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Biomedical subjects

R L Bohn

Publications and source records attributed to R L Bohn.

35 records · Page 2Linked to original sources
PubMed1997

Concurrent use of antiulcerative agents.

Many physicians prescribe more than one antiulcerative agent (AUA) simultaneously to the same patient, although there is little evidence to support this practice. The purposes of this study were to (a) determine patient factors associated with the concurrent use of these agents and (b) estimate the excess costs generated by the prescription of multiple rather than a single agent. We conducted a case-control study of concurrent AUA users among New Jersey Medicaid enrollees age 65 years and older. To evaluate the excess cost generated by the ongoing prescription of an additional AUA, we measured the additional drug expenditures associated with each regimen of concurrent use. Nearly 1 in 15 AUA users (6.6%) met our conservative definition of concurrent AUA use. In a multiple logistic regression model, previous gastrointestinal procedure, use of a nonsteroidal anti-inflammatory drugs, nursing home residency, and recent hospitalization for more than 20 days were all predictors of concurrent use of more than one AUA. No association was found with age, sex, or number of pharmacies used. The upper bound estimate of the cost generated by the concurrent prescription of a second AUA was $210 (range: $2-$942) over the 180-day study period, with a lower bound of $151 (range: $1-$449). Annually, such excess cost would range from $301 to $420 per patient. This would account for between $457 million and $637 million per year for the nation's elderly if these patterns are generalizable. Despite the lack of evidence of therapeutic benefit from multiple concurrent AUA use in most patients, this practice is fairly common. Besides introducing the risk of additional costs and side effects in the absence of additional efficacy, the costs of such duplicative prescribing are substantial.

Aged↗
PubMed1997

Policy analysis of the conversion of histamine2 antagonists to over-the-counter use.

OBJECTIVES: The authors assess the costs associated with treatment of dyspepsia with histamine2 antagonists versus without availability of over-the-counter (OTC). METHODS: A cost analysis was performed using a decision-analysis model. Patients with an initial episode of dyspepsia were studied. The model includes costs associated with consumption of OTC and prescription (Rx) medications for dyspepsia, physician visits and associated diagnostic testing, time spent for physician visits and diagnostic tests, and hospitalization costs. RESULTS: The model is sensitive to the relative cost of histamine2 antagonists when purchased Rx or OTC, as well as to the efficacy of these drugs in relieving dyspeptic symptoms. For patients with nonulcer dyspepsia (the largest group of likely consumers), the model demonstrates a cost savings if the OTC cost of the medication is slightly less than one third the Rx cost. Costs are similar whether or not histamine2 antagonists are available OTC. If the symptom relief efficacies of histamine2 antagonists are equivalent whether purchased by prescription only or OTC, then the health-care expenditures for a typical patient with dyspepsia are $204 for OTC availability and $203 for Rx-only use. Viewing costs from the perspective of a managed-care organization, expenditures for an episode of dyspepsia are $149 regardless of whether or not histamine2 antagonists are available OTC. Restricting the analysis to patients with underlying nonulcer dyspepsia yields similar results. Variation of numerous assumptions and probabilities other than histamine antagonist cost and efficacy, including costs associated with physician visits and diagnostic tests, and the likelihood of seeking medical care, do not substantially affect the results of the model. CONCLUSIONS: Health-care costs associated with initial treatment of dyspepsia are similar regardless of the availability of histamine2 antagonists OTC. This is due largely to the similar efficacy of these drugs compared with antacids and the predicted increase in diagnostic testing that may result if a patient visits a physician after failure to achieve symptom relief with OTC use of histamine2 antagonists.

Cost Savings↗
PubMed1997

The impact of thiazide diuretics on the initiation of lipid-reducing agents in older people: a population-based analysis.

OBJECTIVE: The objective of this study was to examine how often treatment for hyperlipidemia followed the use of thiazides, compared with the use of other antihypertensive drugs, in older patients. DESIGN: Retrospective follow-up of all health claims filed over a 12-month period. SETTING: New Jersey Medicaid and Medicare programs. PARTICIPANTS: A total of 9274 enrollees, aged 65 to 99, who were newly initiated on antihypertensive medications from 1981-1989. MEASUREMENTS: We measured rates of lipid-reducing agent (LRA) initiation among patients in the 2 years following antihypertensive initiation (thiazide, non-thiazide drug, or combinations of the two) compared with rates among patients not currently taking antihypertensive agents. We used Cox regression analyses to estimate relative risks (RR), accounting for switching in antihypertensive therapy and for time when drug therapy was not currently available according to pharmacy refill records. RESULTS: There were 226 patients (2.4%) in the cohort who were started on LRA during the follow-up period. After adjusting for potential confounders, we found no significant relationship between LRA initiation and overall thiazide use (RR 1.47, 95% CI 0.89-2.40), or other antihypertensive use, relative to no current exposure. However, use of high-dose thiazides (> or = 50 mg) was associated significantly with LRA initiation (RR 1.97, 95% CI 1.12-3.45). Factors associated with decreased incidence of LRA use included age > or = 85 (RR 0.59, 95% CI 0.36-0.96), black race (RR 0.58, 95% CI 0.37-0.91), and nursing home residency (RR 0.20, 95% CI 0.11-0.35). CONCLUSION: Use of low-cost and effective thiazide diuretics in older hypertensives was not associated with more common initiation of lipid-reducing agents, except with high-dose use of thiazides currently seen as inappropriate in most cases. Age and race were important determinants of LRA use.

Aged↗
PubMed1996

Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race.

OBJECTIVES: This study measured compliance and related demographic factors in a retrospective cohort of 4068 elderly outpatients newly starting antihypertensive therapy from 1982 through 1988. METHODS: Logistic regression modeling of data from the New Jersey Medicaid program was used. RESULTS: These patients filled antihypertensive prescriptions covering an average of only 179 days in the 365-day follow-up period (49%) Good compliance (> or = 80%) was associated with advanced age (odds ratio [OR] = 2.12, for patients 85 or older) and White race (OR = 0.55 for Blacks). There was no relationship between compliance and gender. CONCLUSIONS: Despite the efficacy of antihypertensive therapy in preventing cardiovascular morbidity, such high rates of noncompliance may contribute to suboptimal patient outcomes.

Age Factors↗
PubMed1996

Prophylaxis and continuous infusion for hemophilia: can we afford it?

Little is known about the ideal factor regimen for hemophiliacs nor how treatment should be administered. A prospective multicenter study evaluated different dosage regimens and defined orthopedic outcomes, based on factor consumption and a comparison of prophylaxis with on-demand therapy. Prophylaxis led to better outcomes, whether joints were initially normal or previously affected. Factor use was substantially more costly if prophylaxis was used, but a major reduction could be achieved if continuous infusion were feasible.

Cost-Benefit Analysis↗
PubMed1995

Increased incidence of levodopa therapy following metoclopramide use.

OBJECTIVE: To determine whether there is an increase in use of antiparkinsonian therapy in older persons taking metoclopramide hydrochloride. DESIGN: Case-control study. SETTING: New jersey Medicaid program. PATIENTS: Medicaid enrollees aged 65 years and older. Cases were patients newly prescribed a levodopa-containing medication (n = 1253); a secondary case group were patients newly prescribed an anticholinergic antiparkinsonian drug (n = 2377). The control group consisted of 16435 Medicaid enrollees older than 65 years who were not users of any antiparkinsonian therapy. MAIN OUTCOME MEASURES: We used logistic regression to determine the odds ratio (OR) for the initiation of antiparkinsonian therapy in patients using metoclopramide relative to nonusers, after adjusting for age, sex, race, nursing home residence, exposure to antipsychotic medication, and days hospitalized. RESULTS: Metoclopramide users were three times more likely to begin use of a levodopa-containing medication compared with nonusers (OR = 3.09; 95% confidence interval [Cl], 2.25 to 4.26). Risk increased with increasing daily metoclopramide dose: the OR was 1.19 (95% Cl, 0.50 to 2.81) for more than 0 to 10 mg per day, 3.33 (95% Cl, 1.98 to 5.58) for more than 10 to 20 mg per day, and 5.25 (95% Cl, 1.16 to 8.50) for more than 20mg per day. The effect persisted after adjustment for demographic, health service utilization, and medication use variables. The OR for initiation of anticholinergic antiparkinsonian drugs was also elevated in metoclopramide users. CONCLUSION: Metoclopramide use confers an increased risk for the initiation of treatment generally reserved for the management of idiopathic Parkinson's disease in patients with drug-induced parkinsonian symptoms, which should be ruled out before starting dopaminergic therapy for this condition.

Aged↗
PubMed1995

Neuroleptic drug exposure and treatment of parkinsonism in the elderly: a case-control study.

PURPOSE: Despite the widespread use of neuroleptic medications for the elderly, little is known about the frequency of treatment for drug-induced parkinsonian syndromes in this age group, particularly with L-dopa-type drugs, which are more appropriate for the treatment of true idiopathic Parkinson's disease. PATIENTS AND METHODS: We identified 3,512 patients aged 65 to 99 enrolled in a large state Medicaid program who were newly prescribed a drug to treat parkinsonian symptoms. Controls were comparable program enrollees of similar age who had not been prescribed an antiparkinsonian drug. In a case-control study, we evaluated the use of neuroleptic drugs in the 90 days before initiation of antiparkinsonian therapy. RESULTS: Patients taking neuroleptics were 5.4 times more likely to begin antiparkinsonian medication than were nonusers (95% confidence interval [CI] 4.8 to 6.1). They also had a greater than two-fold increase in risk of beginning therapy with a dopaminergic drug specific for idiopathic Parkinson's disease, not generally indicated for treatment of drug-induced parkinsonism (adjusted odds ratio 2.2, 95% CI 1.9 to 2.7). Clear dose-response relationships were demonstrated, as were differences among neuroleptics. Among all patients started on dopaminergic drugs in this population, 37% of such therapy was attributable to prior neuroleptic use. Continuation of the neuroleptic persisted in 71% of patients so treated. CONCLUSION: Neuroleptic use is a common cause of extrapyramidal dysfunction in the elderly, and the side effect is frequently treated by adding an anticholinergic or dopaminergic drug to the regimen. The use of anticholinergic drugs presents risks of additional drug side effects; the use of dopaminergic drugs, generally not appropriate for drug-induced parkinsonian syndrome, suggests that extrapyramidal neuroleptic side effects may often be mistaken for idiopathic Parkinson's disease in older patients.

Age Distribution↗
PubMed1995

Hemophilia home treatment. Economic analysis and implications for health policy.

This analysis describes the development of technology for home self-infusion of factor VII in the treatment of hemophilia and its clinical, economic, and social consequences, and uses the case study of such home care treatment to illustrate the potentials and pitfalls of formal economic analyses of programs to treat chronically ill children. A comprehensive review of all original data on hemophilia programs, their related costs, and outcomes, conducted from 1966 through 1993, examined the economic outcomes for two hypothetical cohorts, one aged 0-4 years and the other aged 30-34 years. Including the measurement of treatment effects on the productivity of parental caregivers substantially increases the benefit-cost relationship of an intervention directed at chronically ill children. Increased economic productivity and societal return resulting from such a program for young adults exceeds those for a cohort of children, primarily due to assumptions related to discounting. However, estimation of quality-adjusted life years favors the younger age cohort, since children survive for a longer period of time and with each year survived comes a higher quality of life. Unlike simpler instances in which economic benefits can be shown to outweigh resource costs, policy decisions concerning services for chronically ill children raise an additional set of complex analytic issues. Inclusion of the benefits in productivity experienced by family caregivers provides an important added dimension to such analyses. The development of cost-benefit or cost-effectiveness analyses of these programs illustrates the importance of careful measurement of outcomes and explicit statements of underlying assumptions. Such an analysis of home care for children with hemophilia therefore demonstrates both the strengths and the limitations of this approach.

Adult↗
PubMed1995

Antipsychotic prescribing patterns and the treatment of extrapyramidal symptoms in older people.

OBJECTIVES: We have previously identified antipsychotic use as a risk factor for the use of both dopaminergic and anticholinergic antiparkinsonian drugs in older people. This study examines whether and how such antipsychotic regimens were adjusted before the addition of an antiparkinsonian drug. DESIGN: Retrospective comparison study PARTICIPANTS: There were 1307 antipsychotic users begun on anticholinergic antiparkinsonian drugs and 345 antipsychotic users begun on dopaminergic drugs; 1864 antipsychotic users not prescribed antiparkinsonian drugs served as comparison subjects. Data were drawn from health care claims of patients aged 65-99 in the New Jersey Medicaid Program from 1981 to 1990. MEASUREMENTS: We determined if antipsychotic regimens were discontinued, reduced in dosage, or modified to reduce extrapyramidal toxicity before the institution of antiparkinsonian therapy. RESULTS: Thirty-five percent of the patients begun on dopaminergic drugs had their antipsychotic medication discontinued before beginning antiparkinsonian therapy; the antipsychotic was discontinued in only 12% of patients who started anticholinergic medications (P < .001). Among the smaller subset of patients with sufficient duration of antipsychotic exposure to examine changes in dose, 54% of patients begun on dopaminergic agents had their antipsychotic regimen reduced or discontinued before antiparkinsonian therapy, whereas 33% of patients begun on anticholinergic agents had one of these regimen changes (P < .001). Controlling for potential clinical and demographic confounders using multivariate logistic regression did not substantively alter these results. CONCLUSIONS: These data indicate that physicians frequently fail to discontinue or modify an antipsychotic regimen before adding a new drug to treat probable drug-induced extrapyramidal symptoms. Such prescribing patterns preceding use of dopaminergic antiparkinsonian drugs suggest that addition of such drugs may represent an inappropriate attempt to treat presumed idiopathic Parkinson's disease in many cases.

Aged↗
PubMed1995

Trends in medication choices for hypertension in the elderly. The decline of the thiazides.

We studied the evolution in choice of antihypertensive therapy in the elderly over a seven-year period and defined factors associated with such prescribing. To accomplish this, we performed a retrospective analysis of 8428 enrollees older than 65 years of age in the New Jersey Medicaid and Medicare programs newly begun on antihypertensive therapy between 1982 and 1988. Diuretics were the most common agents prescribed (51%), followed by calcium channel blockers (14%), beta-blockers (13%), central adrenergic antagonists (11%), and angiotensin-converting enzyme inhibitors (5%). However, the use of diuretics declined sharply during the latter part of the time interval studied. Using logistic regression modeling, we determined that the odds of a subject being started on a diuretic compared with any other antihypertensive drug decreased from 1.0 during the referent years 1982 to 1984 to 0.75 in 1985 to 1986 and to 0.41 in 1987 to 1988, after controlling for demographics, comorbidity, and hospital and physician visits (P < .001). The relative odds of diuretic use were significantly increased (P < .05) for the oldest subjects (odds ratio, 1.28 for age 85 and older versus ages 65 to 74 odds), women (odds ratio, 1.15), and blacks (odds ratio, 1.14). Despite the growing evidence during the study interval of the efficacy of diuretics in treating hypertension in the elderly, diuretic use diminished throughout this period in relation to other antihypertensive drugs. Subject characteristics (oldest subjects, women, and blacks) were important determinants of physicians' choice of antihypertensive therapy.

Aged↗
PubMed1994

Initiation of antihypertensive treatment during nonsteroidal anti-inflammatory drug therapy.

OBJECTIVE: To determine whether there is an increased risk for the initiation of antihypertensive therapy in older persons prescribed nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDs). DESIGN: Case-control study. SETTING: New Jersey Medicaid program. PATIENTS: Medicaid enrollees aged 65 years and older. The 9411 case patients were newly started on an antihypertensive medication between November 1981 and February 1990. A similar number of controls were randomly selected among other enrollees. MAIN OUTCOME MEASURES: We used logistic regression to determine the odds ratio for the initiation of antihypertensive therapy in patients using NSAIDs relative to nonusers, after adjusting for age, sex, race, nursing home residence, number of prescriptions filled, intensity of physician utilization, and days hospitalized. RESULTS: The adjusted odds ratio for the initiation of antihypertensive therapy for recent NSAID users compared with nonusers was 1.66 (95% confidence interval, 1.54 to 1.80). The odds ratio increased with increasing daily NSAID dose: the adjusted odds ratio for users of low average daily doses relative to nonusers was 1.55 (95% CI, 1.38 to 1.74), that for medium-dose users was 1.64 (95% CI, 1.44 to 1.87), and that for high-dose users was 1.82 (95% CI, 1.62 to 2.05). CONCLUSIONS: Use of NSAIDs may increase the risk for initiation of antihypertensive therapy in older persons. Given the high prevalence of NSAID use by elderly persons, this association may have important public health implications for the management of hypertension in the older population.

Aged↗
PubMed1994

Noncompliance with congestive heart failure therapy in the elderly.

BACKGROUND: Noncompliance with long-term medication regimens, such as those employed in the treatment of congestive heart failure (CHF), has been found to be approximately 50%. However, no evaluation has been performed on a population-based cohort of elderly patients beginning the use of digoxin and followed up longitudinally for an extended observation period. METHODS: To study patterns of medication compliance, we conducted a retrospective follow-up of 7247 outpatients aged 65 to 99 years newly prescribed digoxin between 1981 and 1991, with the use of the complete prescription claims file of the New Jersey Medicaid program. Noncompliance was measured in terms of the number of days during the 12-month period after an initial digoxin prescription in which no CHF medication was available to the patient. RESULTS: Patients started on a regimen of digoxin were without digoxin or any other common alternative CHF drug for an average of 111 of the 365 days of follow-up. Only 10% of the population filled enough prescriptions to have daily CHF medication available for the entire year of follow-up. Compliance rates were higher in patients over 85 years of age, women, those taking multiple medications, and those with hospital or nursing home stays before the initiation of therapy. CONCLUSIONS: A large proportion of patients who begin digoxin therapy end CHF therapy or consume substantially less medication than expected in the first year of therapy. Such high rates of cessation could represent an important impediment to effective CHF therapy.

Aged↗
PubMed1994

Glucocorticoids and the risk for initiation of hypoglycemic therapy.

PURPOSE: To quantify risk for the occurrence of hyperglycemia requiring initiation of hypoglycemic therapy in patients treated with oral glucocorticoids. PATIENTS AND METHODS: A case-control study of enrollees in the New Jersey Medicaid program 35 years of age or older. The 11,855 case patients had newly initiated treatment with a hypoglycemic agent (oral or insulin) between 1981 and 1990. The 11,855 controls represented a random sample of other Medicaid enrollees. RESULTS: In patients using oral glucocorticoids, the estimated relative risk for development of hyperglycemia requiring treatment was 2.23 (95% confidence interval, 1.92 to 2.59) as compared with nonusers. Risk increased with increasing average daily steroid dose, in hydrocortisone-equivalent milligrams; the odds ratio was 1.77 for 1 to 39 mg/d, 3.02 for 40 to 79 mg/d, 5.82 for 80 to 119 mg/d, and 10.34 for 120 mg/d or more. The estimated effects persisted after adjustment for a variety of potentially confounding demographic, health service utilization, and medication use variables. CONCLUSION: The findings of this population-based study quantify the risk of developing hyperglycemia requiring hypoglycemic therapy after oral glucocorticoid use. The magnitude of risk increases substantially with increasing glucocorticoid dose. These findings demonstrate the utility of large-scale health claims databases in defining the risk of important adverse drug effects.

Administration, Oral↗
PubMed1994

Topical glaucoma medications and cardiovascular risk in the elderly.

OBJECTIVE: To determine the frequency of congestive heart failure and cardiac conduction disturbances in elderly patients treated with topical glaucoma medications. METHODS: These case-control studies were conducted among participants in the New Jersey Medicaid and Medicare program from 1986 to 1990. A total of 35,445 subjects (ages 65 to 99 years) were included in the congestive heart failure analysis, and 4278 subjects were included in the conduction disorder analysis. RESULTS: The frequency of initiation of congestive heart failure therapy, defined as the new use of digoxin or furosemide, was not increased for users of topical glaucoma medications. The frequency of pacemaker placement was also not increased for topical glaucoma medication users. Analyses were adjusted for age, race, gender, nursing home or hospital status, number of prescription medications, and selected medication exposures. Advanced age and heavy use of other prescription medications were associated with an increased likelihood of both cardiovascular outcomes. CONCLUSION: Major cardiovascular side effects did not occur at an increased rate among patients using topical beta-blockers or other glaucoma medications compared with control subjects. This population-based study places findings from case reports and small clinical trials in a broader context to help with clinical assessment of the risks and benefits of glaucoma therapy in the elderly.

Administration, Topical↗
PubMed1993

Old age and race as determinants of initiation of glaucoma therapy.

Demographic differences in the prevalence of blindness may be partly due to undertreatment of susceptible population subgroups. The authors examined the relation of age, race, and other demographic characteristics with initiation of treatment for glaucoma and compared treatment rates with expected rates based on known disease prevalence. Data were from Medicaid enrollees aged 65-99 years in New Jersey between March 1981 and February 1990. Based on review of all claims for prescription medications and laser and incisional surgery, there were 6,173 cases with at least 6 months of documented system eligibility before their initial treatment for glaucoma. The overall rate of new treatment was 11.5 cases per 1,000 person-years, and increased throughout the 1980s. The age-adjusted relative rate of new treatment was 1.58 times higher in blacks compared with whites; however, this was less than half the relative rate expected based on estimated relative incidence rates. Similarly, enrollees aged 70-99 years had only 7% to 27% higher treatment rates than those aged 65-69 years, substantially less than expected. Treatment for glaucoma was also less likely to be initiated in nursing home residents, compared with those living in the community. Blacks and the very old are much less likely to have treatment for glaucoma initiated than would be predicted based on the magnitude of disease burden in these populations.

Black or African American↗
PubMed1993

Antihypertensive drug therapy and the initiation of treatment for diabetes mellitus.

OBJECTIVE: To quantify the risk for the occurrence of hyperglycemia requiring initiation of therapy among patients taking various antihypertensive regimens. DESIGN: Case-control study. SETTING: New Jersey Medicaid program. PATIENTS: The study included New Jersey Medicaid enrollees 35 years of age or older. The 11,855 case patients were newly started on a hypoglycemic agent (oral agent or insulin) between 1981 and 1990. The 11,855 controls were selected randomly from among other Medicaid enrollees. MEASUREMENTS AND MAIN RESULTS: The frequency of initiation of hypoglycemic therapy was increased for users of virtually all antihypertensive agents relative to nonusers after adjustment for age, gender, race, nursing home residency, number of days hospitalized, total number of prescriptions, and selected medication exposures. The estimated relative risk for initiation of hypoglycemic therapy was 1.40 for patients receiving thiazide diuretics (95% CI, 1.26 to 1.58) and ranged from 1.56 to 1.77 for patients receiving other antihypertensive medications, depending on the medication category. A higher risk was associated with multiple-agent regimens, whether they excluded a thiazide diuretic (odds ratio, 1.76; CI, 1.49 to 2.07) or included one (odds ratio, 1.93; CI, 1.75 to 2.13). When the analysis was restricted to users of antihypertensive agents (n = 8005), the risk associated with other single-agent antihypertensive regimens was not significantly different from that associated with thiazide diuretics. However, patients receiving multiple-agent regimens continued to be at increased risk for hyperglycemia requiring hypoglycemic therapy relative to those who used thiazide diuretic therapy alone. CONCLUSION: The association between antihypertensive therapy and the initiation of treatment for diabetes mellitus is more closely related to the intensity of therapy than to the individual agent used. Our data do not support the hypothesis that thiazide diuretics are more strongly associated with the initiation of hypoglycemic therapy than are other antihypertensive agents.

Adult↗