratios for the association of levels outside guideline recommended targets and death, adjusting for age, comorbidity, race, and albumin. The proportion of patients outside guideline targets ranged from 33% to 81%, and the impact of levels outside guideline targets on mortality varied substantially. Elevated calcium-phosphate product and glycosylated hemoglobin had harmful effects, with adjusted hazard ratios of 1.58 (95% CI 1.00-2.50; p = 0.050) and 2.21 (95% CI 0.99-4.97; p = 0.054), respectively. Nontarget levels for blood pressure, hemoglobin, and parathyroid hormone had little effect, with adjusted hazard ratios of 1.15 (95% CI 0.74-1.78; p = 0.542), 1.04 (95% CI 0.65-1.68; p = 0.866), and 0.90 (95% CI 0.50-1.61; p = 0.722), respectively. Elevated low-density lipoprotein had a paradoxically beneficial effect, with an adjusted hazard ratio of 0.48 (95% CI 0.23-1.00; p = 0.049). These results suggest that the prognostic impact of current threshold levels recommended by select NKF guidelines on mortality is variable. Accordingly, the development and implementation of clinical practice guidelines should be accompanied by corresponding efforts to confirm their impact on patient outcomes. Such efforts are essential for the improvement of guidelines and to inform health policy optimally.

Aged↗
PubMed2006

Light to moderate alcohol consumption is associated with better cognitive function among older male veterans receiving primary care.

Among older persons, the effects of light to moderate alcohol consumption on cognitive function remain inadequately defined. The authors sought to determine whether light to moderate drinking is associated with better cognitive function among older men. Participants included men aged 65 years or older enrolled in a Veteran's Administration (VA) primary care clinic. Current (past 1 year) and lifetime use, cognitive functioning (as determined by the Trail Making Part B, Symbol Digit, FAS, and Hopkins Verbal Learning tests), and demographic, psychosocial, and medical status were obtained using standardized methods. Participants (N = 760) had a mean age of 74 (range, 65-89) years. Current drinkers (n = 509) as compared with never (n = 31) and former (n = 220) drinkers demonstrated significantly better cognitive performance on 3 (Trails B, Symbol Digit, and Hopkins Verbal Learning) of the 4 tests (P < .01 for all comparisons). In multiple linear regression models, current light to moderate drinking (ie, 7 or fewer drinks per week), as compared to a reference group of never and former drinkers, was associated with better performance on the Trails B, Symbol Digit, and Hopkins Verbal Learning tests (P < .01 for all comparisons). The number of years drinking 7 or fewer drinks per week also was independently associated with better cognitive performance. Current consumption of 7 or fewer drinks per week and the number of years drinking at this level are both associated with better cognitive performance in older male veterans receiving primary care. These findings are consistent with the hypothesis that light to moderate drinking confers cognitive benefits to older persons.

Aged↗
PubMed2006

Prostate-specific antigen 'velocity' as a diagnostic test for prostate cancer.

BACKGROUND: Prostate-specific antigen "velocity" (slope) is promoted as a diagnostic test for prostate cancer, but its clinical usefulness is uncertain. Accordingly, we evaluated the sensitivity of prostate-specific antigen (PSA) velocity among men who are diagnosed subsequently with prostate cancer. METHODS: Among 64,545 men receiving primary care at any of nine Veterans Affairs Medical Centers during 1989-1990, 1,313 men at least 50 years old had an incident diagnosis of prostate cancer during 1991-1995. PSA velocity values obtained prior to diagnosis ("test") were compared with results from prostate biopsies ("truth"). RESULTS: Among men (n = 493) with at least two tests before diagnosis, the sensitivity of PSA velocity > or = 0.75 ng/mL/yr was 75.5% (95% confidence interval [CI] 71.7-79.3) overall and 48.1% (95% CI 34.8-61.5) among men with normal values of PSA (< 4.0 ng/mL). Based on published data for specificity and prevalence, the estimated positive predictive value of PSA velocity > or = 0.75 ng/mL/yr is as low as 5%. CONCLUSION: PSA velocity may have limited usefulness as a diagnostic test for prostate cancer.

Aged↗
PubMed2005

Obstructive sleep apnea as a risk factor for stroke and death.

BACKGROUND: Previous studies have suggested that the obstructive sleep apnea syndrome may be an important risk factor for stroke. It has not been determined, however, whether the syndrome is independently related to the risk of stroke or death from any cause after adjustment for other risk factors, including hypertension. METHODS: In this observational cohort study, consecutive patients underwent polysomnography, and subsequent events (strokes and deaths) were verified. The diagnosis of the obstructive sleep apnea syndrome was based on an apnea-hypopnea index of 5 or higher (five or more events per hour); patients with an apnea-hypopnea index of less than 5 served as the comparison group. Proportional-hazards analysis was used to determine the independent effect of the obstructive sleep apnea syndrome on the composite outcome of stroke or death from any cause. RESULTS: Among 1022 enrolled patients, 697 (68 percent) had the obstructive sleep apnea syndrome. At baseline, the mean apnea-hypopnea index in the patients with the syndrome was 35, as compared with a mean apnea-hypopnea index of 2 in the comparison group. In an unadjusted analysis, the obstructive sleep apnea syndrome was associated with stroke or death from any cause (hazard ratio, 2.24; 95 percent confidence interval, 1.30 to 3.86; P=0.004). After adjustment for age, sex, race, smoking status, alcohol-consumption status, body-mass index, and the presence or absence of diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension, the obstructive sleep apnea syndrome retained a statistically significant association with stroke or death (hazard ratio, 1.97; 95 percent confidence interval, 1.12 to 3.48; P=0.01). In a trend analysis, increased severity of sleep apnea at baseline was associated with an increased risk of the development of the composite end point (P=0.005). CONCLUSIONS: The obstructive sleep apnea syndrome significantly increases the risk of stroke or death from any cause, and the increase is independent of other risk factors, including hypertension.

Cohort Studies↗
PubMed2005

Racial disparities in stroke risk factors: the impact of socioeconomic status.

BACKGROUND AND PURPOSE: In the US, blacks have a higher incidence of stroke and more severe strokes than whites. Our objective was to determine if differences in income, education, and insurance, as well as differences in the prevalence of stroke risk factors, accounted for the association between ethnicity and stroke. METHODS: We used data from the Third National Health and Nutrition Survey (NHANES III), a cross-sectional sample of the noninstitutionalized US population (1988-1994), and included blacks and whites aged 40 years or older with a self-reported stroke history. Income was assessed using a ratio of income to US Census Bureau annual poverty threshold. RESULTS: Among 11 163 participants, 2752 (25%) were black and 619 (6%) had a stroke history (blacks: 160/2752 [6%]; whites: 459/8411 [6%]; P=0.48). Blacks had a higher prevalence of 5 risk factors independently associated with stroke: hypertension, treated diabetes, claudication, higher C-reactive protein, and inactivity; whites had a higher prevalence of 3 risk factors: older age, myocardial infarction, and lower high-density lipoprotein cholesterol. Ethnicity was independently associated with stroke after adjusting for the 8 risk factors (adjusted odds ratio, 1.32; 95% CI, 1.04 to 1.67). Ethnicity was not independently associated with stroke after adjustment for income and income was independently associated with stroke (adjusted odds ratios for: ethnicity, 1.15; 95% CI, 0.88 to 1.49; income, 0.89; 95% CI, 0.82 to 0.95). Adjustment for neither education nor insurance altered the ethnicity-stroke association. CONCLUSIONS: In this study of community-dwelling stroke survivors, ethnic differences exist in the prevalence of stroke risk factors and income may explain the association between ethnicity and stroke.

Adult↗
PubMed2005

Association between impaired insulin sensitivity and stroke.

BACKGROUND: Prior research has indicated an association between insulin resistance and stroke; we sought to determine if this association persists after adjusting for stroke risk factors, including glycemic control. METHODS: We used data from the Third National Health and Nutrition Survey (1988-1994), including participants aged > or =40 years. We assessed insulin sensitivity using the homeostasis model assessment (HOMA): HOMA = (FPGSI x FPI)/22.5, where FPGSI refers to fasting plasma glucose (mmol/l) and FPI refers to fasting plasma insulin (microU/l). Increasing HOMA indicates decreasing insulin sensitivity. We used glycosylated hemoglobin (HbA1c) to measure glycemic control. Multivariable logistic regression analysis was used to identify factors that were independently associated with stroke. RESULTS: Among 3,844 participants, 168 (4%) reported a stroke history. Participants with stroke had lower insulin sensitivity than participants without stroke: HOMA mean +/- standard deviation, 4.0 +/- 4.0 vs. 3.3 +/- 3.0; p = 0.022. HOMA was independently associated with stroke (odds ratio 1.06, 95% CI: 1.01-1.12; adjusted for age, hypertension, myocardial infarction, claudication, activity, and HbA1c). The strength of the association between HOMA and stroke was similar to the association between claudication and stroke (index R(2): 0.0032 vs. 0.0036). CONCLUSIONS: Impaired insulin sensitivity is independently associated with stroke, even after adjustment for glycemic control.

Adult↗
PubMed2005

Diagnosis, evaluation, and treatment of childhood obesity in pediatric practice.

OBJECTIVE: To determine rates of diagnosis and treatment, and types of treatment, among overweight children in clinical practice. DESIGN: Six hundred randomly selected records were reviewed. SETTING: Two community-based and 2 hospital-based clinics in New Haven. PARTICIPANTS: Children aged 3 to 17 years with a health maintenance visit from January 1, 1999, to December 31, 2000. Children classified according to body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) lower than the 85th percentile were designated as nonoverweight; 85th to 94th percentile, at risk of overweight; and 95th percentile or greater, overweight. MAIN OUTCOME MEASURES: We examined the text of the encounter note for documentation of BMI, corresponding diagnosis regarding overweight, examination for comorbid disease, and treatment for overweight. RESULTS: Among 600 patients, 52.6% were male, 34.5% were black, 35.1% were Latin American, 57.2% were in single-parent households, and 84.0% received Medicaid. Overall, 39.8% were at risk of overweight (n = 107; range across sites, 14.7%-20.0%) or were overweight (n = 132; range across sites, 18.0%-28.0%). The BMI was documented in 0.5% (n = 3) of medical records. Among the 239 children at risk of overweight or overweight, 20.5% had a documented diagnosis (range, 12%-37%) and 16.9% had documented treatment (range, 6%-34%). The most common strategies among the 41 subjects with documented treatment (overweight and at risk of overweight patients) were diet (74%) and increased activity (49%). Treatment recommendations were often limited to general advice (eg, "recommended diet" [n = 19] or "increase exercise" [n = 16]). CONCLUSION: Despite a high burden of overweight, routine screening with BMI was not documented and few children received a formal diagnosis or treatment.

Adolescent↗
PubMed2005

Doctor-patient communication about prognosis: the influence of race and financial status.

CONTEXT: Although many studies have documented problems in communication between physicians and patients, few have focused on discussions regarding prognosis among community dwelling patients with terminal illness. OBJECTIVE: To examine the association of patient race and financial status with patient and clinician reports of discussions about prognosis. DESIGN: Cross-sectional survey. SETTING: Participants' homes. PARTICIPANTS: Two hundred fourteen patients age 60 years or older seriously ill secondary to congestive heart failure, chronic obstructive pulmonary disease, or cancer; and their primary clinicians. MAIN OUTCOME MEASURES: Patient/clinician agreement regarding discussions of prognosis. RESULTS: In adjusted analysis, patients and clinicians were more likely to agree that discussions about prognosis had taken place when patients had a lower financial status (odds ratio [OR] 2.26, 95% confidence interval [CI] 1.03-4.96), or were nonwhite (OR 2.56, CI 0.85-7.68), compared to patients who had a higher financial status or were white. Agreement about prognosis discussions was also more likely (adjusted OR 4.12, 95% CI 1.15-14.76) when patients were younger (i.e., age < 80). CONCLUSIONS: Among a cohort of seriously ill community-dwelling patients, patients and clinicians were more likely to agree that discussions about prognosis had occurred when patients were poorer and nonwhite. These findings contrast with the majority of studies examining the relationship between race or income and patient-physician communication about other end-of-life issues.

Aged↗
PubMed2005

Validity of using an electronic medical record for assessing quality of care in an outpatient setting.

OBJECTIVE: We sought to evaluate the validity of retrieving data from a commercial, outpatient electronic medical record (EMR) to assess the management of pharyngitis, an important measure of quality of healthcare in pediatrics and a new measure for the Health Plan Employer Data and Information Set (HEDIS). METHODS: For children ages 3-18 years, we electronically identified clinical encounters with diagnoses of pharyngitis using 3 different strategies (an EMR-based strategy, an administrative data-based strategy, and a reference strategy which used medical record review). By each strategy, we calculated the proportion of episodes of pharyngitis during 1 year for which management of pharyngitis adhered to published guidelines. RESULTS: Among 479 total episodes of pharyngitis, 434 (91%) were from the EMR-based strategy and 281 (59%) from the administrative data-based strategy. Review of the records (the reference strategy) found that 391 of 479 (82%) were confirmed episodes of pharyngitis. A diagnostic test for group A streptococcus (GAS) was performed at 310 of 434 (71%) of episodes identified by the EMR-based strategy and at 214 of 281 (76%) of episodes by the administrative data-based strategy (P = 0.045). By the reference strategy, a diagnostic test was done in 301 of 391 (77%); more than at episodes found by the EMR-based strategy (71%, P < 0.001). CONCLUSIONS: The EMR-based strategy resulted in a statistically different proportion of episodes having diagnostic testing for GAS compared with a reference strategy. Complete evaluations to validate strategies for extracting data from electronic databases are necessary before assuming that measures of quality of care will be the same regardless of the source of data.

Ambulatory Care↗
PubMed2005

Do age and comorbidity affect intensity of pharmacological therapy for poorly controlled diabetes mellitus?

OBJECTIVES: To examine the influence of age and comorbidity on intensification of medical therapy for patients with poorly controlled diabetes mellitus (DM). DESIGN: Observational cohort study using data from Department of Veterans Affairs (VA) national databases. SETTING: Thirteen VA medical centers in New England, Florida, and Puerto Rico. PARTICIPANTS: Veterans (N=5,317) with poorly controlled DM receiving regular medical care MEASUREMENTS: An increase in hypoglycemic medications, or intensification of therapy, was considered present at the visit if a new hypoglycemic medication was started or the dosage of an existing medication was increased. RESULTS: The overall rate of intensification of therapy was 20.8% (1,106/5,317). The rate of intensification was highest in the youngest patients without comorbidity (24.5%) and lowest in the oldest patients with comorbidity (15.7%) (P<.001). CONCLUSION: Rates of intensification at a single clinic visit were quite low in all groups and were lowest in older patients with comorbidity.

Adult↗
PubMed2005

Are commonly ordered lab tests useful screens for alcohol disorders in older male veterans receiving primary care&#63.

Although mean corpuscular volume (MCV), aspartate aminotransferase (AST), alanine aminotransferases (ALT), and the AST/ALT ratio are sometimes used as markers of alcohol disorders, their utility has not been established in older persons. We determined the tests' performance characteristics for (1) at-risk drinking, (2) CAGE positivity, (3) at-risk drinking and CAGE positivity, and (4) a clinician-recorded diagnosis of alcohol abuse/dependence in a study of older male veterans receiving primary care. Participants (n = 587) included patients who had MCV, AST, and/or ALT data collected as part of routine care no more than 12 weeks before or after enrollment. MCV, AST, and ALT test results were obtained from the VA's database. At enrollment, the Timeline Followback and Alcohol Use Disorders Identification Test (AUDIT) were used to identify at-risk drinkers (> or = 15 drinks per week or AUDIT score > or = 8), and the CAGE questionnaire was administered to identify participants with a history abuse/dependent drinking (CAGE score > or = 2). Participants' medical records were reviewed to identify subjects with a clinician-recorded diagnosis of alcohol abuse/dependence. The prevalence of abnormal test results for MCV (threshold value = > 98), AST (> 41), ALT (> 41), and the AST/ALT ratio (> 2) was 11%, 4%, 4%, and 5%, respectively. The occurrence of at-risk drinking, CAGE positivity, at-risk drinking and CAGE positivity, and a clinician-recorded diagnosis of alcohol abuse/dependence was 11%, 25%, 5%, and 9%, respectively. Test sensitivity ranged from 3.9% to 25.4% and specificity from 88.5% to 97.1%, whereas positive likelihood ratios varied from 0.72 to 4.01 and negative likelihood ratios from 0.82 to 1.04. Areas under the receiver operating characteristic curve were similar (range = 0.50-0.58) across tests. In conclusion, MCV, AST, ALT, and the AST/ALT ratio are not useful markers of alcohol disorders in older male veterans.

Aged↗
PubMed2004

Informed consent for thrombolytic therapy for patients with acute ischemic stroke treated in routine clinical practice.

BACKGROUND AND PURPOSE: Little is known about informed consent for tissue plasminogen activator (tPA). Our objectives were to determine how frequently informed consent is obtained when tPA is given to stroke patients in clinical practice and whether the person providing consent (patient or surrogate) was the appropriate decision-maker. METHODS: This retrospective cohort included acute stroke patients given tPA in 10 Connecticut hospitals (1996-1998). Consent was defined as any documentation of discussion about risks and benefits of tPA. Patients had adequate decision-making capacity if they were alert, oriented, and without aphasia or neglect (patient was appropriate decision-maker). Patients with any of these deficits were considered to have diminished capacity (surrogate was appropriate decision-maker). RESULTS: Among 63 patients who received tPA, 53 (84%) had informed consent documented; 16/53 (30%) gave their own consent. Among patients with adequate decision-making capacity, 5/8 (63%) had consent by surrogate. Among patients with diminished capacity, 7/38 (18%) provided their own consent. CONCLUSIONS: A substantial percentage of patients who received tPA for stroke had no consent documented. Surrogates often provided consent when the patients had capacity; conversely, patients with diminished capacity sometimes provided their own consent. Given the urgency and weight of the decision regarding tPA, more explicit informed consent and capacity assessment should be considered for treatment protocols.

Acute Disease↗
PubMed2004

Treatment options in knee osteoarthritis: the patient's perspective.

BACKGROUND: The objectives of this study were to (1) examine patient treatment preferences for knee osteoarthritis, (2) determine the influence of specific medication characteristics on patients' choices, and (3) examine whether patient preferences are consistent with current practice. METHODS: A total of 100 consecutive patients with symptomatic knee osteoarthritis completed an interactive computer questionnaire administered during a face-to-face interview. We measured the relative impact of specific medication characteristics (including administration, risks, benefits, and cost) on patients' choice, and the percentage of patients preferring nonselective nonsteroidal antiinflammatory drugs (NSAIDs), cyclooxygenase-2 inhibitors, glucosamine and/or chondroitin sulfate, opioid derivatives, and capsaicin across varying risks, benefits, and costs. RESULTS: Of the characteristics studied, variation in the risk of common adverse effects and gastrointestinal ulcer had the greatest impact on patients' choice. Assuming patients are responsible for the full cost of their medications, over 40% prefer capsaicin. Cyclooxygenase-2 inhibitors become patients' preferred choice only if they are described as being 3 times as effective as capsaicin and are covered by insurance. Nonselective NSAIDs are among the least preferred options across all simulations. CONCLUSIONS: When evaluating multiple alternatives, many older patients with knee osteoarthritis are willing to forgo treatment effectiveness for a lower risk of adverse effects. The patient treatment preferences derived in this study conflict with the current widespread use of nonselective NSAIDs in older patients with arthritis.

Aged↗