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PubMed2006

Asthma and allergy medication use and costs among pediatric primary care patients on asthma controller therapy.

As observational studies in children initiating GINA-Step 3 therapies are scarce, we evaluated outcomes and costs in a primary care cohort. Two-yr retrospective cohort study included French children (age: 6-14) continuously followed in BKL-Thalès database who received > or =2 consecutive prescriptions for GINA-Step 3 therapy (=addition of montelukast or other controllers ('other'), such as increasing inhaled-corticosteroid dose (hICS), adding long-acting beta agonist (LABA), or ICS + LABA). After matching on gender and propensity score, medication use [rescue (short-acting beta agonists), acute (antibiotics (AB), oral corticosteroids (OCS)), allergy (antihistamines, nasal steroids) and other respiratory] was estimated via mean number of prescriptions and mean cost (per child/per month), and cost trends. During 12-month follow-up, children adding montelukast (n = 71) vs. 'other' (n = 213) had similar asthma rescue/acute and allergy medication use. Subgroup with asthma and allergic rhinitis (A + AR) adding montelukast used less OCS and AB (p = 0.014). Two-yr cost trends suggest stable asthma/allergy medication use in montelukast group (0.83 euro) compared with increase in 'other' (5.39 euro), which was driven by nasal steroid use [0.32 euro ('other') vs. -0.04 euro (montelukast), p = 0.0013]. In subgroup with A + AR decline in asthma/allergy medication use in montelukast group (-0.47 euro) vs. increase in 'other' (11.05 euro), p = 0.015, was driven by differences in AB and OCS (p = 0.04) and nasal steroid use (p = 0.001). Concomitant asthma/allergy medication use was similar in children adding montelukast or 'other' controllers (hICS, LABA, ICS + LABA), while children with allergic rhinitis on montelukast used less AB. Concomitant medication costs after addition of montelukast remained stable, while 'other' group experienced increase, especially in children with concomitant allergic rhinitis.

Acetates↗

PubMed2005

Comparison of pioglitazone with other antidiabetic drugs for associated incidence of liver failure: no evidence of increased risk of liver failure with pioglitazone.

AIM: The aim of this study was to assess the incidence of liver failure in association with antidiabetic treatment using pioglitazone vs. other oral antidiabetic medications. METHODS: The study was a retrospective analysis of claim data from the PharMetrics Patient-Centric Database that had over 1.12 million enrollees with type 2 diabetes. All patients, > or =18 years of age with type 2 diabetes, who had initiated treatment either with a thiazolidinedione (pioglitazone and rosiglitazone), sulfonylurea or metformin were identified and matched on the basis of propensity scores, which served as a proxy for severity of disease. The primary measure of interest was the incidence of liver failure or hepatitis post-index date. In addition to unadjusted comparisons, Cox proportional hazard models were employed to estimate the risk of developing liver failure or hepatitis. RESULTS: There was no significant difference in the 1- and 2-year incidence rates of liver failure or hepatitis (primary and secondary diagnoses) between the pioglitazone monotherapy group and the respective comparator groups. In Cox proportional hazard models controlling for age, pre-index total healthcare costs, Charlson comorbidity index, procedures and a hospitalization or Emergency room (ER) visit for pre-index hyperglycaemia, and pioglitazone were not associated with an increased risk of liver failure or hepatitis, compared to all other defined groups. Furthermore, no primary or secondary diagnosis of liver failure was reported in the pioglitazone group during the follow-up period. CONCLUSIONS: Results of retrospective data analysis demonstrate no evidence of increased risk of liver failure or hepatitis for patients initiating therapy on pioglitazone, compared to other oral antidiabetic agents. Pioglitazone therapy was not associated with an increased risk of liver failure at 2 years relative to other oral antidiabetic therapies.

Administration, Oral↗

PubMed2005

Reduced cardiovascular morbidity and mortality associated with metformin use in subjects with Type 2 diabetes.

AIM: Metformin therapy reduces microvascular complications in Type 2 diabetes; questions remain, however, regarding its impact on macrovascular events. This study examined metformin use in relation to risk of cardiovascular-related hospitalization and mortality. METHODS: We conducted a retrospective cohort analysis, using Saskatchewan Health administrative databases to identify new users of oral antidiabetic drugs. Subject groups were defined by medication use during 1991-1999: sulphonylurea monotherapy, metformin monotherapy, or combination therapy. Deaths and non-fatal hospitalizations recorded during the study period were identified as cardiovascular-related from ICD-9 codes. The main outcome was a composite of first non-fatal hospitalization or death. Standard multivariate techniques, including propensity scores, were used to adjust for potential confounding. Multivariate Cox proportional hazard models were used to examine the relationship between metformin use and the composite endpoint. RESULTS: Metformin monotherapy was associated with a lower risk of the composite endpoint (adjusted hazard ratio 0.81; 95% confidence interval 0.68, 0.97) compared with sulphonylurea monotherapy. Combination therapy with meformin and a sulphonylurea was associated with lower mortality, but had similar hospitalization rates, to sulphonylurea monotherapy. CONCLUSIONS: Metformin monotherapy was associated with a lower risk of cardiovascular-related morbidity and mortality, and combination metformin and sulphonylurea therapy was associated with a reduced risk of fatal cardiovascular events, when compared with sulphonylurea monotherapy.

Aged↗

PubMed2004

Care following acute myocardial infarction in the Veterans Administration Medical Centers: a comparison with Medicare.

OBJECTIVE: To compare patients treated for acute myocardial infarction (AMI) in a Veterans Health Administration (VHA) facility to similar patients treated under Medicare. DATA SOURCES: Administrative data on 13,129 elderly male veterans hospitalized for AMI in a VHA facility between October 1, 1996, and September 30, 1999, and a matched set of male Medicare beneficiaries with AMI treated in a non-VHA facility during the same time period. STUDY DESIGN: We conducted a retrospective cohort study using propensity score methods to identify a matched set of male elderly AMI patients treated either in a VHA facility or in a non-VHA facility under Medicare. We compared the two groups of patients according to characteristics of the admitting hospital, distances traveled for care, the use of invasive procedures, and mortality. We assessed the robustness of our conclusions to biases arising from unmeasured confounders using sensitivity analyses. PRINCIPAL FINDINGS: VHA patients were significantly less likely than Medicare beneficiaries to be admitted to high-volume facilities (for example, 25 percent versus 46 percent in 1999, p<0.001) or facilities with the capability to perform invasive cardiac procedures. Compared to Medicare patients, VHA patients traveled almost twice as far to their admitting hospital. The VHA patients were significantly less likely to undergo coronary angiography or revascularization in the 30 days following their AMI (p<0.001 for all comparisons). Veterans treated in the VHA had significantly higher mortality at one-year in all years studied (for example, 35.2 percent versus 30.6 percent in 1999). The proportion of elderly VHA patients admitted to high-volume facilities increased and 30-day mortality rates decreased between 1997 and 1999. Using sensitivity analyses to assess possible effects of unmeasured confounders, we could explain some but not all of the observed mortality differences. CONCLUSIONS: We observed differences in the way care for AMI patients was structured, in the use of invasive therapies, and in long term mortality between patients treated in VHA hospitals and those treated in non-VHA facilities under Medicare. Future research should focus on explanations for the differences between the two systems and for the reduction in short-term mortality among VHA patients. Further study of these differences both between and within the systems of care may help identify cost-effective strategies to improve care in both sectors.

Aged↗

PubMed2005

The effect of Medicaid payment generosity on access and use among beneficiaries.

OBJECTIVE: This study examines the effects of Medicaid payment generosity on access and care for adult and child Medicaid beneficiaries. DATA SOURCE: Three years of the National Surveys of America's Families (1997, 1999, 2002) are linked to the Urban Institute Medicaid capitation rate surveys, the Area Resource File, and the American Hospital Association survey files. STUDY DESIGN: In order to identify the effect of payment generosity apart from unmeasured differences across areas, we compare the experiences of Medicaid beneficiaries with groups that should not be affected by Medicaid payment policies. To assure that these groups are comparable to Medicaid beneficiaries, we reweight the data using propensity score methods. We use a difference-in-differences model to assess the effects of Medicaid payment generosity on four categories of access and use measures (continuity of care, preventive care, visits, and perceptions of provider communication and quality of care). PRINCIPAL FINDINGS: Higher payments increase the probability of having a usual source of care and the probability of having at least one visit to a doctor and other health professional for Medicaid adults, and produce more positive assessments of the health care received by adults and children. However, payment generosity has no effect on the other measures that we examined, such as the probability of receiving preventive care or the probability of having unmet needs. CONCLUSIONS: Higher payment rates can improve some aspects of access and use for Medicaid beneficiaries, but the effects are not dramatic.

Adult↗

PubMed2004

Use of angiotensin-converting enzyme inhibitor therapy and dose-related outcomes in older adults with new heart failure in the community.

OBJECTIVE: To evaluate the dose-related benefit of angiotensin-converting enzyme (ACE) inhibitor therapy among older adults with heart failure and to evaluate whether low-dose ACE inhibitor therapy is better than none. DESIGN: Observational cohort study. SETTING: Community-dwelling older adults in Ontario, Canada. PATIENTS/PARTICIPANTS: We identified 16539 adults 66 years or older who survived 45 days following their first heart failure hospitalization discharge. MEASUREMENT AND MAIN RESULTS: Multivariate techniques including propensity scores were used to study the association between the dose of ACE inhibitor therapy dispensed and 3 outcomes: survival, survival or heart failure rehospitalization, and survival or all-cause hospitalization at 1 year of follow-up. Logistic regression models explored the association between initial dose dispensed and subsequent dose reduction or drug cessation. Overall, 10793 (65.3%) of patients were dispensed ACE inhibitor therapy, with more than a third (3935; 36.5%) initiated on low-dose therapy. Relative to dispensing of low-dose ACE inhibitor therapy, nonuse was associated with increased mortality (hazard ratio [HR], 1.12; 95% confidence interval [CI], 1.02 to 1.22). Dispensing medium-dose therapy provided a benefit similar to low-dose (HR, 0.94; CI, 0.86 to 1.03) and dispensing of high-dose therapy was associated with improved survival benefit (HR, 0.76; CI, 0.68 to 0.85). Relative to dispensing of low-dose ACE inhibitor therapy, dispensing high-dose conferred a benefit (HR, 0.87; CI, 0.80 to 0.95) on the composite outcome of 1-year mortality or heart failure hospitalization and the composite outcome of 1-year mortality or all-cause hospitalization (HR, 0.87; CI, 0.81 to 0.93). Relative to those dispensed low-dose ACE inhibitor therapy, those initially dispensed high-dose therapy were twice as likely to have their subsequent dose reduced or the therapy discontinued (odds ratio, 2.36; CI, 2.07 to 2.69). CONCLUSION: Our findings suggest that when possible, older adults should be titrated to the higher doses of ACE inhibitor therapy evaluated in clinical trials. If older adults cannot tolerate higher doses, then low-dose ACE inhibitor therapy is superior to none. High-dose ACE inhibitor therapy is not as well tolerated as lower doses.

Aged↗

PubMed2006

Perceived discrimination and use of preventive health services.

BACKGROUND: Little is known about the relation between perceptions of health care discrimination and use of health services. OBJECTIVES: To determine the prevalence of perceived discrimination in health care, its association with use of preventive services, and the contribution of perceived discrimination to disparities in these services by race/ethnicity, gender, and insurance status. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 54,968 respondents to the 2001 California Health Interview Survey. MEASUREMENTS: Subjects were asked about experience with discrimination in receiving health care and use of 6 preventive health services, all within the previous 12 months. METHODS: We used multivariate logistic regression with propensity-score methods to examine the adjusted relationship between perceived discrimination and receipt of preventive care. RESULTS: Discrimination was reported by 4.7% of respondents, and among these respondents the most commonly reported reasons were related to type of insurance (27.6%), race or ethnicity (13.7%), and income (6.7%). In adjusted analyses, persons who reported discrimination were less likely to receive 4 preventive services (cholesterol testing for cardiovascular disease, hemoglobin A1c testing and eye exams for diabetes, and flu shots), but not 2 other services (aspirin for cardiovascular disease, prostate specific antigen testing). Adjusting for perceived discrimination did not significantly change the relative likelihood of receipt of preventive care by race/ethnicity, gender, and insurance status. CONCLUSIONS: Persons who report discrimination may be less likely to receive some preventive health services. However, perceived discrimination is unlikely to account for a large portion of observed disparities in receipt of preventive care.

Adult↗

PubMed1998

The effect of HMO status on the outcomes of home-care after hospitalization in a Medicare population.

OBJECTIVE: The literature suggests that Medicare health maintenance organization (HMO) patients may have poorer outcomes with formal home-health care than do fee-for-service (FFS) patients, but it is unclear whether this is related to case-mix or quality. Our objective was to compare the home-health care outcomes for HMO and FFS Medicare patients after hospitalization for stroke, COPD, CHF, hip replacement, or hip fracture with fixation or replacement while controlling for site of discharge and other patient characteristics. DESIGN: Patients were identified before hospital discharge with data collected at that time and then prospectively for 1 year. SETTING: Nineteen acute general hospitals in Minneapolis/St. Paul, Minnesota. PATIENTS: All Medicare patients in the above hospitals identified predischarge with stroke, COPD, CHF, hip replacement, or hip fracture with fixation or replacement. MEASURES OUTCOME: weighted ADL scale and hospital readmission. Independent factors: site of discharge, HMO status, comorbidity, severity, and demographic factors. RESULTS: A total of 970 subjects were studied, 211 of whom were discharged to home-care. HMO patients were more likely to be discharged to a nursing home than to home-care after controlling for other factors (OR = 1.7; P = .015). After controlling for site of discharge and patient characteristics through either propensity scores or regression analysis, there was no statistically significant difference in ADL function at 6 weeks or at 6 months between HMO and FFS patients. Nor was there was a statistically significant difference in hospital readmission rates at 6 weeks and 6 months between HMO and FFS home-care patients. CONCLUSIONS: The outcomes of Medicare HMO patients discharged to home-care are not worse than those of FFS patients.

Activities of Daily Living↗

PubMed2004

A matched-cohort study of health services utilization and financial outcomes for a heart failure disease-management program in elderly patients.

OBJECTIVES: To investigate the utilization and financial outcomes of a telephonic nursing disease-management program for elderly patients with heart failure. DESIGN: A 1-year concurrent matched-cohort study employing propensity score matching. SETTING: Medicare+Choice recipients residing in Ohio, Kentucky, and Indiana. PARTICIPANTS: A total of 533 program participants aged 65 and older matched to nonparticipants. INTERVENTION: Disease-management heart failure program employing a structured, evidence-based, telephonic nursing intervention designed to provide patient education, counseling, and monitoring services. MEASUREMENTS: Medical service utilization, including hospitalizations, emergency department visits, medical doctor visits, skilled nursing facility (SNF) days, selected clinical indicators, and financial effect. RESULTS: The intervention group had considerably and significantly lower rates of acute service utilization than the control group, including 23% fewer hospitalizations, 26% fewer inpatient bed days, 22% fewer emergency department visits, 44% fewer heart failure hospitalizations, 70% fewer 30-day readmissions, and 45% fewer SNF bed days. Claims costs were 1,792 dollars per person lower in the intervention group than in the control group (inclusive of intervention costs), and the return on investment was calculated to be 2.31. CONCLUSION: The study demonstrates that a commercially delivered heart failure disease-management program significantly reduced hospitalizations, emergency department visits, and SNF days. The intervention group had 17% lower costs than the control group; when intervention costs were included, the intervention group had 10% lower costs.

Aged↗

PubMed2005

Physical and mental health status of older long-term cancer survivors.

OBJECTIVES: To assess the physical and mental health status of older long-term cancer survivors. DESIGN: Cohort study using propensity score methods to control for baseline differences between cancer survivors and controls. SETTING: General community population in the United States. PARTICIPANTS: Nine hundred sixty-four cancer patients who had survived for more than 4 years and 14,333 control patients who had never had cancer from a population-based sample of Americans aged 55 and older responding to the 2002 Health and Retirement Study. MEASUREMENTS: Medical conditions, symptoms, health behaviors, health status, mobility, activities of daily living, mental health diagnoses, self-rated memory, depressive symptoms, cognitive function, and self-reported life expectancy. RESULTS: Cancer survivors reported higher rates of lung disease (13.9% vs 9.6%; P=.001), heart condition (29.3% vs 22.9%; P<.001), arthritis (69.4% vs 59.4%; P<.001), incontinence (26.6% vs 19.7%; P=.001), frequent pain (36.4% vs 29.4%; P=.005), and obesity (27.0% vs 24.2%; P=.001) than individuals without cancer but lower rates of smoking (12.0% vs 14.8%; P=.03). Cancer survivors were less likely than persons without cancer to report excellent or very good health status (37.2% vs 44.6%; P<.001) and had more mobility (P<.001) and activity of daily living (P=.01) limitations. Cancer survivors did not differ from persons without cancer in rates of depression or cognitive function (both P>.2) but were less optimistic about their life expectancy (P=.004). CONCLUSION: The physical health status of older long-term cancer survivors is somewhat worse than that of comparable persons who have never had cancer, but they have surprisingly similar mental health status. Future research is needed to understand factors contributing to poorer health status and identify patients at highest risk of long-term cancer-related problems.

Aged↗

PubMed2006

Hydroxymethylglutaryl-CoA reductase inhibitors in older persons with acute myocardial infarction: evidence for an age-statin interaction.

OBJECTIVES: To characterize the relationship between hydroxymethylglutaryl-CoA reductase inhibitors (statins) and outcomes in older persons with acute myocardial infarction (AMI). DESIGN: Observational study. SETTING: Acute care hospitals in the United States from April 1998 to June 2001. PARTICIPANTS: Medicare patients aged 65 and older with a principal discharge diagnosis of AMI (N=65,020) who did and did not receive a discharge prescription for statins. MEASUREMENTS: The primary outcome of interest was all-cause mortality at 3 years after discharge. RESULTS: Of 23,013 patients with AMI assessed, 5,513 (24.0%) were receiving a statin at discharge. Nearly 40% of eligible patients (n=8,452) were aged 80 and older, of whom 1,310 (15.5%) were receiving a statin at discharge. In a multivariable model taking into account demographic, clinical, physician and hospital characteristics, and propensity score, discharge statin therapy was associated with significantly lower 3-year mortality (hazard ratio (HR)=0.89 (95% confidence interval (CI)=0.83-0.96)). In an analysis stratified by age, discharge statins were associated with lower mortality in patients younger than 80 (HR=0.84, 95% CI=0.76-0.92) but not in those aged 80 and older (HR=0.97, 95% CI=0.87-1.09). CONCLUSION: Statin therapy is associated with lower mortality in older patients with AMI younger than 80 but not in those aged 80 and older, as a group. This finding questions whether statin efficacy data in younger patients can be broadly applied to the very old and indicates the need for further study of this group.

Age Factors↗

PubMed2006

Provider characteristics related to antidepressant use in older people.

OBJECTIVES: To determine whether the characteristics of the usual medical care providers of older antidepressant users changed between 1986 and 1997 with the introduction of selective serotonin reuptake inhibitors. DESIGN: Longitudinal study. SETTING: Five-county Piedmont area of North Carolina. PARTICIPANTS: Stratified random sample of African-American (n=2,261) and white (n=1,875) community residents aged 65 to 105. MEASUREMENTS: Sample members provided information on prescription medications, demographic and health status, and usual medical care provider (matched to North Carolina Health Professions Data Systems files to ascertain provider characteristics) in 1986/87, 1989/90, 1992/93, and 1996/97. Most (77.5%) named a provider (name unmatchable for 4.1%). Sample member characteristics were aggregated into probability (propensity) scores summarizing predisposing (demographic), enabling (medical care access), and need (health status) categories. Along with wave of study and whether a provider was named, these were entered as control variables in generalized estimating equation models that examined the association between provider race (white vs nonwhite), sex, age, location of practice, and primary versus specialist care and antidepressant use. RESULTS: The characteristics of the usual medical care providers remained stable over the decade, although prevalence of antidepressant use increased. Two provider characteristics--race and area of practice (but not the interaction between them)--were significantly associated with patients' use of antidepressants. Patients of white physicians and of physicians with urban practices were more likely to use antidepressants. CONCLUSION: Although use of antidepressants has increased over time, there has been little change in the characteristics of users' usual medical care providers.

Aged↗

PubMed2005

Fundoplication and the risk of esophageal cancer in gastroesophageal reflux disease: a Veterans Affairs cohort study.

BACKGROUND AND AIMS: It has been proposed that fundoplication can reduce the risk of esophageal cancer in patients with gastroesophageal reflux disease (GERD). In this cohort study, we assessed the effect of fundoplication on the incidence of esophageal cancer. METHODS: We identified all Veterans Affairs (VA) patients with GERD who had fundoplication between 1986 and 1990 and matched (1-2) to controls with GERD and no fundoplication and to controls with no GERD. We calculated incidence rates for esophageal cancer through October 2002 and examined the effect of fundoplication on the risk of esophageal cancer using Kaplan-Meier survival analysis and Cox proportional hazard analysis. We calculated and adjusted for the propensity score for receiving fundoplication. RESULTS: We identified 946 patients who had fundoplication, 1,892 patients who had GERD without fundoplication, and 5,676 patients with no GERD. The mean age was 55 yr and 97.5% were men in all three groups. During a follow-up of 11,156 patient-years (PY), there were eight cases of esophageal cancer (72/100,000) in the fundoplication group. During a follow-up of 20,115 PY, there were eight cases of esophageal cancer (40/100,000) in the GERD without fundoplication group. During a follow-up of 59,439 PY, no patients in the group with no GERD developed esophageal cancer. The Kaplan-Meier analysis showed no significant difference in cumulative esophageal cancer rates between the fundoplication group and the GERD no-fundoplication group. The adjusted hazard ratio of esophageal cancer with fundoplication was 1.88 (95% CI: 0.70-5.03). CONCLUSIONS: GERD is a risk factor for esophageal cancer, but there is insufficient evidence that fundoplication reduces that risk.

Adult↗

PubMed2004

Quality of life in persons with schizophrenia in out-patient treatment with first- or second-generation antipsychotics.

OBJECTIVE: Effects of first in comparison with second-generation antipsychotics on the subjective quality of life (QoL) of patients with schizophrenia under routine treatment conditions were examined. METHOD: In a prospective naturalistic trial the QoL, social, clinical, and treatment-related characteristics and type of antipsychotic medication of 307 patients with schizophrenia (ICD-10 F 20) were assessed five times with 6-month intervals over 2.5 years. Longitudinal and cross-sectional effects of antipsychotic medication were assessed by hierarchical regression models. Selection bias was controlled by propensity scores. RESULTS: While positive effects of first-generation antipsychotics on subjective QoL in comparison with no antipsychotic treatment were found, second-generation antipsychotics caused no better QoL than first-generation antipsychotics. CONCLUSION: The hypothesis that second-generation in comparison with first-generation antipsychotics have a better effect on the improvement of subjective QoL of people with schizophrenia in routine out-patient treatment was not supported.

Adolescent↗

PubMed2006

Advanced methods for evaluating the impact of family planning communication programs: evidence from Tanzania and Nepal.

Evaluations of national family planning communication campaigns are often complicated by nonrandomized research designs and self-reported measures of exposure to media messages, both of which can bias estimates of campaign effectiveness if suitable analytical methods are not employed. This study uses three methods to address these problems: (1) single-equation multiple regression analysis; (2) propensity score matching (PSM); and (3) maximum-likelihood simultaneous equation models (SEM), namely bivariate probit. We use these methods to evaluate the impact of family planning health-communication campaigns on the use of modern family planning methods, focusing primarily on the radio drama Zinduka! in Tanzania and Ghanti Heri Haad Nilaun in Nepal. We find that these methods led to substantially different estimates of the magnitude of the impact of these communication campaigns. Specifically, we found that self-reported exposure to each radio program was exogenously related to family planning use and that PSM and multiple regression analysis gave similar estimates in those situations. An indicator of exposure to any type of family planning message was found to be endogenous, in which case bivariate probit and PSM gave different estimates of program impact. Researchers should, therefore, pay close attention to the results of tests for endogeneity and identification that guide the appropriate use of the different methods.

Adolescent↗

PubMed2005

Dental insurance and clinical dental outcomes in NHANES III.

OBJECTIVES: The National Health and Nutrition Examination Survey (NHANES III) 1988-1994 is one of the few nationally representative data sets with information on both private dental insurance and a clinical dental exam. The objective of this analysis was to examine the possible associations between private dental insurance and clinical exam outcomes, demographic variables, and dental visits. METHODS: Using NHANES III data, analysis was limited to persons aged 20 years or older who had a dental exam and reported on their private dental insurance status. Initial analyses were based on comparisons between those with and without private dental insurance. Propensity scoring method was used to examine the effects of dental insurance on clinical exam variables. RESULTS: The percentage of individuals with private dental insurance was significantly greater among non-Hispanic blacks, those with higher educational attainment, those living at/above the federal poverty level, and those with a dental visit in the past year compared to their respective counterparts. Those with untreated caries, those with a loss of attachment of greater than 4 mm, and those with 12-27 missing teeth were significantly less likely to have dental insurance (p < 0.05) than their respective counterparts. CONCLUSIONS: These results suggest that having private dental insurance is associated with better clinical oral health status.

Adult↗

PubMed2001

Clinical isolation and resistance patterns of and superinfection with 10 nosocomial pathogens after treatment with ceftriaxone versus ampicillin-sulbactam.

Isolation of pathogens from clinical cultures and their resistance patterns may be altered by antecedent antibiotic treatment. The objective of this study was to assess the influence of treatment with ceftriaxone versus that with ampicillin-sulbactam on recovery and superinfections with 10 nosocomial pathogens. The study was designed as a historical cohort study, using a propensity score to adjust for confounding by indication and multivariate survival analyses to adjust for other confounding. Two thousand four hundred forty-five patients were treated with ampicillin-sulbactam, and 1, 308 were treated with ceftriaxone. The study analyzed two outcomes: (i) recovery of pathogens from clinical cultures and (ii) microbiologically documented infections. Data were obtained from administrative, pharmacy, clinical, and laboratory databases and by chart extraction. Following treatment, new isolation of at least 1 of the 10 target pathogens occurred for 244 patients. After adjustment, more infections occurred in the ampicillin-sulbactam group (hazard ratio [HR], 1.55; P = 0.009). This was observed with all gram-negative rods combined (HR, 3.6; P < 0.001) and with each genus of the family Enterobacteriaceae. No differences in isolation of gram-positive bacteria were evident (P = 0.33). Microbiologically documented superinfections occurred in 172 patients and were less frequent in the ceftriaxone group (3.8% versus 5%; HR, 1.6; P = 0. 015). All the Escherichia coli and Klebsiella spp. isolates were susceptible to ceftriaxone, but half were resistant to ampicillin-sulbactam. The prevalence of oxacillin resistance among Staphylococcus aureus isolates was higher in the ceftriaxone group (63% versus 31%; odds ratio, 3.8; P = 0.08). Differences in the rates of superinfections and the likely causative organisms following treatment with ceftriaxone or ampicillin-sulbactam were evident. This may guide clinicians in empirical choices of antibiotics to treat superinfection.

Aged↗

PubMed2005

Treatment continuation in patients receiving biological agents or conventional DMARD therapy.

OBJECTIVE: To compare drug continuation rates in patients with rheumatoid arthritis who start on a biological agent and in a control group of patients with a change in disease modifying antirheumatic drug (DMARD) treatment after previous DMARD failure. METHODS: Patients with rheumatoid arthritis enrolled in the German biologics register between May 2001 and September 2003 were included in the study. Data were available for 511 patients treated with etanercept, 343 with infliximab, 70 with anakinra, and 599 controls. Propensity scores were used to select a subsample of patients from the control group who were likely to be treated with biological agents because of their disease severity, as well as comparable infliximab and etanercept cases. RESULTS: Treatment continuation after 12 months was similar for etanercept (68.6% (95% confidence interval, 62% to 75%)) and infliximab (65.4% (58% to 73%)) but lower for anakinra (59% (41% to 77%)). Treatment continuation was more likely for patients on combinations of biological agents and DMARDs than for those on infliximab or etanercept alone. Patients treated with biological agents were more severely ill than those in the control group and had more previous DMARD failures. After adjustment for baseline differences, the continuation rates were higher in patients treated with biological agents than in comparable control patients treated with leflunomide or leflunomide/methotrexate. CONCLUSIONS: Treatment continuation of biological agents in clinical practice is less likely than in randomised clinical trials but more likely than in comparable controls treated with conventional DMARDs.

Adolescent↗