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Results for “Propensity Score”

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PubMed2005

Hypothermic circulatory arrest is not a risk factor for neurologic morbidity in aortic surgery: a propensity score analysis.

OBJECTIVE: Hypothermic circulatory arrest has been an important tool in aortic arch surgery, even though its use has recently been discussed controversially. We sought to clarify the role of hypothermic circulatory arrest as a risk factor for mortality and neurologic morbidity in aortic surgery by using a propensity score-matching analysis. METHODS: Five hundred eleven patients (60 +/- 13 years, 349 male patients) who underwent replacement of the ascending aorta with (n = 273) or without (n = 238) arch involvement were analyzed by means of multivariate analysis. Using propensity score matching, we identified comparable patient groups: HCA(+) group and HCA(-) group (n = 110 each). For aortic arch replacement, hypothermic circulatory arrest was used with a mean duration of 14 +/- 9 minutes: 12 +/- 7 minutes or 26 +/- 8 minutes for partial or total arch replacement, respectively. RESULTS: In the entire cohort multivariate analysis identified acute dissection and duration of cardiopulmonary bypass as significant predictors for hospital death. Predictors for stroke were acute dissection, diabetes mellitus, peripheral arterial disease, and concomitant mitral valve surgery, and predictors for temporary neurologic dysfunction were peripheral arterial disease and age. After propensity score matching, the incidence of death (HCA[+]: 0.9% vs HCA[-]: 2.7%), stroke (0% vs 1.8%, respectively), and temporary neurologic dysfunction (15.5% vs 13.6%, respectively) was comparable between the 2 groups. Multivariate analysis identified age, diabetes mellitus, peripheral arterial disease, and concomitant coronary artery bypass grafting as the independent risk factors for temporary neurologic dysfunction. CONCLUSIONS: In a standard clinical setting (hypothermic circulatory arrest of <30 minutes and nasopharyngeal temperature of <20 degrees C), hypothermic circulatory arrest constitutes no significant risk for mortality or neurologic morbidity and thus appears clinically safe. Patient-related risk factors primarily determine clinical outcome.

Adolescent↗

PubMed2026

Overall survival of immunotherapy versus standard of care in chemorefractory microsatellite stable metastatic colorectal cancer: a propensity score matched analysis of 708 patients.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have limited efficacy in proficient mismatch repair/microsatellite stable (pMMR/MSS) metastatic colorectal cancer (mCRC). However, selected patients with specific metastatic patterns may derive benefit. METHODS: Patients with chemorefractory pMMR/MSS mCRC treated with ICI-based regimens were retrospectively identified. A comparison cohort treated with trifluridine/tipiracil±bevacizumab, regorafenib, or fruquintinib as standard of care (SOC) was generated through 1:1 propensity score matching by age, sex, Eastern Cooperative Oncology Group performance status (ECOG PS), liver metastases (present/absent), and RAS/BRAF status. Overall survival (OS) was compared using Cox regression. RESULTS: A total of 354 patients treated with ICIs and 354 treated with SOC were matched. Median age was 55 years, 52% male, 32% ECOG PS 0, 30% right-sided, and 69% RAS mutated in both groups, while 61% and 60% had liver metastases, respectively. Median OS (mOS) was 10.8 months with ICIs and 9.0 months with SOC (HR 0.76, 95% CI 0.64 to 0.92, p=0.004). In patients without liver metastases, mOS was longer with ICIs than SOC (19.1 vs 13.2 months, HR 0.59, 95% CI 0.43 to 0.80, p<0.001), whereas outcomes were similar in patients with liver metastases (6.4 vs 6.5 months, p=0.303). In univariable analyses, age, sex, primary tumor site, and RAS/BRAF status were not associated with OS. Treatment with ICIs, absence of liver metastases, one prior line of therapy, less than three metastatic sites, and ECOG PS 0 were associated with the most favorable outcomes in univariable and multivariable models. CONCLUSIONS: In chemorefractory pMMR/MSS mCRC without liver metastases, ICI-based regimens yielded longer OS than SOC. Further investigation of ICIs in this patient population is warranted.

Humans↗

PubMed2005

Analytic strategies to adjust confounding using exposure propensity scores and disease risk scores: nonsteroidal antiinflammatory drugs and short-term mortality in the elderly.

Little is known about optimal application and behavior of exposure propensity scores (EPS) in small studies. In a cohort of 103,133 elderly Medicaid beneficiaries in New Jersey, the effect of nonsteroidal antiinflammatory drug use on 1-year all-cause mortality was assessed (1995-1997) based on the assumption that there is no protective effect and that the preponderance of any observed effect would be confounded. To study the comparative behavior of EPS, disease risk scores, and "conventional" disease models, the authors randomly resampled 1,000 subcohorts of 10,000, 1,000, and 500 persons. The number of variables was limited in disease models, but not EPS and disease risk scores. Estimated EPS were used to adjust for confounding by matching, inverse probability of treatment weighting, stratification, and modeling. The crude rate ratio of death was 0.68 for users of nonsteroidal antiinflammatory drugs. "Conventional" adjustment resulted in a rate ratio of 0.80 (95% confidence interval: 0.77, 0.84). The rate ratio closest to 1 (0.85) was achieved by inverse probability of treatment weighting (95% confidence interval: 0.82, 0.88). With decreasing study size, estimates remained further from the null value, which was most pronounced for inverse probability of treatment weighting (n = 500: rate ratio = 0.72, 95% confidence interval: 0.26, 1.68). In this setting, analytic strategies using EPS or disease risk scores were not generally superior to "conventional" models. Various ways to use EPS and disease risk scores behaved differently with smaller study size.

Aged↗

PubMed2001

Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores.

We determined whether adherence to recommendations for coronary angiography more than 12 h after symptom onset but prior to hospital discharge after acute myocardial infarction (AMI) resulted in better survival. Using propensity scores, we created a matched retrospective sample of 19,568 Medicare patients hospitalized with AMI during 1994-1995 in the United States. Twenty-nine percent, 36%, and 34% of patients were judged necessary, appropriate, or uncertain, respectively, for angiography while 60% of those judged necessary received the procedure during the hospitalization. The 3-year survival benefit was largest for patients rated necessary [mean survival difference (95% CI): 17.6% (15.1, 20.1)] and smallest for those rated uncertain [8.8% (6.8, 10.7)]. Angiography recommendations appear to select patients who are likely to benefit from the procedure and the consequent interventions. Because of the magnitude of the benefit and of the number of patients involved, steps should be taken to replicate these findings.

Aged↗

PubMed2005

National analysis of in-hospital resource utilization in choledocholithiasis management using propensity scores.

BACKGROUND: Two treatment options exist for choledocholithiasis (CDL): endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (CBDE). Resource utilization measured by total in-hospital charges (THC) and length of stay (LOS) was compared using the propensity score (PS). In this study, PS was the probability that a patient received CBDE based on comorbidities and demographics. The power of this method lies in balancing groups on variables by PS, resulting in 90% bias reduction and improved inferential validity compared to traditional analytic techniques. METHODS: Laparoscopic cholecystectomy (LC) patients with CDL who had ERCP or CBDE were identified in the 2002 U.S. Nationwide Inpatient Sample. Patients were ordered into five PS balanced strata. Mean THC, LOS, and estimated costs were compared. A linear regression model was used to estimate the contribution that LOS had on estimated costs. Monetary values were adjusted to 2004 dollars. RESULTS: A total of 40,982 patients underwent LC with CDL in 2002; 27,739 had either ERCP (93%) or CBDE (7%). Mean age was 52.7 +/- 0.4 years, with 74% women. Mean THC were less for CBDE (25,200 dollars +/- 1,800 dollars) than for ERCP (29,900 dollars +/- 800 dollars, p < 0.05). Mean LOS was less for CBDE (4.9 +/- 0.2 days) than for ERCP (5.6 +/- 0.1 days, p < 0.05). PS adjusted analysis revealed an estimated overall cost savings of 4,500 dollars +/- 1,600 dollars and reduced LOS (0.6 +/- 0.2 days) per hospitalization for CBDE. Mean THC, LOS, and estimated costs across PS score balanced strata were generally higher in the ERCP group compared to the CBDE group. LOS contributed 53% to increased THC and 62% of estimated costs. A higher cumulative incidence of complications was evident with CBDE (0.5-4.6%) compared to ERCP (0.3-3.6%). CONCLUSIONS: Based on this PS analysis, CBDE incurs less THC, reduces LOS, and has less estimated costs for CDL compared to ERCP. Furthermore, CBDE appears to be dramatically underutilized.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2000

Costs and outcomes associated with alternative discharge strategies following joint replacement surgery: analysis of an observational study using a propensity score.

We estimated the impact of alternative discharge strategies, following joint replacement (JR) surgery, on acute care readmission rates and the total cost of a continuum of care. Following surgery, patients were discharged to one of four destinations. Propensity scores were used to adjust costs and outcomes for potential bias in the assignment of discharge destinations. We demonstrated that the use of rehabilitation hospitals may lower readmission rates, but at a prohibitive incremental cost of each saved readmission, that patients discharged with home care had longer acute care stays than other patients, that the provision of home care services increased health system costs, and that acute care readmission rates were greatest among patients discharged with home care. Our study should be seen as one important stepping stone towards a full economic evaluation of the continuum of care for patients.

Aftercare↗

PubMed2004

Propensity score analysis of a six-year experience with minimally invasive isolated aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Although minimally invasive aortic valve replacement (MIAVR) is becoming an accepted technique, additional outcome evaluation is required. To correct for non-randomized treatment, the propensity score was used to analyze the present authors' experience with MIAVR compared to standard sternotomy (SS). METHODS: Between January 1995 and December 2002, a total of 921 consecutive patients underwent isolated AVR; 438 of these patients had MIAVR. Two matched cohorts each of 233 patients, and with comparable distributions of risk factors, were constructed using propensity analysis of prospectively collected data. Matching variables included left ventricular ejection fraction <30%, previous myocardial infarction, congestive heart failure, previous cardiac surgery, renal insufficiency, age, gender, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, previous stroke or carotid disease, urgent/emergent operation, valvular pathophysiology, and atheromatous aortic disease. RESULTS: Hospital mortality and major morbidity were similar in the MIAVR and SS groups: 5.6% versus 7.3% (p = 0.45) and 13.3% versus 14.2% (p = 0.79), respectively. Multivariable analysis of all patients revealed increased mortality with severe atheromatous aortic disease (p = 0.001), COPD (p = 0.002), and urgent operation (p = 0.02). Freedom from any major perioperative morbidity was similar in both groups (86.7% versus 85.8%; p = 0.79). However, the median length of stay was shorter with MIAVR (6 versus 8 days; p <0.001). During the past three years, a greater percentage of MIAVR patients than SS patients was discharged home rather than sent to rehabilitation facilities or nursing homes (65.7% versus 52.9%; p = 0.05). CONCLUSION: MIAVR can be performed safely, with morbidity and mortality outcomes similar to those of standard sternotomy. MIAVR is associated with a decreased length of hospital stay, and a greater proportion of patients are discharged home directly.

Aged↗

PubMedDate not supplied

The use of propensity scores to evaluate outcomes for community clinics: identification of an exceptional home-based program.

This article presents a model for mental health programs to estimate causal effects of treatment in community settings, where experimental studies, in which subjects are randomly assigned to treatment and control groups, are not feasible. This article describes an observational study that used a propensity score analysis with stratification and a repeated-measures analysis of covariance model to estimate treatment effects. This article includes results from one example site that was identified as having an exceptional home-based community program. The results include treatment effects for 3 outcomes identified as useful goals for home-based community programs. The study also serves as a model of how local programs can establish credibility where no evidence-based treatments exist for severely impaired youths.

Adolescent↗

PubMed2006

Heart failure, chronic diuretic use, and increase in mortality and hospitalization: an observational study using propensity score methods.

AIMS: Non-potassium-sparing diuretics are commonly used in heart failure (HF). They activate the neurohormonal system, and are potentially harmful. Yet, the long-term effects of chronic diuretic use in HF are largely unknown. We retrospectively analysed the Digitalis Investigation Group (DIG) data to determine the effects of diuretics on HF outcomes. METHODS AND RESULTS: Propensity scores for diuretic use were calculated for each of the 7788 DIG participants using a non-parsimonious multivariable logistic regression model, and were used to match 1391 (81%) no-diuretic patients with 1391 diuretic patients. Effects of diuretics on mortality and hospitalization at 40 months of median follow-up were assessed using matched Cox regression models. All-cause mortality was 21% for no-diuretic patients and 29% for diuretic patients [hazard ratio (HR) 1.31; 95% confidence interval (CI) 1.11-1.55; P = 0.002]. HF hospitalizations occurred in 18% of no-diuretic patients and 23% of diuretic patients (HR 1.37; 95% CI 1.13-1.65; P = 0.001). CONCLUSION: Chronic diuretic use was associated with increased long-term mortality and hospitalizations in a wide spectrum of ambulatory chronic systolic and diastolic HF patients. The findings of the current study challenge the wisdom of routine chronic use of diuretics in HF patients who are asymptomatic or minimally symptomatic without fluid retention, and are on complete neurohormonal blockade. These findings, based on a non-randomized design, need to be further studied in randomized trials.

Adult↗

PubMed2006

Effectiveness of physical therapy for the management of chronic spine disorders: a propensity score approach.

BACKGROUND AND PURPOSE: Evidence on the effectiveness of physical therapy for the management of chronic spine disorders is limited. The purpose of this study was to use a large current database, the National Spine Network database, to assess the effectiveness of physical therapy in the management of chronic spine disorders. SUBJECTS: The participants were people who had spine problems lasting 3 months or longer and who were seen for an initial visit and a follow-up visit (N=4,479) at 1 of 17 US spine centers. METHODS: A propensity score approach was used to create a matched sample of participants who received physical therapy (intervention group) and participants who did not receive physical therapy (control group). The 2 groups were similar with regard to more than 50 baseline characteristics. Outcomes were assessed with the Oswestry Disability Index (ODI) and the 36-Item Short-Form Health Survey (SF-36). RESULTS: Both the intervention and control groups improved between the initial and the follow-up visits on ODI scores and on SF-36 physical function, role physical, and bodily pain scores. Although the amount of improvement in the outcome measures was significantly greater for the intervention group than for the control group, the differences were small (3-5 points). When the subgroup of participants who had the greatest propensity for receiving physical therapy was examined, differences in the amount of improvement between the intervention and control groups were larger (5-13 points). DISCUSSION AND CONCLUSION: Physical therapy was effective in the management of chronic spine disorders in participants with the greatest propensity for receiving physical therapy. When the entire sample was considered, differences in the amount of improvement between the intervention and control groups were not clinically relevant.

Adolescent↗

PubMed2003

Impact of intraoperative radiation on postoperative and disease-specific outcome after pancreatoduodenectomy for adenocarcinoma: a propensity score analysis.

For periampullary cancer,intraoperative radiation therapy (IORT) administered to the site with the highest locoregional recurrence risk carries the rationale to improve tumor control. An IORT effect on survival remains unclear. IORT impact on postoperative outcomes after pancreatectomy for adenocarcinoma was analyzed, with a specific attempt to correct for the nonrandom IORT treatment assignment, and to account for treatment group imbalances in the interpretation of outcome differences. A propensity-score-adjusted analysis, based on variable selection by logistic regression, was used to rebalance treatments. Between 1989 and 1999, 61 patients underwent partial or total pancreatectomy for a primary periampullary adenocarcinoma at the City of Hope National Medical Center. Diagnoses included pancreatic (n = 36), duodenal (n = 11), ampullary (n = 10), and bile duct cancer (n = 4). Thirty patients received IORT to the resection area, with a median dose of 15 Gy (range: 10-20), followed by postoperative external beam radiation (n = 24). Mortality was 0%, the complication rate 61%. Of 33 patients with a documented recurrence, 6 had an isolated locoregional recurrence only (1 IORT versus 5 no IORT, = 0.05); the systemic recurrence pattern differed as well (IORT 94%, no IORT 67%; = 0.04). IORT had no significant impact on hospital stay (overall median: 17 days), disease-free survival (16 months), and overall survival (23 months) when adjusted for those most relevant variables reflecting IORT treatment group assignment propensity. After adjustment for relevant propensity factors, IORT was not linked to a significantly increased risk for complications, hospital stay, or survival hazard. The recurrence pattern may be affected in some patients, but systemic recurrences predominate. We continue to explore IORT in combination with systemic chemotherapy.

Adenocarcinoma↗

PubMed2005

Communication, ideation and contraceptive use in Burkina Faso: an application of the propensity score matching method.

OBJECTIVE: The study aim was to assess the effects of a multi-component communication campaign that promoted contraceptive use in Burkina Faso. METHODS: This was a cross-sectional survey conducted in 2001 involving 1421 women of reproductive age from Ouagadougou and Bobo-Dioulasso. Participants during the 2001 survey were randomly selected from 54 enumeration areas that were covered during the 1999 Demographic and Health Survey. The propensity score matching (PSM) technique was the analytical method used to assess the effects of the campaign. RESULTS: More than three-quarters of the respondents reported exposure to at least one example of campaign material. Compared with no exposure, high campaign exposure is associated with an adjusted increase of 21.8 percentage points in the proportion of women currently using modern contraceptive methods. Similarly, low exposure is associated with a 7.3 percentage point increase over no exposure. The campaign is also associated with increased knowledge about contraceptives and more favourable attitudes towards family planning. CONCLUSIONS: The multiple-component nature of the campaign makes it easy for many members of the target audience to hear consistent messages from a variety of sources. This is a key element responsible for the documented effectiveness of the campaign. Despite its limitations, the PSM technique is a straightforward method that should be used more often to assess the effects of communication programmes.

Adolescent↗

PubMed2005

What happens when hospital-based skilled nursing facilities close? A propensity score analysis.

OBJECTIVE: To assess the effects of hospital-based skilled nursing facility (HBSNF) closures on health care utilization, spending, and outcomes among Medicare fee-for-service beneficiaries. DATA SOURCES: One hundred percent Medicare fee-for-service claims files for 1997-2002 were merged with Medicare Provider of Services files and beneficiary-level enrollment records. STUDY DESIGN: Medicare spending, the use of postacute care, and health outcomes, were compared among hospitals that did and did not close their HBSNFs between 1997 and 2001. Hospitals were stratified according to propensity scores (i.e., predicted probability of closure from a logistic regression) and analyses were conducted within these strata. PRINCIPAL FINDINGS: HBSNF closures were associated with increased utilization of alternative postacute care settings, and longer acute care hospital stays. Because of increased use of alternative settings, HBSNF closures were associated with a slight increase in total Medicare spending. There are no statistically robust associations between HBSNF closures and changes in either mortality or rehospitalization. CONCLUSIONS: HBSNF closures altered utilization patterns, but there is no indication that closures adversely affect beneficiaries' health outcomes.

Fee-for-Service Plans↗

PubMed2004

Late nephrology referral and mortality among patients with end-stage renal disease: a propensity score analysis.

BACKGROUND: Late nephrology referral has been associated with adverse outcomes among patients with end-stage renal disease; however, its relationship to mortality is unclear. We examined the impact of timing of nephrology care relative to initiation of dialysis on mortality after initiation of dialysis. METHODS: Data from the Dialysis Morbidity and Mortality Study - Wave II, a prospective study of incident dialysis patients, were used. Late referral (LR) was defined as first nephrology visit <4 months and early referral (ER) as first nephrology visit >or=4 months prior to initiation of dialysis. Propensity scores (PS) were estimated using logistic regression to predict the probability that a given patient was LR. A Cox proportional hazards model was built to examine the association between timing of nephrology referral and mortality. RESULTS: The cohort was comprised of 2195 patients: 54% were males, 66% were Caucasians, 26% were African-Americans and 33% were referred late. A Cox proportional hazards analysis demonstrated that compared with ER patients, LR patients had a 44% higher risk of death at 1 year after initiation of dialysis [hazards ratio (HR) = 1.44; 95% confidence interval (CI): 1.15-1.80], which remained significant after adjusting for quintiles of PS (HR = 1.42; 95% CI: 1.12-1.80). CONCLUSIONS: Among patients with chronic kidney disease (CKD) who initiated dialysis, LR was associated with higher risk of death at 1 year after initiation of dialysis compared with ER.

Female↗

PubMed2005

Renal dysfunction in high-risk patients after on-pump and off-pump coronary artery bypass surgery: a propensity score analysis.

BACKGROUND: Cardiopulmonary bypass may be a causal factor in the development of renal impairment after cardiac surgery. When acute renal failure requiring dialysis occurs after cardiac surgery, it is associated with high mortality. We attempted to determine whether off-pump coronary artery bypass grafting surgery prevents postoperative renal dysfunction in patients at high risk for renal failure. METHODS: Retrospective analysis identified 2,869 patients who had preexisting renal dysfunction (preoperative creatinine clearance less than 60 mL/min) and who underwent isolated coronary artery bypass grafting between 1995 and 2003. Patients who required preoperative dialysis were excluded. Propensity scores were computed to match off-pump coronary artery bypass surgery patients 3:1 with those who underwent conventional coronary artery bypass grafting surgery, and the independent predictors of postoperative renal dysfunction were determined. RESULTS: Two thousand seven hundred eleven patients with preexisting renal dysfunction underwent conventional coronary artery bypass grafting surgery, and 158 patients underwent coronary artery bypass grafting surgery without cardiopulmonary bypass (off-pump coronary artery bypass grafting surgery group). The matched groups showed no differences in any of the preoperative or postoperative variables examined. Diabetes (odds ratio, 1.96; p = 0.01), peripheral vascular disease (odds ratio, 2.50; p < 0.001), and reduced preoperative creatinine clearance (odds ratio, 1.02; p = 0.02) were independent risk factors for the development of postoperative renal dysfunction. Off-pump coronary artery bypass grafting surgery was not associated with a decreased risk of renal dysfunction by univariate or multivariable analysis. CONCLUSIONS: Off-pump coronary artery bypass grafting surgery did not reduce the risk of postoperative renal dysfunction in this large, unselected, sequential series of patients at high risk for renal failure after coronary artery bypass grafting surgery. Our results suggest that renal function should not be a deciding factor when determining whether or not a patient undergoes off-pump coronary artery bypass grafting surgery.

Aged↗

PubMed2006

Effects of angiotensin-converting enzyme inhibitors in systolic heart failure patients with chronic kidney disease: a propensity score analysis.

BACKGROUND: Chronic kidney disease (CKD) is common in systolic heart failure (SHF) and is associated with poor outcomes. It is also associated with underuse of angiotensin-converting enzyme (ACE) inhibitors, yet the effect of these drugs in these (SHF-CKD) patients has not been well studied. The objective of this analysis was to determine if ACE inhibitor use was associated with reduction in mortality and hospitalization in SHF-CKD patients. METHODS AND RESULTS: Of the 6800 SHF patients (ejection fraction < or = 45%) in the Digitalis Investigation Group trial, 1707 had CKD (serum creatinine 1.3-2.5 mg/dL for women and 1.5-2.5 mg/dL for men). Propensity scores for ACE inhibitor use were calculated for each of the 1707 patients and were used to match 104 of the 127 no-ACE inhibitor patients with 104 ACE inhibitor patients. We estimated the effect of ACE inhibitor use on outcomes at 2 years using multivariable-adjusted Cox regression analyses. Overall, 35% of patients died and 67% were hospitalized. Compared with 30% of ACE inhibitor patients, 39% of no-ACE inhibitor patients died (adjusted HR = 0.58; 95% CI = 0.35-0.96; P = .034). Compared with 64% of ACE inhibitor patients, 69% of no-ACE inhibitor patients had hospitalizations from all causes (adjusted HR = 0.69; 95% CI = 0.48-0.98; P = .040). CONCLUSION: We observed an association between use of ACE inhibitor and reductions in mortality and hospitalization in ambulatory chronic SHF patients with mild to moderate CKD. However, the results of this observational study should be interpreted with caution, and need to be replicated in larger and more recent databases, and confirmed prospectively in well-designed follow-up studies and/or randomized clinical trials.

Aged↗

PubMed2006

Geriatric heart failure, depression, and nursing home admission: an observational study using propensity score analysis.

OBJECTIVE: Heart failure (HF) and depression are both common in older adults, and the presence of depression is known to worsen HF outcomes. For community-dwelling older adults, admission to a nursing home (NH) is associated with loss of independent living and poor outcomes. The objective of this study was to examine the effect of depression on NH admission for older adults with HF. METHODS: Using the 2001-2003 National Hospital Discharge Survey datasets, the authors identified all community-dwelling older adults who were discharged alive with a primary discharge diagnosis of HF. The authors then identified those with a secondary diagnosis of depression. Using a multivariable logistic regression model, the authors then determined probability or propensity to have depression for each patient. The authors used propensity scores for depression to match all 680 depressed patients with 2,040 nondepressed patients. Finally, the authors estimated the association between depression and NH admission using bivariate and multivariable logistic regression analyses. RESULTS: Patients had a mean (+/- standard deviation) age of 79 (+/- 8) years, 72% were women, and 9% were blacks. Compared with 17% nondepressed patients, 25% depressed patients were discharged to a NH. Depression was associated with 50% increased risk of NH admission (unadjusted relative risk [RR]: 1.50; 95% confidence interval [CI]: 1.28-1.74). The association became somewhat stronger after multivariable adjustment for various demographic and care covariates (adjusted RR: 1.60; 95% CI: 1.35-1.68). CONCLUSION: In ambulatory older adults hospitalized with HF, a secondary diagnosis of depression was associated with a significant increased risk of NH admission.

Aged↗

PubMed2005

A propensity score analysis of the impact of angiotensin-converting enzyme inhibitors on long-term survival of older adults with heart failure and perceived contraindications.

OBJECTIVES: The purpose of this study is to determine the association between discharge use of angiotensin-converting enzyme (ACE) inhibitors in patients with perceived contraindications to these drugs and 4-year post-discharge survival among hospitalized older adults discharged alive with a primary discharge diagnosis of systolic heart failure. BACKGROUND: Perceived contraindications to the use of ACE inhibitors are often associated with underuse of these life-saving drugs. METHODS: Chronic renal insufficiency, hypotension, hyperkalemia, and severe aortic stenosis were conditions perceived as contraindications. Using a multivariable logistic regression model, we at first determined propensity scores for receipt of ACE inhibitors for each patient. Bivariate and multivariable Cox proportional hazard analyses were used to determine crude and adjusted risks of 4-year mortality compared with patients without perceived contraindications who were discharged on an ACE inhibitor (referent group). RESULTS: Compared with the referent group, patients with perceived contraindications who were not discharged on an ACE inhibitor had a significant 2-fold increase in the risk of 4-year mortality (adjusted hazard ratio [HR] = 2.33, 95% CI = 1.30-4.19). Patients with perceived contraindications who were discharged on ACE inhibitors had a non significant 23% higher risk of 4-year mortality (versus the referent group) (adjusted HR = 1.23, 95% CI = 0.71-2.13). CONCLUSION: Discharge use of ACE inhibitors was associated with significant long-term survival benefit in patients considered to have contraindication to these drugs.

Aged↗