Time trends and seasonal patterns of asthma deaths and hospitalisations among Maori and non-Maori

AIM: To examine the time trends and seasonal patterns in asthma mortality and hospitalisations in Maori and non-Maori. METHODS: We studied asthma deaths in Maori and non-Maori during 1962-1998 and asthma hospitalisations during 1976-1998 in the 5-34 and 35-74 year age-groups. Average monthly mortality and hospital discharge rates were calculated for 1978-1998 to observe the seasonal patterns. RESULTS: The two asthma mortality epidemics of the 1960s and 1970s affected Maori disproportionately, with the peak rates in 1979 being twice that of non-Maori (7.4 vs 3.7 per 100 000) although the rates are now similar. Hospitalisation rates for Maori were consistently higher than non-Maori with the rates remaining elevated until 1987. The most recent hospitalisation figures show a fall of 61.2% from the 1987 rate. For Maori in the 5-34 year age-group, deaths were highest in spring while hospitalisations peaked in the winter month of May. CONCLUSION: Although asthma mortality and hospitalisation rates for Maori have declined over the period under study, Maori continue to experience more severe asthma and have a higher number of hospital admissions for asthma than non-Maori.     

The role of insurance claims databases in drug therapy outcomes research

The use of insurance claims databases in drug therapy outcomes research holds great promise as a cost-effective alternative to post-marketing clinical trials. Claims databases uniquely capture information about episodes of care across healthcare services and settings. They also facilitate the examination of drug therapy effects on cohorts of patients and specific patient subpopulations. However, there are limitations to the use of insurance claims databases including incomplete diagnostic and provider identification data. The characteristics of the population included in the insurance plan, the plan benefit design, and the variables of the database itself can influence the research results. Given the current concerns regarding the completeness of insurance claims databases, and the validity of their data, outcomes research usually requires original data to validate claims data or to obtain additional information. Improvements to claims databases such as standardisation of claims information reporting, addition of pertinent clinical and economic variables, and inclusion of information relative to patient severity of illness, quality of life, and satisfaction with provided care will enhance the benefit of such databases for outcomes research.     

The 1996 pertussis epidemic in New Zealand: descriptive epidemiology

AIM: To describe the 1996 pertussis epidemic. METHODS: Hospitalisation, notification and laboratory data were used to describe the 1996 pertussis epidemic and compare it with previous epidemics. RESULTS: The 1996 epidemic spanned 24 months. The crude hospitalisation rate from 1 June 1995 to 31 May 1997, was 10.1 per 100,000 person years, being highest for children aged six weeks to two months (42 to 90 days old inclusive; 1402 per 100,000). The 1996 epidemic involved more hospitalisations than the 1991 and 1986 epidemics, and a greater proportion for children under the age of one year (77%), compared to previous epidemics (60-70%). There were no deaths. Pertussis only became notifiable from 1 June 1996. The crude notification rate for the following twelve months was 19.8 per 100,000 (equivalent hospitalisation rate 6.7 per 100,000); children aged six weeks to two months of age had the highest notification rate (531 per 100,000; equivalent hospitalisation rate 1021 per 100,000). In 1996-97, children aged under 15 months accounted for 21% of notifications, but 82% of hospitalisations. Europeans tended to have higher rates of notifications than non-Europeans, but lower rates of hospitalisation. CONCLUSIONS: New Zealand continues to experience high rates of pertussis as a result of inadequate immunisation coverage. The increase in hospitalisations during the 1996 epidemic may reflect a real increase in the population-based incidence, or other changes (e.g. hospitalisation practice, increase in vulnerable children with poor access to primary care). Improved rates, accuracy and completeness of pertussis notifications will improve the ability of notification data to accurately describe future epidemics and estimate vaccine effectiveness. Further debate is required regarding the aims of pertussis immunisation; accelerating the timing of the first three doses and adding further doses of pertussis vaccine on the national immunisation schedule; and the role of acellular pertussis vaccines. In the meantime, the priority must be increasing on-time immunisation coverage.     

Developments of the incidence of osteoporosis in The Netherlands: a PHARMO study

PURPOSE: To assess recent and to predict future time trends in the incidence of osteoporosis using routine databases in The Netherlands in the period 1993-2015 and to compare estimations based on hip fractures versus a proxy based on pharmacy and hospitalisation data. METHODS: The incidence of hip fractures was estimated over the period 1986-2002 using information from the Dutch Medical Registry, covering more than 99% of all Dutch hospitalisations. Additionally, a proxy (hospitalisation for osteoporosis or osteoporotic fractures, treatment with glucocorticosteroids or treatment with anti-osteoporosis drugs) was constructed in order to identify osteoporotic patients in the PHARMO database. Age and gender specific incidences of hip fractures and osteoporosis were calculated and extrapolated to The Netherlands. Results of both studies were extrapolated till 2015 using a power function. RESULTS: The incidence of hip fractures decreased slightly (270 per 100,000 in 1993, 260 per 100,000 in 2002). The incidence of osteoporosis using the constructed proxy decreased from 870 per 100,000 in 1993 to 700 per 100,000 in 2002.The incidence of hip fractures and osteoporosis remained fairly constant when modelled till 2015. Both studies showed the same time trends. CONCLUSION: Both the estimations based on the hospitalisations for hip fracture and on our proxy for osteoporosis showed that the increase in the incidence of osteoporosis as observed in the 1990s is levelling off. Due to ageing of the population the absolute number of hip fractures will however increase. Our definition of osteoporosis resulted in a higher estimation of the incidence of osteoporosis and may be used in future studies to follow developments in osteoporosis prevalence and incidence.     

Cost analysis of paroxetine versus imipramine in major depression

A simulation decision analytical model was used to compare the annual direct medical costs of treating patients with major depression using the selective serotonin reuptake inhibitor (SSRI) paroxetine or the tricyclic antidepressant (TCA) imipramine. Medical treatment patterns were determined from focus groups of general and family practitioners and psychiatrists in Boston, Dallas and Chicago, US. Direct medical costs included the wholesale drug acquisition costs (based on a 6-month course of drug therapy), psychiatrist and/or general practitioner visits, hospital outpatient visits, hospitalisation and electroconvulsive therapy. Acute phase treatment failure rates were derived from an intention-to-treat analysis of a previously published trial of paroxetine, imipramine and placebo in patients with major depression. Maintenance phase relapse rates were obtained from a 12-month trial of paroxetine, supplemented from the medical literature. The relapse rates for the final 6 months of the year were obtained from medical literature and expert opinion. Direct medical costs were estimated from a health insurance claims database. The estimated total direct medical cost per patient was slightly lower using paroxetine ($US2348) than generic imipramine ($US2448) as first-line therapy. This result was sensitive to short term dropout rates but robust to changes in other major parameters, including hospitalisation costs and relapse rates. The financial benefit of paroxetine, despite its 15-fold higher acquisition cost compared with imipramine, is attributable to a higher rate of completion of the initial course of therapy and consequent reduced hospitalisation rates.     

Signal detection of methylphenidate by comparing a spontaneous reporting database with a claims database

Data mining is critical for signal detection in pharmacovigilance systems. In this study, we compared signals between spontaneous reporting data and health insurance claims data for a socially issued drug, methylphenidate. We implemented data-mining tools for signal detection in both databases: Reporting Odds Ratios (ROR), Proportional Reporting Ratios (PRR), Chi-squared test, and Information Component (IC), in addition to a Relative Risk (RR) tool in the claims database. The claims database generated 15, 15, 36, 1, and 1 adverse drug reactions (ADRs) by ROR, PRR, chi-square, IC, and RR, respectively. The World Health Organization (WHO) spontaneous database generated 91, 91, 137, and 96 ADRs by ROR, PRR, chi-square, and IC, respectively. We found seven potential matching associations from the claims and WHO databases, but only one of them was present in the Korean spontaneous reporting database. In Korea, spontaneous reporting is still underreported and there is a small amount of data for Koreans. Signal comparison between the claims and WHO databases can provide additional regulatory insight.     

Economic impact of respiratory syncytial virus-related illness in the US: an analysis of national databases

OBJECTIVE: To determine the impact of respiratory syncytial virus (RSV) infection on healthcare resource use and costs in the US from the third-party payer perspective. DESIGN: The study retrospectively analysed cross-sectional medical encounter data from three federally funded databases that comprise nationally representative samples of hospital inpatient stays, physician office visits and visits to hospital outpatient departments and emergency rooms. METHODS: Identification of RSV infection-related medical encounters was based on the occurrence of RSV-specific International Classification of Diseases (9th Edition)-Clinical Modification diagnosis codes (079.6, 466.11, 480.1) as principal discharge diagnoses or the assumption that 10-15% of all otitis media visits were due to RSV infection. Outpatient drug costs were estimated based on average wholesale price, and physician fees and test/procedure costs were estimated based on prevailing national fees. Inpatient costs were estimated from total billed charges using a cost-to-charge ratio of 0.53. RESULTS: In 2000, nearly 98% of RSV infection-related hospitalisations occurred in children <5 years old. There were approximately 86,000 hospitalisations, 1.7 million office visits, 402 000 emergency room visits and 236,000 hospital outpatient visits for children <5 years old that were attributable to RSV infection. Total annual direct medical costs for all RSV infection-related hospitalisations ($US394 million) and other medical encounters ($US258 million) for children <5 years old were estimated at $US652 million in 2000. Otitis media was a major cost driver for physician visits. RSV infection-related hospitalisations increased from 1993 to 2000, but average costs per hospitalisation were relatively stable. CONCLUSION: Treatment of RSV infection-related illness represents a significant healthcare burden in the US. The economic impact of ambulatory care for RSV infection-related illness could be as important as that for RSV infection-related hospitalisation.     

Hospitalisation of and mortality from bleeding peptic ulcer in Sweden: a nationwide time-trend analysis

Aliment Pharmacol Ther 2011; 33: 578–584

Summary

Background Time‐trend analyses of incidence and mortality in bleeding peptic ulcer show divergent results. Aim To conduct a detailed national analysis of hospitalisation of and mortality from bleeding peptic ulcer in Sweden. Method Data from all hospitalisations at departments with primary responsibility for patients with bleeding ulcer in Sweden, with main diagnosis or co‐diagnosis of bleeding ulcer from 1987 to 2005 were retrieved from the Hospital Discharge Register. A validation study was performed due to an uncertainty in diagnostic setting after the introduction of ICD‐10 in 1997. Annual hospitalisation rates per 100 000 inhabitants in relation to gender, age and ulcer location were calculated as well as age‐standardised 30‐day mortality rates. Results Hospitalisations for bleeding ulcer decreased from 63.9 to 35.3 per 100 000 inhabitants per year during the study period. The decrease was greater among men (men: from 80.4 to 40.9; women: from 47.7 to 29.7) and in younger age groups. Bleeding gastric ulcer decreased in both genders, and bleeding duodenal ulcer decreased most among men, but was stable in a subgroup of elderly women. Median age increased from 70 to 76 years. Standardised 30‐day mortality increased from 5.3% to 6.2%. The increased mortality was found in those aged more than 65 years and with duodenal ulcer disease, whereas mortality remained unchanged in those with bleeding gastric ulcer. Conclusion Hospitalisation rates for bleeding peptic ulcer have markedly decreased in Sweden in all age groups. The 30‐day mortality is low compared with other nationwide studies in the western world, but has increased among patients with duodenal ulcer disease.     

The national healthcare system claims databases in France,SNIIRAM and EGB: Powerful tools for pharmacoepidemiology

The French health care system is based on universal coverage by one of several health care insurance plans. The SNIIRAM database merges anonymous information of reimbursed claims from all these plans, linked to the national hospital‐discharge summaries database system (PMSI) and the national death registry. It now covers 98.8% of the French population, over 66 million persons, from birth (or immigration) to death (or emigration), making it possibly the world's largest continuous homogeneous claims database. The database includes demographic data; health care encounters such as physician or paramedical visits, medicines, medical devices, and lab tests (without results); chronic medical conditions (ICD10 codes); hospitalisations with ICD10 codes for primary, linked and associated diagnoses, date and duration, procedures, diagnostic‐related groups, and cost coding; date but currently not cause of death. The power of the database is correlatively great, and its representativeness is near perfect, since it essentially includes the whole country's population. The main difficulty in using the database, beyond its sheer size and complexity, is the administrative process necessary to access it. Recent legislative advances are making this easier. EGB (Echantillon Généraliste de Bénéficiaires) is the 1/97th random permanent representative sample of SNIIRAM, with planned 20‐year longitudinal data (10 years at this time). Access time is 1 to 3 months, but its power is less (780 000 subjects). This is enough to study common issues with older drugs but may be limited for new products or rare events.     

Clinical pharmacy services, pharmacy staffing, and hospital mortality rates

OBJECTIVE: To determine if hospital-based clinical pharmacy services and pharmacy staffing continue to be associated with mortality rates. METHODS: A database was constructed from 1998 MedPAR, American Hospital Association's Annual Survey of Hospitals, and National Clinical Pharmacy Services databases, consisting of data from 2,836,991 patients in 885 hospitals. Data from hospitals that had 14 clinical pharmacy services were compared with data from hospitals that did not have these services; levels of hospital pharmacist staffing were also compared. A multiple regression analysis, controlling for severity of illness, was used. RESULTS: Seven clinical pharmacy services were associated with reduced mortality rates: pharmacist-provided drug use evaluation (4491 reduced deaths, p=0.016), pharmacist-provided in-service education (10,660 reduced deaths, p=0.037), pharmacist-provided adverse drug reaction management (14,518 reduced deaths, p=0.012), pharmacist-provided drug protocol management (18,401 reduced deaths, p=0.017), pharmacist participation on the cardiopulmonary resuscitation team (12,880 reduced deaths, p=0.009), pharmacist participation on medical rounds (11,093 reduced deaths, p=0.021), and pharmacist-provided admission drug histories (3988 reduced deaths, p=0.001). Two staffing variables, number of pharmacy administrators/100 occupied beds (p=0.037) and number of clinical pharmacists/100 occupied beds (p=0.023), were also associated with reduced mortality rates. CONCLUSION: The number of clinical pharmacy services and staffing variables associated with reduced mortality rates increased from two in 1989 to nine in 1998. The impact of clinical pharmacy on mortality rates mandates consideration of a core set of clinical pharmacy services to be offered in United States hospitals. These results have important implications for health care in general, as well as for our profession and discipline.     

Influenza vaccination in the elderly: impact on hospitalisation and mortality

Influenza causes substantial morbidity across the age spectrum. However, the elderly are especially vulnerable to the serious complications of influenza that might result in hospitalisation or death, and high rates of influenza-associated excess hospitalisation or death that exceed by several-fold the rates seen among most other age groups have consistently been observed in many countries and across many seasons. Thus, the elderly are included among the high priority groups for routine influenza vaccination by many national health authorities. Inactivated influenza virus vaccines are widely available across the globe and are safe and effective. Vaccination of elderly persons has been associated with significant reductions in hospitalisations for pneumonia and influenza as well as hospitalisations for other cardiopulmonary disorders and even cerebrovascular disease. Vaccination has also been associated with reductions in influenza-associated and all-cause mortality during influenza seasons. The benefits of vaccination extend not only to community-dwelling elderly but also to elderly who reside in nursing homes. Likewise, vaccination provides benefits to the very old and to elderly persons with underlying co-morbidities as well as to the healthy elderly. Despite the substantially increased risk for serious complications and impressive benefits from vaccination among the elderly, influenza vaccine utilisation remains below target rates for this group in nearly all countries. The need for improved prevention and control of influenza is recognised as a priority for the global community--both to reduce the morbidity and mortality associated with epidemic influenza and to prepare for the next pandemic. Enhancing vaccine delivery to elderly persons would represent important progress toward that goal.     

All-cause and cause-specific mortality rates of patients treated for alcohol use disorders: A meta-analysis

Background: Although alcohol use disorders (AUDs) are known to increase the relative risk of all-cause and some cause-specific mortality, the absolute mortality rates of the AUD population are unknown. Such knowledge would benefit planners of the provision of services for this population, including in prioritizing the identification and/or treatment of diseases likely to cause their death. Methods: We conducted a systematic review of studies in English, reporting the cause-specific mortality rates among people treated for AUDs. Number of deaths by cause and total person-years of follow-up were extracted. All-cause and cause-specific mortality rates per 1000 person-years were meta-analyzed assuming random effects. Results: Thirty-one studies were included. Participants were mainly middle-aged males. The quality of studies was generally good. A total of 6768 all-cause deaths in 276,990.7 person-years of follow-up (36,375 patients) were recorded, and the pooled all-cause mortality rate was 27.67/1000 person-years (py) (95% confidence interval [CI]: 23.9, 32.04). The most common cause of death in the AUD population was cardiovascular disease (CVD) (6.9/1000 py; 95% CI: 5.61, 8.49), followed by gastrointestinal deaths (5.63/1000 py; 95% CI: 4.1, 7.74), unnatural deaths (4.95/1000 py; 95% CI: 4.01, 6.09)), neoplasms, respiratory diseases, and substance use disorders. Conclusions: Patients with AUDs have increased rates of all-cause and cause-specific mortality compared with the general population. Like the general population, they are most likely to die of CVD. In contrast to the general population, gastrointestinal and unnatural deaths are the next most common causes of death. We believe these facts should be considered when planning health care services for patients with AUDs.     

Identification of patients with Churg-Strauss syndrome (CSS) using automated data

PURPOSE: Our aim was to identify individuals with Churg-Strauss syndrome (CSS) among asthma drug users, based on patterns of diagnostic and procedural codes (termed 'algorithms') contained in automated claims data. METHODS: A retrospective study was conducted among patients who had been dispensed asthma drugs at three HMOs. Individuals who received > or =3 dispensings of an asthma drug during any consecutive 12-month period beginning 1 January 1994 through 20 June 2000 were identified. Information on patient age, gender, enrollment status, asthma drugs dispensed, inpatient and outpatient diagnoses and procedures were obtained from the HMO automated databases. Twelve combinations of diagnostic and billing codes ('algorithms') were developed using the claims data to identify potential cases of CSS. Chart reviews blinded to drug exposure were performed using a standardized abstraction form. A rheumatologist reviewed abstracted information on all subjects, and those who met two or more American College of Rheumatology (ACR) criteria for CSS were further reviewed by two clinical experts. Cases were classified as unlikely, possible, or probable/definite CSS. Each clinical expert independently rated the cases; disagreements were resolved by consensus. RESULTS: A total of 185 604 patients who had been dispensed asthma drugs were identified. Three hundred fifty subjects were selected for chart review, and 15 were classified as having 'probable/definite' CSS. The algorithms that were most successful in identifying patients with CSS were as follows: (1) two or more codes for vasculitis (13 confirmed cases from 129 reviewed; positive predictive value 10%); (2) codes for both vasculitis and neurologic symptoms (6 confirmed cases from 15 reviewed; positive predictive value 40%) and (3) codes for both eosinophilia and vasculitis (4 confirmed cases from 5 reviewed; positive predictive value 80%). CONCLUSION: Automated claims data can be used to identify patients with CSS. This approach can facilitate better epidemiologic study of the risk factors for the condition.     

Tailored dose baclofen in patients with alcoholic liver disease: A case series with 2-year follow-up of hospitalisation

Introduction: Alcohol addiction is a major health burden with its consequences including liver disease and frequent hospitalisations. We used tailored-dose baclofen in patients with alcoholic liver disease and investigated hospital re-admissions before and after baclofen dose was initiated as well as tolerability and patient-reported alcohol consumption. Methods: Fifty-three hospitalised patients with alcoholic liver disease started tailored dose baclofen (median: 5.05 months, median highest dose before tapering down: 60?mg). Patients were followed-up for hospitalisation data from the health board database (mean hospitalisation follow up: 31 months) and patients were sent standardized questionnaires. Results: Baclofen was generally well tolerated with dose reductions in four patients. In the 2 years after initiation of the treatment, patients spent on an average of 19.1?d in the hospital per year compared to 25.48?d before the treatment initiation (p?=?0.59). Respondents (19 patients) reported a reduction in alcohol consumption by an average of 58.7% (240.1?g to 144.09?g). Conclusions: After initiation of the baclofen treatment, there was a trend towards decrease in hospitalisations and in patients who answered the questionnaire, alcohol consumption decreased.     

Persistent bisphosphonate use and the risk of osteoporotic fractures in clinical practice: a database analysis study

INTRODUCTION: International guidelines on the treatment and prevention of osteoporosis recommend the use of bisphosphonates to prevent fractures in this population. However, low persistent use of bisphosphonates could considerably limit the prevention of fractures in clinical practice. OBJECTIVE: This study aimed to investigate the association between persistent use of bisphosphonates and the risk of osteoporotic fractures in clinical practice. METHODS: Data were obtained from the PHARMO Record Linkage System, which includes, among other databases, drug-dispensing records from community pharmacies linked to hospital discharge records of more than two million subjects in defined areas in the Netherlands. Persistence with bisphosphonate therapy was assessed during a period of 3 years. A nested matched case control study (cases:controls = 1:10) was performed to study the association between persistent bisphosphonate use and hospitalisation for osteoporotic fractures and analysed by conditional logistic regression analysis. The analyses were adjusted for patient characteristics such as previous hospitalisations for fractures, co-morbidity and co-medication. RESULTS: 14,760 new female users of bisphosphonates were identified of which 541 women had a hospitalisation for osteoporotic fracture after start of bisphosphonate treatment (1-3 years follow-up). One-year persistence rates increased from 33% with alendronate daily to 48% with alendronate weekly, an increase of 15%. Similar results were obtained with risedronate daily and weekly. One year persistent use of bisphosphonates resulted in a statistical significant 26% lower fracture rate (OR 0.74; 95%CI 0.57-0.95) whereas 2 year persistent use resulted in a 32% lower rate (OR 0.68; 95%CI 0.47-0.96). CONCLUSIONS: Persistent use of bisphosphonates decreases the risk of osteoporotic fractures in clinical practice. Approximately 6% of fractures among users of bisphosphonates could be prevented if persistence was improved by 20%. However, current persistence with bisphosphonate therapy is suboptimal and strategies that further increase persistence are likely to further prevent the number of fractures.     

Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies

Aim: to establish the percentage hospital admission related to adverse drug reactions (ADRs) from the data available in the literature.Method: literature search in the Medline database, meta-analysis.Results: from the literature it is revealed that a considerable part of all hospital admissions are related to adverse drug reactions. However, these data are not homogenous, i.e. larger studies display a lower percentage of ADR related hospital admission, while smaller studies display a higher percentage. Subgroup analysis showed that for elderly people the odds of being hospitalised by ADR related problems is 4 times higher than for younger ones (16.6% vs. 4.1%). A considerable part of these hospitalisations can be prevented. Subgroup analysis revealed that in the elderly up to 88% of the ADR related hospitalisations are preventable; for the non-elderly this is only 24%. Comparatively more elderly people are hospitalised than younger ones. Combining these findings, twice as much elderly people are hospitalised by ADR related problems than non-elderly, while preventability of ADR related hospitalisation might yield 7 times more people in the elderly than in the non-elderly. The estimation of the costs of ADR related hospitalisations in the Health Care system in The Netherlands is discussed.Conclusion: many elderly people are hospitalised by ADR related problems; an important part of these hospitalisations can be avoided.     

Characterisation of asthma management in the Fallon Community Health Plan from 1988 to 1991

In order to characterise asthma management in a managed care setting, we identified 10,301 patients who were diagnosed with asthma between 1 January 1988 and 31 December 1991 at a group model health maintenance organisation in central Massachusetts, US. We obtained for these patients automated utilisation files containing data on medications, hospitalisations, emergency room visits, office visits, and estimated costs of these services. The medication dispensed to the greatest proportion of patients was beta 2 agonists either by inhalation (56%) or orally (21%). Theophylline was dispensed to 23% of the patients. Maintenance therapy was inhaled anti-inflammatory medication was uncommon, as inhaled corticosteroids (17%) and sodium cromoglycate (cromolyn sodium) [8%] were dispensed to fewer patients than other asthma medications. Among patients who had been hospitalised in the previous year, 36% were presently receiving inhaled corticosteroids, and among patients who used at least one beta 2 agonist metered-dose inhaler per month, 49% were presently receiving inhaled corticosteroids. Economic analyses showed that only 8% of the patients had either a hospital admission or an emergency room visit, but hospital costs among these patients accounted for 25% of the total costs of asthma care. In addition, the top 10% most expensive patients accounted for 42% of the total cost of asthma care. We conclude that a substantial proportion of patients at increased risk of a severe attack, by virtue of having a recent hospitalisation, do not receive maintenance anti-inflammatory therapy, and that hospitalisations among a relatively small proportion of asthma patients contribute significantly to the cost of asthma care.