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Doug Brunk is a San Diego-based award-winning reporter who began covering health care in 1991. Before joining the company, he wrote for the health sciences division of Columbia University and was an associate editor at Contemporary Long Term Care magazine when it won a Jesse H. Neal Award. His work has been syndicated by the Los Angeles Times and he is the author of two books related to the University of Kentucky Wildcats men's basketball program. Doug has a master’s degree in magazine journalism from the S.I. Newhouse School of Public Communications at Syracuse University. Follow him on Twitter @dougbrunk.
Treat-to-target approach for psoriatic arthritis found beneficial
SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.
"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.
Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.
Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).
After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.
The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).
Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."
He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."
The researchers have yet to perform a cost analysis comparing the two treatment groups.
The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.
*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage.
SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.
"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.
Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.
Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).
After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.
The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).
Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."
He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."
The researchers have yet to perform a cost analysis comparing the two treatment groups.
The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.
*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage.
SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.
"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.
Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.
Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).
After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.
The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).
Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."
He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."
The researchers have yet to perform a cost analysis comparing the two treatment groups.
The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.
*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage.
AT THE ACR ANNUAL MEETING
Major finding: At 48 weeks, a higher proportion of psoriatic arthritis patients in the intensive management group achieved ACR70, compared with those in the standard care group (38% vs. 17%, respectively).
Data source: A multicenter trial of 206 patients with early psoriatic arthritis who were randomized to standard care or intensive management and followed for 48 weeks.
Disclosures: The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.
Orthopedic surgery among RA patients declining, study finds
SAN DIEGO – The overall proportion of rheumatoid arthritis patients undergoing orthopedic surgery is declining as intensive pharmacologic intervention with agents such as biologics play an increasingly prominent role in the treatment of the inflammatory disease, judging from results from a large, long-term study.
In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat and his associates enrolled 2,342 men and women from RA patient registries in Sweden who filled out questionnaires including visual analog scales for general health and pain, and the Health Assessment Questionnaire (HAQ) in 1997, 2002, 2005, and 2009.
The response rate ranged from 62% to 74%, and the researchers linked responses to Swedish national health registry records to correlate the data with records of inpatient and outpatient surgeries, as well as the use of biologics. They went on to evaluate the incidence rate of orthopedic surgery in three time periods: from 1998-2001 (time period A), 2002-2006 (time period B), and 2007-2011 (time period C).
Dr. Hekmat, a rheumatologist and a PhD fellow at Malmö University, Sweden, reported that between 1998 and 2011 the incidence of all orthopedic procedures performed was 82.3 per 1,000 person-years. Significant declines were observed over the three time periods studied. For example, the incidence of any orthopedic surgery declined from 94.6 per 1,000 person-years in time period A to 82.6 per 1,000 person-years in time period B, and 71.8 per 1,000 person-years in time period C (P less than .001).
A similar association was observed for hip surgery alone (which fell from 27.8 per 1,000 person-years in time period A to 17.6 per 1,000 person-years in time period C; P less than .001). The incidence of orthopedic surgery on small joints such as hands, wrists, feet, and ankles fell from 43.8 per 1,000 person-years in time period A to 30.5 per 1,000 person-years in time period C (P less than .001).
No significant decline occurred in the incidence of knee surgeries performed during the study period. This actually rose slightly from 12.3 per 1,000 person-years in time period A to 12.9 per 1,000 person-years in time period C (P = .759).
Independent predictors of undergoing any orthopedic surgery included being female (hazard ratio 1.50) and having greater disability as measured by the HAQ (HR 1.37).
Dr. Hekmat speculated that the rate of orthopedic surgery was reduced by early intensive treatment in patients with RA, since the time period studied coincided with the increased use of pharmacologic interventions. "In this cohort we are targeting the patients more aggressively," he said. "It’s not wrong to guess that this decline may lead to better [disease] management."
Dr. Hekmat said that he had no relevant financial conflicts to disclose.
In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat, Health Assessment Questionnaire, Malmö University, Sweden, orthopedic procedures,
SAN DIEGO – The overall proportion of rheumatoid arthritis patients undergoing orthopedic surgery is declining as intensive pharmacologic intervention with agents such as biologics play an increasingly prominent role in the treatment of the inflammatory disease, judging from results from a large, long-term study.
In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat and his associates enrolled 2,342 men and women from RA patient registries in Sweden who filled out questionnaires including visual analog scales for general health and pain, and the Health Assessment Questionnaire (HAQ) in 1997, 2002, 2005, and 2009.
The response rate ranged from 62% to 74%, and the researchers linked responses to Swedish national health registry records to correlate the data with records of inpatient and outpatient surgeries, as well as the use of biologics. They went on to evaluate the incidence rate of orthopedic surgery in three time periods: from 1998-2001 (time period A), 2002-2006 (time period B), and 2007-2011 (time period C).
Dr. Hekmat, a rheumatologist and a PhD fellow at Malmö University, Sweden, reported that between 1998 and 2011 the incidence of all orthopedic procedures performed was 82.3 per 1,000 person-years. Significant declines were observed over the three time periods studied. For example, the incidence of any orthopedic surgery declined from 94.6 per 1,000 person-years in time period A to 82.6 per 1,000 person-years in time period B, and 71.8 per 1,000 person-years in time period C (P less than .001).
A similar association was observed for hip surgery alone (which fell from 27.8 per 1,000 person-years in time period A to 17.6 per 1,000 person-years in time period C; P less than .001). The incidence of orthopedic surgery on small joints such as hands, wrists, feet, and ankles fell from 43.8 per 1,000 person-years in time period A to 30.5 per 1,000 person-years in time period C (P less than .001).
No significant decline occurred in the incidence of knee surgeries performed during the study period. This actually rose slightly from 12.3 per 1,000 person-years in time period A to 12.9 per 1,000 person-years in time period C (P = .759).
Independent predictors of undergoing any orthopedic surgery included being female (hazard ratio 1.50) and having greater disability as measured by the HAQ (HR 1.37).
Dr. Hekmat speculated that the rate of orthopedic surgery was reduced by early intensive treatment in patients with RA, since the time period studied coincided with the increased use of pharmacologic interventions. "In this cohort we are targeting the patients more aggressively," he said. "It’s not wrong to guess that this decline may lead to better [disease] management."
Dr. Hekmat said that he had no relevant financial conflicts to disclose.
SAN DIEGO – The overall proportion of rheumatoid arthritis patients undergoing orthopedic surgery is declining as intensive pharmacologic intervention with agents such as biologics play an increasingly prominent role in the treatment of the inflammatory disease, judging from results from a large, long-term study.
In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat and his associates enrolled 2,342 men and women from RA patient registries in Sweden who filled out questionnaires including visual analog scales for general health and pain, and the Health Assessment Questionnaire (HAQ) in 1997, 2002, 2005, and 2009.
The response rate ranged from 62% to 74%, and the researchers linked responses to Swedish national health registry records to correlate the data with records of inpatient and outpatient surgeries, as well as the use of biologics. They went on to evaluate the incidence rate of orthopedic surgery in three time periods: from 1998-2001 (time period A), 2002-2006 (time period B), and 2007-2011 (time period C).
Dr. Hekmat, a rheumatologist and a PhD fellow at Malmö University, Sweden, reported that between 1998 and 2011 the incidence of all orthopedic procedures performed was 82.3 per 1,000 person-years. Significant declines were observed over the three time periods studied. For example, the incidence of any orthopedic surgery declined from 94.6 per 1,000 person-years in time period A to 82.6 per 1,000 person-years in time period B, and 71.8 per 1,000 person-years in time period C (P less than .001).
A similar association was observed for hip surgery alone (which fell from 27.8 per 1,000 person-years in time period A to 17.6 per 1,000 person-years in time period C; P less than .001). The incidence of orthopedic surgery on small joints such as hands, wrists, feet, and ankles fell from 43.8 per 1,000 person-years in time period A to 30.5 per 1,000 person-years in time period C (P less than .001).
No significant decline occurred in the incidence of knee surgeries performed during the study period. This actually rose slightly from 12.3 per 1,000 person-years in time period A to 12.9 per 1,000 person-years in time period C (P = .759).
Independent predictors of undergoing any orthopedic surgery included being female (hazard ratio 1.50) and having greater disability as measured by the HAQ (HR 1.37).
Dr. Hekmat speculated that the rate of orthopedic surgery was reduced by early intensive treatment in patients with RA, since the time period studied coincided with the increased use of pharmacologic interventions. "In this cohort we are targeting the patients more aggressively," he said. "It’s not wrong to guess that this decline may lead to better [disease] management."
Dr. Hekmat said that he had no relevant financial conflicts to disclose.
In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat, Health Assessment Questionnaire, Malmö University, Sweden, orthopedic procedures,
In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat, Health Assessment Questionnaire, Malmö University, Sweden, orthopedic procedures,
AT THE ACR ANNUAL MEETING
Major finding: The incidence of any orthopedic surgery among rheumatoid arthritis patients declined from 94.6 per 1,000 person-years in 1998-2001 to 82.6 per 1,000 person-years in 2002-2016 and 71.8 per 1,000 person-years in 2007-2011 (P less than .001).
Data source: A study of 2,342 men and women from RA patient registries in Sweden who filled out questionnaires including visual analog scales for general health and pain, and the Health Assessment Questionnaire in 1997, 2002, 2005, and 2009.
Disclosures: Dr. Hekmat said that he had no relevant financial conflicts to disclose.
Smoking has damaging impact in ankylosing spondylitis
SAN DIEGO – Smoking increases the effect of inflammation on x-ray damage in people with ankylosing spondylitis by more than fivefold, results from a Dutch study demonstrated. In addition, the effect is amplified by more than 13-fold in male smokers, compared with females who don’t smoke.
Those are the key findings from OASIS (Outcome in AS International Study), which followed ankylosing spondylitis patients for up to 12 years with biannual clinical assessments, including radiographs. Lead investigator Dr. Sofia Ramiro of the Academic Medical Center at the University of Amsterdam discussed the study during a press briefing at the annual meeting of the American College of Rheumatology.
Two reviewers independently scored the x-rays of 127 patients with ankylosing spondylitis according to the Modified Stoke Ankylosing Spondylitis Supine Score (mSASSS). Dr. Ramiro and her associates evaluated the relationship between the AS Disease Activity Score and x-ray damage over a period of 12 years by assessing the effect of inflammation at one point in time on the progression of damage 2 years later.
The mean age of the 127 patients was 41 years and 71% were male. Their mean symptom duration was 18 years, 82% were human leukocyte antigen B27 (HLA-B27) positive, and 40% were smokers.
Overall, smokers had a 5.5-fold higher effect of inflammation on x-ray damage, compared with nonsmokers, and male smokers had a 13.4-fold higher effect of inflammation on damage, compared with female nonsmokers. In addition, smokers with a short symptom duration – defined as those with fewer than 18 years of symptoms – had an 8.1-fold higher effect of inflammation on damage, compared with nonsmokers with long symptom duration.
"Smoking cessation, especially among young males, seems to be an important take-home message," Dr. Ramiro commented. "It will probably lead to less radiographic damage and to better long-term outcomes."
The press briefing’s moderator, Dr. Christie M. Bartels of the division of rheumatology at the University of Wisconsin in Madison, characterized the findings as "additional compelling evidence to say that smoking cessation would be an important process measure to look at in the rheumatology clinic, so that we can help our patients achieve their optimal outcomes."
As to the possible mechanism of action behind the relationship, Dr. Ramiro speculated that "it’s not really smoking itself that’s contributing to the worse outcomes. Smoking is increasing the impact of inflammation on radiographic damage. It’s inflammation that causes the damage."
In an interview, she acknowledged certain limitations of the study, including the fact that the sample size "is not large enough to split the data into several relevant subgroups. For instance, the number of females is rather small, as is the number of HLA-B27–negative males and females."
Dr. Ramiro said that she had no relevant financial conflicts to disclose.
SAN DIEGO – Smoking increases the effect of inflammation on x-ray damage in people with ankylosing spondylitis by more than fivefold, results from a Dutch study demonstrated. In addition, the effect is amplified by more than 13-fold in male smokers, compared with females who don’t smoke.
Those are the key findings from OASIS (Outcome in AS International Study), which followed ankylosing spondylitis patients for up to 12 years with biannual clinical assessments, including radiographs. Lead investigator Dr. Sofia Ramiro of the Academic Medical Center at the University of Amsterdam discussed the study during a press briefing at the annual meeting of the American College of Rheumatology.
Two reviewers independently scored the x-rays of 127 patients with ankylosing spondylitis according to the Modified Stoke Ankylosing Spondylitis Supine Score (mSASSS). Dr. Ramiro and her associates evaluated the relationship between the AS Disease Activity Score and x-ray damage over a period of 12 years by assessing the effect of inflammation at one point in time on the progression of damage 2 years later.
The mean age of the 127 patients was 41 years and 71% were male. Their mean symptom duration was 18 years, 82% were human leukocyte antigen B27 (HLA-B27) positive, and 40% were smokers.
Overall, smokers had a 5.5-fold higher effect of inflammation on x-ray damage, compared with nonsmokers, and male smokers had a 13.4-fold higher effect of inflammation on damage, compared with female nonsmokers. In addition, smokers with a short symptom duration – defined as those with fewer than 18 years of symptoms – had an 8.1-fold higher effect of inflammation on damage, compared with nonsmokers with long symptom duration.
"Smoking cessation, especially among young males, seems to be an important take-home message," Dr. Ramiro commented. "It will probably lead to less radiographic damage and to better long-term outcomes."
The press briefing’s moderator, Dr. Christie M. Bartels of the division of rheumatology at the University of Wisconsin in Madison, characterized the findings as "additional compelling evidence to say that smoking cessation would be an important process measure to look at in the rheumatology clinic, so that we can help our patients achieve their optimal outcomes."
As to the possible mechanism of action behind the relationship, Dr. Ramiro speculated that "it’s not really smoking itself that’s contributing to the worse outcomes. Smoking is increasing the impact of inflammation on radiographic damage. It’s inflammation that causes the damage."
In an interview, she acknowledged certain limitations of the study, including the fact that the sample size "is not large enough to split the data into several relevant subgroups. For instance, the number of females is rather small, as is the number of HLA-B27–negative males and females."
Dr. Ramiro said that she had no relevant financial conflicts to disclose.
SAN DIEGO – Smoking increases the effect of inflammation on x-ray damage in people with ankylosing spondylitis by more than fivefold, results from a Dutch study demonstrated. In addition, the effect is amplified by more than 13-fold in male smokers, compared with females who don’t smoke.
Those are the key findings from OASIS (Outcome in AS International Study), which followed ankylosing spondylitis patients for up to 12 years with biannual clinical assessments, including radiographs. Lead investigator Dr. Sofia Ramiro of the Academic Medical Center at the University of Amsterdam discussed the study during a press briefing at the annual meeting of the American College of Rheumatology.
Two reviewers independently scored the x-rays of 127 patients with ankylosing spondylitis according to the Modified Stoke Ankylosing Spondylitis Supine Score (mSASSS). Dr. Ramiro and her associates evaluated the relationship between the AS Disease Activity Score and x-ray damage over a period of 12 years by assessing the effect of inflammation at one point in time on the progression of damage 2 years later.
The mean age of the 127 patients was 41 years and 71% were male. Their mean symptom duration was 18 years, 82% were human leukocyte antigen B27 (HLA-B27) positive, and 40% were smokers.
Overall, smokers had a 5.5-fold higher effect of inflammation on x-ray damage, compared with nonsmokers, and male smokers had a 13.4-fold higher effect of inflammation on damage, compared with female nonsmokers. In addition, smokers with a short symptom duration – defined as those with fewer than 18 years of symptoms – had an 8.1-fold higher effect of inflammation on damage, compared with nonsmokers with long symptom duration.
"Smoking cessation, especially among young males, seems to be an important take-home message," Dr. Ramiro commented. "It will probably lead to less radiographic damage and to better long-term outcomes."
The press briefing’s moderator, Dr. Christie M. Bartels of the division of rheumatology at the University of Wisconsin in Madison, characterized the findings as "additional compelling evidence to say that smoking cessation would be an important process measure to look at in the rheumatology clinic, so that we can help our patients achieve their optimal outcomes."
As to the possible mechanism of action behind the relationship, Dr. Ramiro speculated that "it’s not really smoking itself that’s contributing to the worse outcomes. Smoking is increasing the impact of inflammation on radiographic damage. It’s inflammation that causes the damage."
In an interview, she acknowledged certain limitations of the study, including the fact that the sample size "is not large enough to split the data into several relevant subgroups. For instance, the number of females is rather small, as is the number of HLA-B27–negative males and females."
Dr. Ramiro said that she had no relevant financial conflicts to disclose.
AT THE ACR ANNUAL MEETING
Major finding: Smokers had a 5.5-fold higher effect of inflammation on x-ray damage, compared with nonsmokers, and male smokers had a 13.4-fold higher effect of inflammation on damage, compared with female nonsmokers.
Data source: An assessment of 127 patients enrolled in the Outcome in AS International Study (OASIS), which followed ankylosing spondylitis patients for up to 12 years with biannual clinical assessments, including radiographs.
Disclosures: Dr. Ramiro said that she had no relevant financial conflicts to disclose.
Treatment adherence poor among Medicaid beneficiaries with lupus
SAN DIEGO – Fewer than one in three Medicaid beneficiaries with systemic lupus erythematosus are adhering to their recommended treatment regimens at least 80% of the time, results from a large national analysis demonstrated.
"As a physician who spends my professional time taking care of people with lupus, these data are highly concerning," Dr. Jinoos Yazdany said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented. "For many individuals with lupus, treatment is very effective and has a proven track record of preventing life-threatening complications and long-term organ damage such as kidney failure. The fact that less than one in three patients are adhering with treatment is alarming and should serve as a call to action for those of providing care to these patients."
Dr. Yazdany, associate director of the lupus clinic at the University of California-San Francisco Medical Center, and her colleagues used MAX (Medicaid Analytic eXtract) data from 2000 to 2006 to identify 23,187 patients with systemic lupus erythematosus (SLE) who were taking at least one immunosuppressive or antimalarial drug. They used pharmacy claims to assess adherence to drugs over a period of 180 days by calculating a medication possession ratio (MPR), defined as the proportion of days covered by the total days’ supply dispensed after the first claim for each drug. The researchers also evaluated the proportion of patients who had an MPR of 80% or greater. The oral drugs studied were hydroxychloroquine, azathioprine, methotrexate, mycophenolate mofetil, cyclosporine, tacrolimus, cyclophosphamide, and leflunomide.
The mean age of the 23,187 patients was 38 years, 94% were female, and the racial and ethnic makeup was diverse (40% black, 34% white, 16% Hispanic, 5% Asian, and 5% other). The highest proportion of SLE patients lived in the southern United States (36%).
Dr. Yazdany reported that the average MPR ranged from 31.1% for tacrolimus to 56% for hydroxychloroquine. In addition, for most drugs, fewer than one in three patients had an MPR of at least 80%. Overall adherence was poorest among those taking tacrolimus (14%) and highest among those taking mycophenolate mofetil (40%).
Across all medications, blacks had lower adherence, compared with whites, and adherence was highest for those residing in the Northeast.
"Our findings underscore the need to understand the reasons behind low adherence in this high-risk and vulnerable group of patients," Dr. Yazdany said. "And we urgently need to develop interventions to improve adherence. Physicians may be unaware of their patient’s adherence with medication, and patients may not be forthcoming about this issue. Concerns about side effects, inadequate understanding of the benefit, and the medication’s cost may be barriers for patients. Treatment-associated side effects may be another important barrier. We need better patient-physician communication around the issue of adherence."
The Medicaid administrative data allowed for an otherwise unobtainable nationwide view of adherence in SLE, but Dr. Yazdany acknowledged certain limitations of the study, including the fact that treatment "may be interrupted for clinically appropriate reasons, so the medication possession ratios in our study may underestimate actual adherence. Also, pharmacy claims are imperfect proxies for whether patients actually take medications that are dispensed, which might lead to an overestimation of adherence."
Dr. Yazdany disclosed that her research is funded by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. She had no other relevant financial conflicts to disclose.
SAN DIEGO – Fewer than one in three Medicaid beneficiaries with systemic lupus erythematosus are adhering to their recommended treatment regimens at least 80% of the time, results from a large national analysis demonstrated.
"As a physician who spends my professional time taking care of people with lupus, these data are highly concerning," Dr. Jinoos Yazdany said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented. "For many individuals with lupus, treatment is very effective and has a proven track record of preventing life-threatening complications and long-term organ damage such as kidney failure. The fact that less than one in three patients are adhering with treatment is alarming and should serve as a call to action for those of providing care to these patients."
Dr. Yazdany, associate director of the lupus clinic at the University of California-San Francisco Medical Center, and her colleagues used MAX (Medicaid Analytic eXtract) data from 2000 to 2006 to identify 23,187 patients with systemic lupus erythematosus (SLE) who were taking at least one immunosuppressive or antimalarial drug. They used pharmacy claims to assess adherence to drugs over a period of 180 days by calculating a medication possession ratio (MPR), defined as the proportion of days covered by the total days’ supply dispensed after the first claim for each drug. The researchers also evaluated the proportion of patients who had an MPR of 80% or greater. The oral drugs studied were hydroxychloroquine, azathioprine, methotrexate, mycophenolate mofetil, cyclosporine, tacrolimus, cyclophosphamide, and leflunomide.
The mean age of the 23,187 patients was 38 years, 94% were female, and the racial and ethnic makeup was diverse (40% black, 34% white, 16% Hispanic, 5% Asian, and 5% other). The highest proportion of SLE patients lived in the southern United States (36%).
Dr. Yazdany reported that the average MPR ranged from 31.1% for tacrolimus to 56% for hydroxychloroquine. In addition, for most drugs, fewer than one in three patients had an MPR of at least 80%. Overall adherence was poorest among those taking tacrolimus (14%) and highest among those taking mycophenolate mofetil (40%).
Across all medications, blacks had lower adherence, compared with whites, and adherence was highest for those residing in the Northeast.
"Our findings underscore the need to understand the reasons behind low adherence in this high-risk and vulnerable group of patients," Dr. Yazdany said. "And we urgently need to develop interventions to improve adherence. Physicians may be unaware of their patient’s adherence with medication, and patients may not be forthcoming about this issue. Concerns about side effects, inadequate understanding of the benefit, and the medication’s cost may be barriers for patients. Treatment-associated side effects may be another important barrier. We need better patient-physician communication around the issue of adherence."
The Medicaid administrative data allowed for an otherwise unobtainable nationwide view of adherence in SLE, but Dr. Yazdany acknowledged certain limitations of the study, including the fact that treatment "may be interrupted for clinically appropriate reasons, so the medication possession ratios in our study may underestimate actual adherence. Also, pharmacy claims are imperfect proxies for whether patients actually take medications that are dispensed, which might lead to an overestimation of adherence."
Dr. Yazdany disclosed that her research is funded by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. She had no other relevant financial conflicts to disclose.
SAN DIEGO – Fewer than one in three Medicaid beneficiaries with systemic lupus erythematosus are adhering to their recommended treatment regimens at least 80% of the time, results from a large national analysis demonstrated.
"As a physician who spends my professional time taking care of people with lupus, these data are highly concerning," Dr. Jinoos Yazdany said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented. "For many individuals with lupus, treatment is very effective and has a proven track record of preventing life-threatening complications and long-term organ damage such as kidney failure. The fact that less than one in three patients are adhering with treatment is alarming and should serve as a call to action for those of providing care to these patients."
Dr. Yazdany, associate director of the lupus clinic at the University of California-San Francisco Medical Center, and her colleagues used MAX (Medicaid Analytic eXtract) data from 2000 to 2006 to identify 23,187 patients with systemic lupus erythematosus (SLE) who were taking at least one immunosuppressive or antimalarial drug. They used pharmacy claims to assess adherence to drugs over a period of 180 days by calculating a medication possession ratio (MPR), defined as the proportion of days covered by the total days’ supply dispensed after the first claim for each drug. The researchers also evaluated the proportion of patients who had an MPR of 80% or greater. The oral drugs studied were hydroxychloroquine, azathioprine, methotrexate, mycophenolate mofetil, cyclosporine, tacrolimus, cyclophosphamide, and leflunomide.
The mean age of the 23,187 patients was 38 years, 94% were female, and the racial and ethnic makeup was diverse (40% black, 34% white, 16% Hispanic, 5% Asian, and 5% other). The highest proportion of SLE patients lived in the southern United States (36%).
Dr. Yazdany reported that the average MPR ranged from 31.1% for tacrolimus to 56% for hydroxychloroquine. In addition, for most drugs, fewer than one in three patients had an MPR of at least 80%. Overall adherence was poorest among those taking tacrolimus (14%) and highest among those taking mycophenolate mofetil (40%).
Across all medications, blacks had lower adherence, compared with whites, and adherence was highest for those residing in the Northeast.
"Our findings underscore the need to understand the reasons behind low adherence in this high-risk and vulnerable group of patients," Dr. Yazdany said. "And we urgently need to develop interventions to improve adherence. Physicians may be unaware of their patient’s adherence with medication, and patients may not be forthcoming about this issue. Concerns about side effects, inadequate understanding of the benefit, and the medication’s cost may be barriers for patients. Treatment-associated side effects may be another important barrier. We need better patient-physician communication around the issue of adherence."
The Medicaid administrative data allowed for an otherwise unobtainable nationwide view of adherence in SLE, but Dr. Yazdany acknowledged certain limitations of the study, including the fact that treatment "may be interrupted for clinically appropriate reasons, so the medication possession ratios in our study may underestimate actual adherence. Also, pharmacy claims are imperfect proxies for whether patients actually take medications that are dispensed, which might lead to an overestimation of adherence."
Dr. Yazdany disclosed that her research is funded by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. She had no other relevant financial conflicts to disclose.
AT THE ACR ANNUAL MEETING
Major finding: Among Medicaid beneficiaries with SLE, the average medication possession ratio ranged from 31.1% for tacrolimus to 56% for hydroxychloroquine.
Data source: A study of 23,187 Medicaid patients with SLE who were taking at least one immunosuppressive or antimalarial drug between 2000 and 2006.
Disclosures: Dr. Yazdany disclosed that her research is funded by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. She had no other relevant financial conflicts to disclose.
HPV Vaccine Uptake Low in Autoimmune Disease Patients
SAN DIEGO – Only 8.5% of children and young adults with autoimmune diseases and 9.1% of those without such diseases received one or more doses of the human papillomavirus vaccine, a large analysis of national claims data showed.
"Despite the high efficacy of HPV vaccine in preventing cervical cancer and clinically acceptable safety profile in the general population, the vast majority of patients aged 9-26 in our study cohort with and without autoimmune diseases did not receive the HPV vaccine," Dr. Seoyoung C. Kim said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented.
"Patients at high risk of persistent HPV infection should be encouraged to receive the vaccine, although future study is needed to determine the effectiveness of HPV vaccine in patients with autoimmune diseases, particularly those on immunosuppressive drugs," she added.
In 2006 and 2009, two three-dose series HPV vaccines were approved for use in males and females aged 9-26 years. Prior research has suggested that patients with lupus or inflammatory bowel disease or those who take immunosuppressive agents have a higher risk of persistent HPV infection or cervical dysplasia, said Dr. Kim of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital, Boston.
"HPV vaccine has been available for the past several years in the U.S. and in other countries," she said. "As far as we know, there has not been any study looking at the uptake of HPV vaccine in the autoimmune disease population."
Using United HealthCare national claims data for 2005-2012, Dr. Kim and her associates identified patients aged 9-26 years with at least 1 year of continuous enrollment who had at least two autoimmune disease diagnosis codes 7 or more days apart. Vaccination was defined as one or more vaccine codes after 2006, and the researchers accounted for coexisting diseases, use of health care treatments, and geographic regions when assessing vaccine uptake.
Dr. Kim, the study’s senior investigator, reported data for 29,255 children and young adults with autoimmune diseases and 117,020 without. The mean age was 19 years, and 59% were female. Patients in the autoimmune diseases group had a higher number of physician visits, abnormal pap smears, and sexually transmitted diseases, compared with their counterparts without autoimmune disease (all P values less than .01).
Overall, autoimmune disease patients and their counterparts had similarly low uptake of at least one vaccine dose (8.5% vs. 9.1%, respectively; P = .34). The uptake was higher among females in both groups (13.1% vs. 14.1%, respectively; P less than .01), yet fewer than 5% of female patients in both groups completed a three-dose vaccine series (4.7% vs. 4.6%; P = .57). A higher percentage of patients in the Northeast received one or more HPV vaccine doses (16.3% vs. 11.8%; P = .02); otherwise vaccinations were equally distributed from a geographic standpoint.
In a subgroup of female patients who had at least 2 years of follow-up, 20.6% with autoimmune disease and 23.1% without autoimmune disease received at least one vaccine dose. Of those, 53.1% and 51.4%, respectively, completed the series.
"We were generally surprised to see how low the uptake has been in both autoimmune and nonautoimmune populations," Dr. Kim said. She acknowledged certain limitations of the study, including the fact that it was conducting using the claims data from United HealthCare, "so it only captures patients who used the insurance card to pay for the vaccine," she said. "However, given the high cost of the HPV vaccine, this limitation is probably not substantial. We [also] did not have information on race/ethnicity."
Dr. Kim disclosed that she is supported by a grant from the National Institutes of Health. She received a research grant from Pfizer and tuition support for the pharmacoepidemiology program at the Harvard School of Public Health, which is funded by Pfizer, Millennium Pharma, and Asisa.
persistent HPV infection, immunosuppressive drugs,
SAN DIEGO – Only 8.5% of children and young adults with autoimmune diseases and 9.1% of those without such diseases received one or more doses of the human papillomavirus vaccine, a large analysis of national claims data showed.
"Despite the high efficacy of HPV vaccine in preventing cervical cancer and clinically acceptable safety profile in the general population, the vast majority of patients aged 9-26 in our study cohort with and without autoimmune diseases did not receive the HPV vaccine," Dr. Seoyoung C. Kim said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented.
"Patients at high risk of persistent HPV infection should be encouraged to receive the vaccine, although future study is needed to determine the effectiveness of HPV vaccine in patients with autoimmune diseases, particularly those on immunosuppressive drugs," she added.
In 2006 and 2009, two three-dose series HPV vaccines were approved for use in males and females aged 9-26 years. Prior research has suggested that patients with lupus or inflammatory bowel disease or those who take immunosuppressive agents have a higher risk of persistent HPV infection or cervical dysplasia, said Dr. Kim of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital, Boston.
"HPV vaccine has been available for the past several years in the U.S. and in other countries," she said. "As far as we know, there has not been any study looking at the uptake of HPV vaccine in the autoimmune disease population."
Using United HealthCare national claims data for 2005-2012, Dr. Kim and her associates identified patients aged 9-26 years with at least 1 year of continuous enrollment who had at least two autoimmune disease diagnosis codes 7 or more days apart. Vaccination was defined as one or more vaccine codes after 2006, and the researchers accounted for coexisting diseases, use of health care treatments, and geographic regions when assessing vaccine uptake.
Dr. Kim, the study’s senior investigator, reported data for 29,255 children and young adults with autoimmune diseases and 117,020 without. The mean age was 19 years, and 59% were female. Patients in the autoimmune diseases group had a higher number of physician visits, abnormal pap smears, and sexually transmitted diseases, compared with their counterparts without autoimmune disease (all P values less than .01).
Overall, autoimmune disease patients and their counterparts had similarly low uptake of at least one vaccine dose (8.5% vs. 9.1%, respectively; P = .34). The uptake was higher among females in both groups (13.1% vs. 14.1%, respectively; P less than .01), yet fewer than 5% of female patients in both groups completed a three-dose vaccine series (4.7% vs. 4.6%; P = .57). A higher percentage of patients in the Northeast received one or more HPV vaccine doses (16.3% vs. 11.8%; P = .02); otherwise vaccinations were equally distributed from a geographic standpoint.
In a subgroup of female patients who had at least 2 years of follow-up, 20.6% with autoimmune disease and 23.1% without autoimmune disease received at least one vaccine dose. Of those, 53.1% and 51.4%, respectively, completed the series.
"We were generally surprised to see how low the uptake has been in both autoimmune and nonautoimmune populations," Dr. Kim said. She acknowledged certain limitations of the study, including the fact that it was conducting using the claims data from United HealthCare, "so it only captures patients who used the insurance card to pay for the vaccine," she said. "However, given the high cost of the HPV vaccine, this limitation is probably not substantial. We [also] did not have information on race/ethnicity."
Dr. Kim disclosed that she is supported by a grant from the National Institutes of Health. She received a research grant from Pfizer and tuition support for the pharmacoepidemiology program at the Harvard School of Public Health, which is funded by Pfizer, Millennium Pharma, and Asisa.
SAN DIEGO – Only 8.5% of children and young adults with autoimmune diseases and 9.1% of those without such diseases received one or more doses of the human papillomavirus vaccine, a large analysis of national claims data showed.
"Despite the high efficacy of HPV vaccine in preventing cervical cancer and clinically acceptable safety profile in the general population, the vast majority of patients aged 9-26 in our study cohort with and without autoimmune diseases did not receive the HPV vaccine," Dr. Seoyoung C. Kim said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented.
"Patients at high risk of persistent HPV infection should be encouraged to receive the vaccine, although future study is needed to determine the effectiveness of HPV vaccine in patients with autoimmune diseases, particularly those on immunosuppressive drugs," she added.
In 2006 and 2009, two three-dose series HPV vaccines were approved for use in males and females aged 9-26 years. Prior research has suggested that patients with lupus or inflammatory bowel disease or those who take immunosuppressive agents have a higher risk of persistent HPV infection or cervical dysplasia, said Dr. Kim of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital, Boston.
"HPV vaccine has been available for the past several years in the U.S. and in other countries," she said. "As far as we know, there has not been any study looking at the uptake of HPV vaccine in the autoimmune disease population."
Using United HealthCare national claims data for 2005-2012, Dr. Kim and her associates identified patients aged 9-26 years with at least 1 year of continuous enrollment who had at least two autoimmune disease diagnosis codes 7 or more days apart. Vaccination was defined as one or more vaccine codes after 2006, and the researchers accounted for coexisting diseases, use of health care treatments, and geographic regions when assessing vaccine uptake.
Dr. Kim, the study’s senior investigator, reported data for 29,255 children and young adults with autoimmune diseases and 117,020 without. The mean age was 19 years, and 59% were female. Patients in the autoimmune diseases group had a higher number of physician visits, abnormal pap smears, and sexually transmitted diseases, compared with their counterparts without autoimmune disease (all P values less than .01).
Overall, autoimmune disease patients and their counterparts had similarly low uptake of at least one vaccine dose (8.5% vs. 9.1%, respectively; P = .34). The uptake was higher among females in both groups (13.1% vs. 14.1%, respectively; P less than .01), yet fewer than 5% of female patients in both groups completed a three-dose vaccine series (4.7% vs. 4.6%; P = .57). A higher percentage of patients in the Northeast received one or more HPV vaccine doses (16.3% vs. 11.8%; P = .02); otherwise vaccinations were equally distributed from a geographic standpoint.
In a subgroup of female patients who had at least 2 years of follow-up, 20.6% with autoimmune disease and 23.1% without autoimmune disease received at least one vaccine dose. Of those, 53.1% and 51.4%, respectively, completed the series.
"We were generally surprised to see how low the uptake has been in both autoimmune and nonautoimmune populations," Dr. Kim said. She acknowledged certain limitations of the study, including the fact that it was conducting using the claims data from United HealthCare, "so it only captures patients who used the insurance card to pay for the vaccine," she said. "However, given the high cost of the HPV vaccine, this limitation is probably not substantial. We [also] did not have information on race/ethnicity."
Dr. Kim disclosed that she is supported by a grant from the National Institutes of Health. She received a research grant from Pfizer and tuition support for the pharmacoepidemiology program at the Harvard School of Public Health, which is funded by Pfizer, Millennium Pharma, and Asisa.
persistent HPV infection, immunosuppressive drugs,
persistent HPV infection, immunosuppressive drugs,
AT THE ACR ANNUAL MEETING
HPV vaccine uptake low in autoimmune disease patients
SAN DIEGO – Only 8.5% of children and young adults with autoimmune diseases and 9.1% of those without such diseases received one or more doses of the human papillomavirus vaccine, a large analysis of national claims data showed.
"Despite the high efficacy of HPV vaccine in preventing cervical cancer and clinically acceptable safety profile in the general population, the vast majority of patients aged 9-26 in our study cohort with and without autoimmune diseases did not receive the HPV vaccine," Dr. Seoyoung C. Kim said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented.
"Patients at high risk of persistent HPV infection should be encouraged to receive the vaccine, although future study is needed to determine the effectiveness of HPV vaccine in patients with autoimmune diseases, particularly those on immunosuppressive drugs," she added.
In 2006 and 2009, two three-dose series HPV vaccines were approved for use in males and females aged 9-26 years. Prior research has suggested that patients with lupus or inflammatory bowel disease or those who take immunosuppressive agents have a higher risk of persistent HPV infection or cervical dysplasia, said Dr. Kim of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital, Boston.
"HPV vaccine has been available for the past several years in the U.S. and in other countries," she said. "As far as we know, there has not been any study looking at the uptake of HPV vaccine in the autoimmune disease population."
Using United HealthCare national claims data for 2005-2012, Dr. Kim and her associates identified patients aged 9-26 years with at least 1 year of continuous enrollment who had at least two autoimmune disease diagnosis codes 7 or more days apart. Vaccination was defined as one or more vaccine codes after 2006, and the researchers accounted for coexisting diseases, use of health care treatments, and geographic regions when assessing vaccine uptake.
Dr. Kim, the study’s senior investigator, reported data for 29,255 children and young adults with autoimmune diseases and 117,020 without. The mean age was 19 years, and 59% were female. Patients in the autoimmune diseases group had a higher number of physician visits, abnormal pap smears, and sexually transmitted diseases, compared with their counterparts without autoimmune disease (all P values less than .01).
Overall, autoimmune disease patients and their counterparts had similarly low uptake of at least one vaccine dose (8.5% vs. 9.1%, respectively; P = .34). The uptake was higher among females in both groups (13.1% vs. 14.1%, respectively; P less than .01), yet fewer than 5% of female patients in both groups completed a three-dose vaccine series (4.7% vs. 4.6%; P = .57). A higher percentage of patients in the Northeast received one or more HPV vaccine doses (16.3% vs. 11.8%; P = .02); otherwise vaccinations were equally distributed from a geographic standpoint.
In a subgroup of female patients who had at least 2 years of follow-up, 20.6% with autoimmune disease and 23.1% without autoimmune disease received at least one vaccine dose. Of those, 53.1% and 51.4%, respectively, completed the series.
"We were generally surprised to see how low the uptake has been in both autoimmune and nonautoimmune populations," Dr. Kim said. She acknowledged certain limitations of the study, including the fact that it was conducting using the claims data from United HealthCare, "so it only captures patients who used the insurance card to pay for the vaccine," she said. "However, given the high cost of the HPV vaccine, this limitation is probably not substantial. We [also] did not have information on race/ethnicity."
Dr. Kim disclosed that she is supported by a grant from the National Institutes of Health. She received a research grant from Pfizer and tuition support for the pharmacoepidemiology program at the Harvard School of Public Health, which is funded by Pfizer, Millennium Pharma, and Asisa.
persistent HPV infection, immunosuppressive drugs,
SAN DIEGO – Only 8.5% of children and young adults with autoimmune diseases and 9.1% of those without such diseases received one or more doses of the human papillomavirus vaccine, a large analysis of national claims data showed.
"Despite the high efficacy of HPV vaccine in preventing cervical cancer and clinically acceptable safety profile in the general population, the vast majority of patients aged 9-26 in our study cohort with and without autoimmune diseases did not receive the HPV vaccine," Dr. Seoyoung C. Kim said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented.
"Patients at high risk of persistent HPV infection should be encouraged to receive the vaccine, although future study is needed to determine the effectiveness of HPV vaccine in patients with autoimmune diseases, particularly those on immunosuppressive drugs," she added.
In 2006 and 2009, two three-dose series HPV vaccines were approved for use in males and females aged 9-26 years. Prior research has suggested that patients with lupus or inflammatory bowel disease or those who take immunosuppressive agents have a higher risk of persistent HPV infection or cervical dysplasia, said Dr. Kim of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital, Boston.
"HPV vaccine has been available for the past several years in the U.S. and in other countries," she said. "As far as we know, there has not been any study looking at the uptake of HPV vaccine in the autoimmune disease population."
Using United HealthCare national claims data for 2005-2012, Dr. Kim and her associates identified patients aged 9-26 years with at least 1 year of continuous enrollment who had at least two autoimmune disease diagnosis codes 7 or more days apart. Vaccination was defined as one or more vaccine codes after 2006, and the researchers accounted for coexisting diseases, use of health care treatments, and geographic regions when assessing vaccine uptake.
Dr. Kim, the study’s senior investigator, reported data for 29,255 children and young adults with autoimmune diseases and 117,020 without. The mean age was 19 years, and 59% were female. Patients in the autoimmune diseases group had a higher number of physician visits, abnormal pap smears, and sexually transmitted diseases, compared with their counterparts without autoimmune disease (all P values less than .01).
Overall, autoimmune disease patients and their counterparts had similarly low uptake of at least one vaccine dose (8.5% vs. 9.1%, respectively; P = .34). The uptake was higher among females in both groups (13.1% vs. 14.1%, respectively; P less than .01), yet fewer than 5% of female patients in both groups completed a three-dose vaccine series (4.7% vs. 4.6%; P = .57). A higher percentage of patients in the Northeast received one or more HPV vaccine doses (16.3% vs. 11.8%; P = .02); otherwise vaccinations were equally distributed from a geographic standpoint.
In a subgroup of female patients who had at least 2 years of follow-up, 20.6% with autoimmune disease and 23.1% without autoimmune disease received at least one vaccine dose. Of those, 53.1% and 51.4%, respectively, completed the series.
"We were generally surprised to see how low the uptake has been in both autoimmune and nonautoimmune populations," Dr. Kim said. She acknowledged certain limitations of the study, including the fact that it was conducting using the claims data from United HealthCare, "so it only captures patients who used the insurance card to pay for the vaccine," she said. "However, given the high cost of the HPV vaccine, this limitation is probably not substantial. We [also] did not have information on race/ethnicity."
Dr. Kim disclosed that she is supported by a grant from the National Institutes of Health. She received a research grant from Pfizer and tuition support for the pharmacoepidemiology program at the Harvard School of Public Health, which is funded by Pfizer, Millennium Pharma, and Asisa.
SAN DIEGO – Only 8.5% of children and young adults with autoimmune diseases and 9.1% of those without such diseases received one or more doses of the human papillomavirus vaccine, a large analysis of national claims data showed.
"Despite the high efficacy of HPV vaccine in preventing cervical cancer and clinically acceptable safety profile in the general population, the vast majority of patients aged 9-26 in our study cohort with and without autoimmune diseases did not receive the HPV vaccine," Dr. Seoyoung C. Kim said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented.
"Patients at high risk of persistent HPV infection should be encouraged to receive the vaccine, although future study is needed to determine the effectiveness of HPV vaccine in patients with autoimmune diseases, particularly those on immunosuppressive drugs," she added.
In 2006 and 2009, two three-dose series HPV vaccines were approved for use in males and females aged 9-26 years. Prior research has suggested that patients with lupus or inflammatory bowel disease or those who take immunosuppressive agents have a higher risk of persistent HPV infection or cervical dysplasia, said Dr. Kim of the division of pharmacoepidemiology and pharmacoeconomics in the department of medicine at Brigham and Women’s Hospital, Boston.
"HPV vaccine has been available for the past several years in the U.S. and in other countries," she said. "As far as we know, there has not been any study looking at the uptake of HPV vaccine in the autoimmune disease population."
Using United HealthCare national claims data for 2005-2012, Dr. Kim and her associates identified patients aged 9-26 years with at least 1 year of continuous enrollment who had at least two autoimmune disease diagnosis codes 7 or more days apart. Vaccination was defined as one or more vaccine codes after 2006, and the researchers accounted for coexisting diseases, use of health care treatments, and geographic regions when assessing vaccine uptake.
Dr. Kim, the study’s senior investigator, reported data for 29,255 children and young adults with autoimmune diseases and 117,020 without. The mean age was 19 years, and 59% were female. Patients in the autoimmune diseases group had a higher number of physician visits, abnormal pap smears, and sexually transmitted diseases, compared with their counterparts without autoimmune disease (all P values less than .01).
Overall, autoimmune disease patients and their counterparts had similarly low uptake of at least one vaccine dose (8.5% vs. 9.1%, respectively; P = .34). The uptake was higher among females in both groups (13.1% vs. 14.1%, respectively; P less than .01), yet fewer than 5% of female patients in both groups completed a three-dose vaccine series (4.7% vs. 4.6%; P = .57). A higher percentage of patients in the Northeast received one or more HPV vaccine doses (16.3% vs. 11.8%; P = .02); otherwise vaccinations were equally distributed from a geographic standpoint.
In a subgroup of female patients who had at least 2 years of follow-up, 20.6% with autoimmune disease and 23.1% without autoimmune disease received at least one vaccine dose. Of those, 53.1% and 51.4%, respectively, completed the series.
"We were generally surprised to see how low the uptake has been in both autoimmune and nonautoimmune populations," Dr. Kim said. She acknowledged certain limitations of the study, including the fact that it was conducting using the claims data from United HealthCare, "so it only captures patients who used the insurance card to pay for the vaccine," she said. "However, given the high cost of the HPV vaccine, this limitation is probably not substantial. We [also] did not have information on race/ethnicity."
Dr. Kim disclosed that she is supported by a grant from the National Institutes of Health. She received a research grant from Pfizer and tuition support for the pharmacoepidemiology program at the Harvard School of Public Health, which is funded by Pfizer, Millennium Pharma, and Asisa.
persistent HPV infection, immunosuppressive drugs,
persistent HPV infection, immunosuppressive drugs,
AT THE ACR ANNUAL MEETING
Major finding: Children and young adults with autoimmune diseases and their counterparts with no such diseases had similarly low uptake of at least one dose of human papillomavirus vaccine (8.5% vs. 9.1%, respectively; P = .34).
Data source: An analysis of national claims data for 29,255 children and young adults with autoimmune diseases and 117,020 without such diseases.
Disclosures: Dr. Kim disclosed that she is supported by a grant from the National Institutes of Health. She received a research grant from Pfizer and tuition support for the pharmacoepidemiology program at the Harvard School of Public Health, which is funded by Pfizer, Millennium Pharma, and Asisa.
Study IDs predictors of unplanned hospital readmission after CEA
SAN FRANCISCO – The 30-day unplanned readmission rate following carotid endarterectomy was 6.5% in a single-center study.
In addition, four variables were significantly associated with unplanned readmission: in-hospital postoperative congestive heart failure (CHF) exacerbation; in-hospital postoperative stroke; in-hospital postoperative hematoma; and prior coronary artery bypass graft (CABG).
"Whether these complications are completely avoidable is unknown, but we do identify a group of patients who would probably benefit from more comprehensive discharge planning and careful postdischarge care," Dr. Karen J. Ho said at the Society for Vascular Surgery annual meeting earlier this year.
According to a study of Medicare claims data from 2003 to 2004, 20% of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days (N. Eng. J. Med. 2009;360:1418-28). The 30-day rehospitalization rate after vascular surgery was 24%, "the highest of all surgical specialties examined in the study," said Dr. Ho of the surgery department at Brigham and Women’s Hospital, Boston, who was not involved with the published study. "Medicare has started to decrease reimbursements for hospitals with excess readmissions after acute MI, heart failure, and pneumonia. Hip and knee replacements and chronic obstructive pulmonary disease will be added in 2014, and we anticipate that additional surgical procedures will be added thereafter," she said.
In an effort to determine the rate of 30-day unplanned readmission after carotid endarterectomy (CEA), Dr. Ho and her associates conducted a retrospective study of a prospectively collected vascular surgery database at Brigham and Women’s Hospital. The cohort included 896 consecutive CEAs performed between 2002 and 2011. Combined CABG/CEA procedures were excluded.
The primary endpoint was unplanned readmission within 30 days, defined as "any unanticipated, nonelective hospital readmission," she said. The secondary endpoint was 1-year survival.
The mean age of the patients was 70 years, 60% were male, and 95% were white. More than half (65%) had asymptomatic evidence of carotid artery disease.
Dr. Ho reported that the median postoperative length of stay was 1 day and that 9.9% of patients had at least one in-hospital complication. The most frequent in-hospital complication was bleeding/hematoma (4.1%), followed by arrhythmia (2.1%), dysphagia (1.7%), stroke (1.3%), and myocardial infarction (1.2%). Only 3% of patients required a reoperation, while most (94%) were discharged to home. The 30-day stroke rate was 1.7%, while the 30-day death rate was 0.6%.
The overall 30-day readmission rate was 8.6%, while the unplanned 30-day readmission rate was 6.5%. "Most of the overall readmissions (80%) occurred in the first 10 days, and the median time to unplanned readmission was 4 days," Dr. Ho said.
The most common reason for an unplanned readmission was a cardiac complication, followed by headache, bleeding/hematoma, stroke/transient ischemic attack/intracerebral hemorrhage, or other medical emergency. More than one-quarter of patients (27.5%) had more than one reason for an unplanned readmission, while 87.9% of patients had a CEA-related unplanned readmission.
When the researchers performed a univariate analysis followed by analysis with a multivariable Cox model for unplanned readmission, four variables were independently associated with unplanned readmission: in-hospital postoperative CHF exacerbation (hazard ratio, 15.1), in-hospital postoperative stroke (HR, 5.0), in-hospital postoperative hematoma (HR, 3.1), and prior CABG (HR, 2.0).
They also observed a significant difference in survival at 1 year between patients who had an unplanned readmission and those who did not (91% vs. 96%, respectively; P less than .01.) "It’s unclear whether these deaths in the unplanned readmission group were preventable or if they were related to carotid disease or to a procedure-related complication," Dr. Ho said. "Our guess is that the increased overall burden of comorbid disease in these patients, rather than the readmission itself, predicted decreased survival."
Limitations of the study included its retrospective design and the fact that it was conducted at a single center, she said, "but we do know that our unplanned readmission rate is comparable to estimates from recent Medicare data."
Dr. Ho said she had no relevant financial disclosures.
Over the past several years, the role of carotid endarterectomy (CEA) for asymptomatic carotid stenosis has, again, come under the microscope; with many proponents still advocating CEA as the treatment of choice for asymptomatic patients with greater than or equal to 60% stenosis, while some propose greater than or equal to 70-80% stenosis in good surgical risk patients. Meanwhile, others oppose this philosophy because of the advances in modern medical therapy for patients with atherosclerosis, in general, with emphasis on risk modification. The findings of this article are quite disturbing, since the authors concluded that the 30-day unplanned re-admission rate after CEA was 6.5%; this is especially surprising to me, coming from this institution.
| Dr. AbuRahma |
The authors also concluded that unplanned re-admission rate was influenced by congestive heart failure, in-hospital postoperative stroke, in-hospital postoperative hematoma, and prior coronary artery bypass grafting. This emphasizes the importance of selection, selection, selection for asymptomatic carotid artery stenosis, if the outcome is to be acceptable to those who still advocate carotid endarterectomy for asymptomatic carotid disease.
Perhaps this procedure should not be encouraged for patients with congestive heart failure or those with severe coronary artery disease, unstable angina. Today, Level I evidence still supports carotid endarterectomy for patients with severe carotid artery stenosis, provided the patient is a good surgical risk, with relatively good longevity; with perioperative stroke and/or death rates of less than 3%. Several modern clinical series have concluded that CEA can be done in these patients with a stroke and/or death rate of less than 1-2%, which was produced most recently in the CREST trial. For those clinicians who cannot keep these numbers down, perhaps this procedure should not be done for asymptomatic carotid disease. What’s also surprising to me, is the in-hospital postoperative hematomas, which I presume necessitated the re-admission and, perhaps, reoperation. This should highlight the fact that, perhaps, we need to look further as to whether or not these patients should be on a combined regimen of aspirin and Plavix, preoperatively and postoperatively, as prescribed by many clinicians.
There is no Level I evidence to support that the combination of aspirin and Plavix, postoperatvely, for these patients would yield a better outcome than simple aspirin daily. It is difficult to determine from this study whether a significant portion of their patients were on dual antiplatelet therapy.
It is also interesting to notice that the authors found that almost 10% of patients had at least one in-hospital complication; some of which were major complications, e.g. stroke, MI, and dysphagia. Including bleeding/hematoma in these complications, which may not have necessitated surgery, may have inflated this number. A similar observation can be made regarding postoperative arrhythmias, particularly if they did not necessitate extra therapy. However, the fact of the matter is that it should be emphasized that the selection of patients for carotid endarterectomy in asymptomatic patients is extremely critical if this procedure is to be continued or blessed.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, and Director, Vascular Surgery Fellowship and Residency Programs, and Medical Director, Vascular Laboratory, Co-Director, Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston. He is a also an associate medical editor of Vascular Specialist.
Over the past several years, the role of carotid endarterectomy (CEA) for asymptomatic carotid stenosis has, again, come under the microscope; with many proponents still advocating CEA as the treatment of choice for asymptomatic patients with greater than or equal to 60% stenosis, while some propose greater than or equal to 70-80% stenosis in good surgical risk patients. Meanwhile, others oppose this philosophy because of the advances in modern medical therapy for patients with atherosclerosis, in general, with emphasis on risk modification. The findings of this article are quite disturbing, since the authors concluded that the 30-day unplanned re-admission rate after CEA was 6.5%; this is especially surprising to me, coming from this institution.
| Dr. AbuRahma |
The authors also concluded that unplanned re-admission rate was influenced by congestive heart failure, in-hospital postoperative stroke, in-hospital postoperative hematoma, and prior coronary artery bypass grafting. This emphasizes the importance of selection, selection, selection for asymptomatic carotid artery stenosis, if the outcome is to be acceptable to those who still advocate carotid endarterectomy for asymptomatic carotid disease.
Perhaps this procedure should not be encouraged for patients with congestive heart failure or those with severe coronary artery disease, unstable angina. Today, Level I evidence still supports carotid endarterectomy for patients with severe carotid artery stenosis, provided the patient is a good surgical risk, with relatively good longevity; with perioperative stroke and/or death rates of less than 3%. Several modern clinical series have concluded that CEA can be done in these patients with a stroke and/or death rate of less than 1-2%, which was produced most recently in the CREST trial. For those clinicians who cannot keep these numbers down, perhaps this procedure should not be done for asymptomatic carotid disease. What’s also surprising to me, is the in-hospital postoperative hematomas, which I presume necessitated the re-admission and, perhaps, reoperation. This should highlight the fact that, perhaps, we need to look further as to whether or not these patients should be on a combined regimen of aspirin and Plavix, preoperatively and postoperatively, as prescribed by many clinicians.
There is no Level I evidence to support that the combination of aspirin and Plavix, postoperatvely, for these patients would yield a better outcome than simple aspirin daily. It is difficult to determine from this study whether a significant portion of their patients were on dual antiplatelet therapy.
It is also interesting to notice that the authors found that almost 10% of patients had at least one in-hospital complication; some of which were major complications, e.g. stroke, MI, and dysphagia. Including bleeding/hematoma in these complications, which may not have necessitated surgery, may have inflated this number. A similar observation can be made regarding postoperative arrhythmias, particularly if they did not necessitate extra therapy. However, the fact of the matter is that it should be emphasized that the selection of patients for carotid endarterectomy in asymptomatic patients is extremely critical if this procedure is to be continued or blessed.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, and Director, Vascular Surgery Fellowship and Residency Programs, and Medical Director, Vascular Laboratory, Co-Director, Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston. He is a also an associate medical editor of Vascular Specialist.
Over the past several years, the role of carotid endarterectomy (CEA) for asymptomatic carotid stenosis has, again, come under the microscope; with many proponents still advocating CEA as the treatment of choice for asymptomatic patients with greater than or equal to 60% stenosis, while some propose greater than or equal to 70-80% stenosis in good surgical risk patients. Meanwhile, others oppose this philosophy because of the advances in modern medical therapy for patients with atherosclerosis, in general, with emphasis on risk modification. The findings of this article are quite disturbing, since the authors concluded that the 30-day unplanned re-admission rate after CEA was 6.5%; this is especially surprising to me, coming from this institution.
| Dr. AbuRahma |
The authors also concluded that unplanned re-admission rate was influenced by congestive heart failure, in-hospital postoperative stroke, in-hospital postoperative hematoma, and prior coronary artery bypass grafting. This emphasizes the importance of selection, selection, selection for asymptomatic carotid artery stenosis, if the outcome is to be acceptable to those who still advocate carotid endarterectomy for asymptomatic carotid disease.
Perhaps this procedure should not be encouraged for patients with congestive heart failure or those with severe coronary artery disease, unstable angina. Today, Level I evidence still supports carotid endarterectomy for patients with severe carotid artery stenosis, provided the patient is a good surgical risk, with relatively good longevity; with perioperative stroke and/or death rates of less than 3%. Several modern clinical series have concluded that CEA can be done in these patients with a stroke and/or death rate of less than 1-2%, which was produced most recently in the CREST trial. For those clinicians who cannot keep these numbers down, perhaps this procedure should not be done for asymptomatic carotid disease. What’s also surprising to me, is the in-hospital postoperative hematomas, which I presume necessitated the re-admission and, perhaps, reoperation. This should highlight the fact that, perhaps, we need to look further as to whether or not these patients should be on a combined regimen of aspirin and Plavix, preoperatively and postoperatively, as prescribed by many clinicians.
There is no Level I evidence to support that the combination of aspirin and Plavix, postoperatvely, for these patients would yield a better outcome than simple aspirin daily. It is difficult to determine from this study whether a significant portion of their patients were on dual antiplatelet therapy.
It is also interesting to notice that the authors found that almost 10% of patients had at least one in-hospital complication; some of which were major complications, e.g. stroke, MI, and dysphagia. Including bleeding/hematoma in these complications, which may not have necessitated surgery, may have inflated this number. A similar observation can be made regarding postoperative arrhythmias, particularly if they did not necessitate extra therapy. However, the fact of the matter is that it should be emphasized that the selection of patients for carotid endarterectomy in asymptomatic patients is extremely critical if this procedure is to be continued or blessed.
Dr. Ali F. AbuRahma is Professor of Surgery and Chief, Vascular & Endovascular Surgery, and Director, Vascular Surgery Fellowship and Residency Programs, and Medical Director, Vascular Laboratory, Co-Director, Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston Area Medical Center, Charleston. He is a also an associate medical editor of Vascular Specialist.
SAN FRANCISCO – The 30-day unplanned readmission rate following carotid endarterectomy was 6.5% in a single-center study.
In addition, four variables were significantly associated with unplanned readmission: in-hospital postoperative congestive heart failure (CHF) exacerbation; in-hospital postoperative stroke; in-hospital postoperative hematoma; and prior coronary artery bypass graft (CABG).
"Whether these complications are completely avoidable is unknown, but we do identify a group of patients who would probably benefit from more comprehensive discharge planning and careful postdischarge care," Dr. Karen J. Ho said at the Society for Vascular Surgery annual meeting earlier this year.
According to a study of Medicare claims data from 2003 to 2004, 20% of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days (N. Eng. J. Med. 2009;360:1418-28). The 30-day rehospitalization rate after vascular surgery was 24%, "the highest of all surgical specialties examined in the study," said Dr. Ho of the surgery department at Brigham and Women’s Hospital, Boston, who was not involved with the published study. "Medicare has started to decrease reimbursements for hospitals with excess readmissions after acute MI, heart failure, and pneumonia. Hip and knee replacements and chronic obstructive pulmonary disease will be added in 2014, and we anticipate that additional surgical procedures will be added thereafter," she said.
In an effort to determine the rate of 30-day unplanned readmission after carotid endarterectomy (CEA), Dr. Ho and her associates conducted a retrospective study of a prospectively collected vascular surgery database at Brigham and Women’s Hospital. The cohort included 896 consecutive CEAs performed between 2002 and 2011. Combined CABG/CEA procedures were excluded.
The primary endpoint was unplanned readmission within 30 days, defined as "any unanticipated, nonelective hospital readmission," she said. The secondary endpoint was 1-year survival.
The mean age of the patients was 70 years, 60% were male, and 95% were white. More than half (65%) had asymptomatic evidence of carotid artery disease.
Dr. Ho reported that the median postoperative length of stay was 1 day and that 9.9% of patients had at least one in-hospital complication. The most frequent in-hospital complication was bleeding/hematoma (4.1%), followed by arrhythmia (2.1%), dysphagia (1.7%), stroke (1.3%), and myocardial infarction (1.2%). Only 3% of patients required a reoperation, while most (94%) were discharged to home. The 30-day stroke rate was 1.7%, while the 30-day death rate was 0.6%.
The overall 30-day readmission rate was 8.6%, while the unplanned 30-day readmission rate was 6.5%. "Most of the overall readmissions (80%) occurred in the first 10 days, and the median time to unplanned readmission was 4 days," Dr. Ho said.
The most common reason for an unplanned readmission was a cardiac complication, followed by headache, bleeding/hematoma, stroke/transient ischemic attack/intracerebral hemorrhage, or other medical emergency. More than one-quarter of patients (27.5%) had more than one reason for an unplanned readmission, while 87.9% of patients had a CEA-related unplanned readmission.
When the researchers performed a univariate analysis followed by analysis with a multivariable Cox model for unplanned readmission, four variables were independently associated with unplanned readmission: in-hospital postoperative CHF exacerbation (hazard ratio, 15.1), in-hospital postoperative stroke (HR, 5.0), in-hospital postoperative hematoma (HR, 3.1), and prior CABG (HR, 2.0).
They also observed a significant difference in survival at 1 year between patients who had an unplanned readmission and those who did not (91% vs. 96%, respectively; P less than .01.) "It’s unclear whether these deaths in the unplanned readmission group were preventable or if they were related to carotid disease or to a procedure-related complication," Dr. Ho said. "Our guess is that the increased overall burden of comorbid disease in these patients, rather than the readmission itself, predicted decreased survival."
Limitations of the study included its retrospective design and the fact that it was conducted at a single center, she said, "but we do know that our unplanned readmission rate is comparable to estimates from recent Medicare data."
Dr. Ho said she had no relevant financial disclosures.
SAN FRANCISCO – The 30-day unplanned readmission rate following carotid endarterectomy was 6.5% in a single-center study.
In addition, four variables were significantly associated with unplanned readmission: in-hospital postoperative congestive heart failure (CHF) exacerbation; in-hospital postoperative stroke; in-hospital postoperative hematoma; and prior coronary artery bypass graft (CABG).
"Whether these complications are completely avoidable is unknown, but we do identify a group of patients who would probably benefit from more comprehensive discharge planning and careful postdischarge care," Dr. Karen J. Ho said at the Society for Vascular Surgery annual meeting earlier this year.
According to a study of Medicare claims data from 2003 to 2004, 20% of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days (N. Eng. J. Med. 2009;360:1418-28). The 30-day rehospitalization rate after vascular surgery was 24%, "the highest of all surgical specialties examined in the study," said Dr. Ho of the surgery department at Brigham and Women’s Hospital, Boston, who was not involved with the published study. "Medicare has started to decrease reimbursements for hospitals with excess readmissions after acute MI, heart failure, and pneumonia. Hip and knee replacements and chronic obstructive pulmonary disease will be added in 2014, and we anticipate that additional surgical procedures will be added thereafter," she said.
In an effort to determine the rate of 30-day unplanned readmission after carotid endarterectomy (CEA), Dr. Ho and her associates conducted a retrospective study of a prospectively collected vascular surgery database at Brigham and Women’s Hospital. The cohort included 896 consecutive CEAs performed between 2002 and 2011. Combined CABG/CEA procedures were excluded.
The primary endpoint was unplanned readmission within 30 days, defined as "any unanticipated, nonelective hospital readmission," she said. The secondary endpoint was 1-year survival.
The mean age of the patients was 70 years, 60% were male, and 95% were white. More than half (65%) had asymptomatic evidence of carotid artery disease.
Dr. Ho reported that the median postoperative length of stay was 1 day and that 9.9% of patients had at least one in-hospital complication. The most frequent in-hospital complication was bleeding/hematoma (4.1%), followed by arrhythmia (2.1%), dysphagia (1.7%), stroke (1.3%), and myocardial infarction (1.2%). Only 3% of patients required a reoperation, while most (94%) were discharged to home. The 30-day stroke rate was 1.7%, while the 30-day death rate was 0.6%.
The overall 30-day readmission rate was 8.6%, while the unplanned 30-day readmission rate was 6.5%. "Most of the overall readmissions (80%) occurred in the first 10 days, and the median time to unplanned readmission was 4 days," Dr. Ho said.
The most common reason for an unplanned readmission was a cardiac complication, followed by headache, bleeding/hematoma, stroke/transient ischemic attack/intracerebral hemorrhage, or other medical emergency. More than one-quarter of patients (27.5%) had more than one reason for an unplanned readmission, while 87.9% of patients had a CEA-related unplanned readmission.
When the researchers performed a univariate analysis followed by analysis with a multivariable Cox model for unplanned readmission, four variables were independently associated with unplanned readmission: in-hospital postoperative CHF exacerbation (hazard ratio, 15.1), in-hospital postoperative stroke (HR, 5.0), in-hospital postoperative hematoma (HR, 3.1), and prior CABG (HR, 2.0).
They also observed a significant difference in survival at 1 year between patients who had an unplanned readmission and those who did not (91% vs. 96%, respectively; P less than .01.) "It’s unclear whether these deaths in the unplanned readmission group were preventable or if they were related to carotid disease or to a procedure-related complication," Dr. Ho said. "Our guess is that the increased overall burden of comorbid disease in these patients, rather than the readmission itself, predicted decreased survival."
Limitations of the study included its retrospective design and the fact that it was conducted at a single center, she said, "but we do know that our unplanned readmission rate is comparable to estimates from recent Medicare data."
Dr. Ho said she had no relevant financial disclosures.
Major finding: Four variables were independently associated with unplanned readmission: in-hospital postoperative CHF exacerbation (hazard ratio, 15.1), in-hospital postoperative stroke (HR, 5.0), in-hospital postoperative hematoma (HR, 3.1), and prior CABG (HR, 2.0).
Data source: A study of 896 consecutive CEAs performed between 2002 and 2011 at Brigham and Women’s Hospital, Boston.
Disclosures: Dr. Ho said she had no relevant financial disclosures.
Referral approach promotes next-day ID consultation for cellulitis
DENVER – Next-day infectious diseases consultation for cellulitis reduced the number of emergency department visits and hospital admissions by 19% and 25%, respectively, a single-center study demonstrated.
This approach "is advantageous for patients if they don’t need to be admitted, and there is potential cost savings, because a lot of cost occurs during hospital admissions, especially in the first couple of days," lead study author Dr. Jennifer F. Gittzus said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Patients with cellulitis are generally very happy if they don’t have to be admitted. They prefer being treated in the outpatient setting."
Repeat emergency department (ED) visits for cellulitis are common, and inpatient admissions for cellulitis are often poorly reimbursed, noted Dr. Gittzus, of the Infectious Disease and International Travel Clinic at Concord (N.H.) Hospital. She and her colleagues hypothesized that a referral model that included next day infectious diseases (ID) consultation and ID management of outpatient intravenous (IV) antibiotics could decrease ED visits for cellulitis and perhaps also decrease admissions and/or length of stay. To find out, the researchers compared ED visits and hospital admission for cellulitis year 2010 (the year prior to this referral service being available), with those that occurred in 2011 and 2012.
Dr. Gittzus reported that between 2010 and 2012, ED visits for cellulitis fell from 948 to 748, for a reduction of 19%, while outpatient cellulitis episodes (defined as one episode potentially encompassing several days of therapy) rose from 23 to 271, an increase of more than 1,000%. Over the same time period, the number of inpatient hospital admissions for cellulitis dropped from 320 to 241, a reduction of 25%. As a consequence, daptomycin use increased at Concord Hospital from 86 days of therapy in 2010 to 571 days of therapy in 2012, "but this occurred mostly in the [ED] and outpatient settings," Dr. Gittzus emphasized.
Overall, the cost for outpatient management of cellulitis was a fraction of the cost of a hospital admission for cellulitis. For example, in 2010, the average daily inpatient charges and average daily outpatient charges were $3,818.79 and $574.42, respectively, while in 2012 those same charges stood at $5,229.96 and $1,633.40.
"We were surprised at how well this referral services was used by the emergency department," Dr. Gittzus said. "We’re actually expanding this [approach] to other diagnoses that benefit from IV antibiotics but don’t necessarily need acute hospital admission."
Dr. Gittzus said that she had no relevant conflicts of interest to disclose.
DENVER – Next-day infectious diseases consultation for cellulitis reduced the number of emergency department visits and hospital admissions by 19% and 25%, respectively, a single-center study demonstrated.
This approach "is advantageous for patients if they don’t need to be admitted, and there is potential cost savings, because a lot of cost occurs during hospital admissions, especially in the first couple of days," lead study author Dr. Jennifer F. Gittzus said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Patients with cellulitis are generally very happy if they don’t have to be admitted. They prefer being treated in the outpatient setting."
Repeat emergency department (ED) visits for cellulitis are common, and inpatient admissions for cellulitis are often poorly reimbursed, noted Dr. Gittzus, of the Infectious Disease and International Travel Clinic at Concord (N.H.) Hospital. She and her colleagues hypothesized that a referral model that included next day infectious diseases (ID) consultation and ID management of outpatient intravenous (IV) antibiotics could decrease ED visits for cellulitis and perhaps also decrease admissions and/or length of stay. To find out, the researchers compared ED visits and hospital admission for cellulitis year 2010 (the year prior to this referral service being available), with those that occurred in 2011 and 2012.
Dr. Gittzus reported that between 2010 and 2012, ED visits for cellulitis fell from 948 to 748, for a reduction of 19%, while outpatient cellulitis episodes (defined as one episode potentially encompassing several days of therapy) rose from 23 to 271, an increase of more than 1,000%. Over the same time period, the number of inpatient hospital admissions for cellulitis dropped from 320 to 241, a reduction of 25%. As a consequence, daptomycin use increased at Concord Hospital from 86 days of therapy in 2010 to 571 days of therapy in 2012, "but this occurred mostly in the [ED] and outpatient settings," Dr. Gittzus emphasized.
Overall, the cost for outpatient management of cellulitis was a fraction of the cost of a hospital admission for cellulitis. For example, in 2010, the average daily inpatient charges and average daily outpatient charges were $3,818.79 and $574.42, respectively, while in 2012 those same charges stood at $5,229.96 and $1,633.40.
"We were surprised at how well this referral services was used by the emergency department," Dr. Gittzus said. "We’re actually expanding this [approach] to other diagnoses that benefit from IV antibiotics but don’t necessarily need acute hospital admission."
Dr. Gittzus said that she had no relevant conflicts of interest to disclose.
DENVER – Next-day infectious diseases consultation for cellulitis reduced the number of emergency department visits and hospital admissions by 19% and 25%, respectively, a single-center study demonstrated.
This approach "is advantageous for patients if they don’t need to be admitted, and there is potential cost savings, because a lot of cost occurs during hospital admissions, especially in the first couple of days," lead study author Dr. Jennifer F. Gittzus said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Patients with cellulitis are generally very happy if they don’t have to be admitted. They prefer being treated in the outpatient setting."
Repeat emergency department (ED) visits for cellulitis are common, and inpatient admissions for cellulitis are often poorly reimbursed, noted Dr. Gittzus, of the Infectious Disease and International Travel Clinic at Concord (N.H.) Hospital. She and her colleagues hypothesized that a referral model that included next day infectious diseases (ID) consultation and ID management of outpatient intravenous (IV) antibiotics could decrease ED visits for cellulitis and perhaps also decrease admissions and/or length of stay. To find out, the researchers compared ED visits and hospital admission for cellulitis year 2010 (the year prior to this referral service being available), with those that occurred in 2011 and 2012.
Dr. Gittzus reported that between 2010 and 2012, ED visits for cellulitis fell from 948 to 748, for a reduction of 19%, while outpatient cellulitis episodes (defined as one episode potentially encompassing several days of therapy) rose from 23 to 271, an increase of more than 1,000%. Over the same time period, the number of inpatient hospital admissions for cellulitis dropped from 320 to 241, a reduction of 25%. As a consequence, daptomycin use increased at Concord Hospital from 86 days of therapy in 2010 to 571 days of therapy in 2012, "but this occurred mostly in the [ED] and outpatient settings," Dr. Gittzus emphasized.
Overall, the cost for outpatient management of cellulitis was a fraction of the cost of a hospital admission for cellulitis. For example, in 2010, the average daily inpatient charges and average daily outpatient charges were $3,818.79 and $574.42, respectively, while in 2012 those same charges stood at $5,229.96 and $1,633.40.
"We were surprised at how well this referral services was used by the emergency department," Dr. Gittzus said. "We’re actually expanding this [approach] to other diagnoses that benefit from IV antibiotics but don’t necessarily need acute hospital admission."
Dr. Gittzus said that she had no relevant conflicts of interest to disclose.
AT ICAAC 2013
Major finding: After implementation of a referral model that supported next-day ID consultation for cellulitis and ID management of IV antibiotics, repeat ED visits for cellulitis fell from 948 to 748, for a reduction of 19%, while the number of inpatient hospital admissions for cellulitis dropped from 320 to 241, a reduction of 25%.
Data source: Comparison of the number of ED visits and hospital admission for cellulitis in 2010 (the year prior to this referral service being available) with 2011 and 2012.
Disclosures: Dr. Gittzus said that she had no relevant financial conflicts of interest to disclose.
Steroids May Cut Antibiotics-related C difficile Risk
DENVER – Use of systemic corticosteroids during antibiotic treatment for respiratory infections may reduce the incidence of Clostridium difficile–associated diarrhea, a single-center study demonstrated.
"Using steroids may not predispose people to having C diff, as previously thought," Amy Wojciechowski, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Don’t be afraid to use steroids when you’re treating with antibiotics. You’re not going to increase your risk of C. diff. You may even be decreasing it."
Dr. Wojciechowski, along with Kari Mergenhagen, Pharm.D., and their associates at the VA Western New York Healthcare System, Buffalo, set out to determine the incidence of Clostridium difficile–associated diarrhea (CDAD) in patients treated in the hospital with antibiotics for a chronic obstructive pulmonary disease (COPD) exacerbation or community-acquired pneumonia (CAP). The investigators evaluated baseline characteristics and risk factors that affect the incidence of CDAD.
The study population comprised 532 veterans who were hospitalized between March 2006 and July 2012 and were treated with moxifloxacin or with ceftriaxone plus azithromycin. CDAD was defined as diarrhea with positive PCR assay or toxin assay for C difficile within 30 days of antibiotic treatment.
The mean age of the veterans was 76 years, and 99% were male. The researchers found that CDAD occurred in 11 patients in the study population, for an incidence rate of 2.07%.
Variables associated with a significantly decreased risk of CDAD were diagnosis of COPD (P = .01) and use of corticosteroids during antibiotics treatment (P = .0035). There was no difference in the incidence of CDAD between patients treated with moxifloxacin and those treated with ceftriaxone plus azithromycin.
After the researchers controlled for COPD, the use of corticosteroids remained linked to a decreased risk of developing CDAD (odds ratio, 0.12).
The researchers hypothesized that steroids "may attenuate the host immune response typically seen in response to C difficile toxins, thus preventing inflammation and cytokine release associated with the symptoms of CDAD." They added that more research is needed to determine whether the findings are the same in other patient populations.
The authors acknowledged as limitations of the study its retrospective design and the fact that the majority of patients where white men.
Dr. Wojciechowski, an infectious diseases pharmacy resident, and Dr. Mergenhagen, a clinical infectious diseases pharmacist, said that they had no relevant conflicts of interest to disclose.
Dr. Marcos I. Restrepo, FCCP, comments: Be careful about jumping to many conclusions regarding the beneficial effects of corticosteroids preventing Clostridium difficile-associated diarrhea. These associations derived from retrospective studies should be assessed in randomized controlled trials before specific recommendations are translated into clinical practice.
Dr. Marco Restrepo, FCCP is with the University of Texas Health Science Center,
San Antonio, Tex.
Dr. Marcos I. Restrepo, FCCP, comments: Be careful about jumping to many conclusions regarding the beneficial effects of corticosteroids preventing Clostridium difficile-associated diarrhea. These associations derived from retrospective studies should be assessed in randomized controlled trials before specific recommendations are translated into clinical practice.
Dr. Marco Restrepo, FCCP is with the University of Texas Health Science Center,
San Antonio, Tex.
Dr. Marcos I. Restrepo, FCCP, comments: Be careful about jumping to many conclusions regarding the beneficial effects of corticosteroids preventing Clostridium difficile-associated diarrhea. These associations derived from retrospective studies should be assessed in randomized controlled trials before specific recommendations are translated into clinical practice.
Dr. Marco Restrepo, FCCP is with the University of Texas Health Science Center,
San Antonio, Tex.
DENVER – Use of systemic corticosteroids during antibiotic treatment for respiratory infections may reduce the incidence of Clostridium difficile–associated diarrhea, a single-center study demonstrated.
"Using steroids may not predispose people to having C diff, as previously thought," Amy Wojciechowski, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Don’t be afraid to use steroids when you’re treating with antibiotics. You’re not going to increase your risk of C. diff. You may even be decreasing it."
Dr. Wojciechowski, along with Kari Mergenhagen, Pharm.D., and their associates at the VA Western New York Healthcare System, Buffalo, set out to determine the incidence of Clostridium difficile–associated diarrhea (CDAD) in patients treated in the hospital with antibiotics for a chronic obstructive pulmonary disease (COPD) exacerbation or community-acquired pneumonia (CAP). The investigators evaluated baseline characteristics and risk factors that affect the incidence of CDAD.
The study population comprised 532 veterans who were hospitalized between March 2006 and July 2012 and were treated with moxifloxacin or with ceftriaxone plus azithromycin. CDAD was defined as diarrhea with positive PCR assay or toxin assay for C difficile within 30 days of antibiotic treatment.
The mean age of the veterans was 76 years, and 99% were male. The researchers found that CDAD occurred in 11 patients in the study population, for an incidence rate of 2.07%.
Variables associated with a significantly decreased risk of CDAD were diagnosis of COPD (P = .01) and use of corticosteroids during antibiotics treatment (P = .0035). There was no difference in the incidence of CDAD between patients treated with moxifloxacin and those treated with ceftriaxone plus azithromycin.
After the researchers controlled for COPD, the use of corticosteroids remained linked to a decreased risk of developing CDAD (odds ratio, 0.12).
The researchers hypothesized that steroids "may attenuate the host immune response typically seen in response to C difficile toxins, thus preventing inflammation and cytokine release associated with the symptoms of CDAD." They added that more research is needed to determine whether the findings are the same in other patient populations.
The authors acknowledged as limitations of the study its retrospective design and the fact that the majority of patients where white men.
Dr. Wojciechowski, an infectious diseases pharmacy resident, and Dr. Mergenhagen, a clinical infectious diseases pharmacist, said that they had no relevant conflicts of interest to disclose.
DENVER – Use of systemic corticosteroids during antibiotic treatment for respiratory infections may reduce the incidence of Clostridium difficile–associated diarrhea, a single-center study demonstrated.
"Using steroids may not predispose people to having C diff, as previously thought," Amy Wojciechowski, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Don’t be afraid to use steroids when you’re treating with antibiotics. You’re not going to increase your risk of C. diff. You may even be decreasing it."
Dr. Wojciechowski, along with Kari Mergenhagen, Pharm.D., and their associates at the VA Western New York Healthcare System, Buffalo, set out to determine the incidence of Clostridium difficile–associated diarrhea (CDAD) in patients treated in the hospital with antibiotics for a chronic obstructive pulmonary disease (COPD) exacerbation or community-acquired pneumonia (CAP). The investigators evaluated baseline characteristics and risk factors that affect the incidence of CDAD.
The study population comprised 532 veterans who were hospitalized between March 2006 and July 2012 and were treated with moxifloxacin or with ceftriaxone plus azithromycin. CDAD was defined as diarrhea with positive PCR assay or toxin assay for C difficile within 30 days of antibiotic treatment.
The mean age of the veterans was 76 years, and 99% were male. The researchers found that CDAD occurred in 11 patients in the study population, for an incidence rate of 2.07%.
Variables associated with a significantly decreased risk of CDAD were diagnosis of COPD (P = .01) and use of corticosteroids during antibiotics treatment (P = .0035). There was no difference in the incidence of CDAD between patients treated with moxifloxacin and those treated with ceftriaxone plus azithromycin.
After the researchers controlled for COPD, the use of corticosteroids remained linked to a decreased risk of developing CDAD (odds ratio, 0.12).
The researchers hypothesized that steroids "may attenuate the host immune response typically seen in response to C difficile toxins, thus preventing inflammation and cytokine release associated with the symptoms of CDAD." They added that more research is needed to determine whether the findings are the same in other patient populations.
The authors acknowledged as limitations of the study its retrospective design and the fact that the majority of patients where white men.
Dr. Wojciechowski, an infectious diseases pharmacy resident, and Dr. Mergenhagen, a clinical infectious diseases pharmacist, said that they had no relevant conflicts of interest to disclose.
AT ICAAC 2013
Steroids may cut antibiotics-related C. difficile risk
DENVER – Use of systemic corticosteroids during antibiotic treatment for respiratory infections may reduce the incidence of Clostridium difficile–associated diarrhea, a single-center study demonstrated.
"Using steroids may not predispose people to having C. diff., as previously thought," Amy Wojciechowski, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Don’t be afraid to use steroids when you’re treating with antibiotics. You’re not going to increase your risk of C. diff. You may even be decreasing it."
Dr. Wojciechowski, along with Kari Mergenhagen, Pharm.D., and their associates at the VA Western New York Healthcare System, Buffalo, set out to determine the incidence of Clostridium difficile–associated diarrhea (CDAD) in patients treated in the hospital with antibiotics for a chronic obstructive pulmonary disease (COPD) exacerbation or community-acquired pneumonia (CAP). The investigators evaluated baseline characteristics and risk factors that affect the incidence of CDAD.
The study population comprised 532 veterans who were hospitalized between March 2006 and July 2012 and were treated with moxifloxacin or with ceftriaxone plus azithromycin. CDAD was defined as diarrhea with positive PCR assay or toxin assay for C. difficile within 30 days of antibiotic treatment.
The mean age of the veterans was 76 years, and 99% were male. The researchers found that CDAD occurred in 11 patients in the study population, for an incidence rate of 2.07%.
Variables associated with a significantly decreased risk of CDAD were diagnosis of COPD (P = .01) and use of corticosteroids during antibiotics treatment (P = .0035). There was no difference in the incidence of CDAD between patients treated with moxifloxacin and those treated with ceftriaxone plus azithromycin.
After the researchers controlled for COPD, the use of corticosteroids remained linked to a decreased risk of developing CDAD (odds ratio, 0.12).
The researchers hypothesized that steroids "may attenuate the host immune response typically seen in response to C. difficile toxins, thus preventing inflammation and cytokine release associated with the symptoms of CDAD." They added that more research is needed to determine whether the findings are the same in other patient populations.
The authors acknowledged as limitations of the study its retrospective design and the fact that the majority of patients where white men.
Dr. Wojciechowski, an infectious diseases pharmacy resident, and Dr. Mergenhagen, a clinical infectious diseases pharmacist, said that they had no relevant conflicts of interest to disclose.
Dr. Marcos I. Restrepo, FCCP, comments: Be careful about jumping to many conclusions regarding the beneficial effects of corticosteroids preventing Clostridium difficile-associated diarrhea. These associations derived from retrospective studies should be assessed in randomized controlled trials before specific recommendations are translated into clinical practice.
Dr. Marco Restrepo, FCCP is with the University of Texas Health Science Center,
San Antonio, Tex.
Dr. Marcos I. Restrepo, FCCP, comments: Be careful about jumping to many conclusions regarding the beneficial effects of corticosteroids preventing Clostridium difficile-associated diarrhea. These associations derived from retrospective studies should be assessed in randomized controlled trials before specific recommendations are translated into clinical practice.
Dr. Marco Restrepo, FCCP is with the University of Texas Health Science Center,
San Antonio, Tex.
Dr. Marcos I. Restrepo, FCCP, comments: Be careful about jumping to many conclusions regarding the beneficial effects of corticosteroids preventing Clostridium difficile-associated diarrhea. These associations derived from retrospective studies should be assessed in randomized controlled trials before specific recommendations are translated into clinical practice.
Dr. Marco Restrepo, FCCP is with the University of Texas Health Science Center,
San Antonio, Tex.
DENVER – Use of systemic corticosteroids during antibiotic treatment for respiratory infections may reduce the incidence of Clostridium difficile–associated diarrhea, a single-center study demonstrated.
"Using steroids may not predispose people to having C. diff., as previously thought," Amy Wojciechowski, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Don’t be afraid to use steroids when you’re treating with antibiotics. You’re not going to increase your risk of C. diff. You may even be decreasing it."
Dr. Wojciechowski, along with Kari Mergenhagen, Pharm.D., and their associates at the VA Western New York Healthcare System, Buffalo, set out to determine the incidence of Clostridium difficile–associated diarrhea (CDAD) in patients treated in the hospital with antibiotics for a chronic obstructive pulmonary disease (COPD) exacerbation or community-acquired pneumonia (CAP). The investigators evaluated baseline characteristics and risk factors that affect the incidence of CDAD.
The study population comprised 532 veterans who were hospitalized between March 2006 and July 2012 and were treated with moxifloxacin or with ceftriaxone plus azithromycin. CDAD was defined as diarrhea with positive PCR assay or toxin assay for C. difficile within 30 days of antibiotic treatment.
The mean age of the veterans was 76 years, and 99% were male. The researchers found that CDAD occurred in 11 patients in the study population, for an incidence rate of 2.07%.
Variables associated with a significantly decreased risk of CDAD were diagnosis of COPD (P = .01) and use of corticosteroids during antibiotics treatment (P = .0035). There was no difference in the incidence of CDAD between patients treated with moxifloxacin and those treated with ceftriaxone plus azithromycin.
After the researchers controlled for COPD, the use of corticosteroids remained linked to a decreased risk of developing CDAD (odds ratio, 0.12).
The researchers hypothesized that steroids "may attenuate the host immune response typically seen in response to C. difficile toxins, thus preventing inflammation and cytokine release associated with the symptoms of CDAD." They added that more research is needed to determine whether the findings are the same in other patient populations.
The authors acknowledged as limitations of the study its retrospective design and the fact that the majority of patients where white men.
Dr. Wojciechowski, an infectious diseases pharmacy resident, and Dr. Mergenhagen, a clinical infectious diseases pharmacist, said that they had no relevant conflicts of interest to disclose.
DENVER – Use of systemic corticosteroids during antibiotic treatment for respiratory infections may reduce the incidence of Clostridium difficile–associated diarrhea, a single-center study demonstrated.
"Using steroids may not predispose people to having C. diff., as previously thought," Amy Wojciechowski, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "Don’t be afraid to use steroids when you’re treating with antibiotics. You’re not going to increase your risk of C. diff. You may even be decreasing it."
Dr. Wojciechowski, along with Kari Mergenhagen, Pharm.D., and their associates at the VA Western New York Healthcare System, Buffalo, set out to determine the incidence of Clostridium difficile–associated diarrhea (CDAD) in patients treated in the hospital with antibiotics for a chronic obstructive pulmonary disease (COPD) exacerbation or community-acquired pneumonia (CAP). The investigators evaluated baseline characteristics and risk factors that affect the incidence of CDAD.
The study population comprised 532 veterans who were hospitalized between March 2006 and July 2012 and were treated with moxifloxacin or with ceftriaxone plus azithromycin. CDAD was defined as diarrhea with positive PCR assay or toxin assay for C. difficile within 30 days of antibiotic treatment.
The mean age of the veterans was 76 years, and 99% were male. The researchers found that CDAD occurred in 11 patients in the study population, for an incidence rate of 2.07%.
Variables associated with a significantly decreased risk of CDAD were diagnosis of COPD (P = .01) and use of corticosteroids during antibiotics treatment (P = .0035). There was no difference in the incidence of CDAD between patients treated with moxifloxacin and those treated with ceftriaxone plus azithromycin.
After the researchers controlled for COPD, the use of corticosteroids remained linked to a decreased risk of developing CDAD (odds ratio, 0.12).
The researchers hypothesized that steroids "may attenuate the host immune response typically seen in response to C. difficile toxins, thus preventing inflammation and cytokine release associated with the symptoms of CDAD." They added that more research is needed to determine whether the findings are the same in other patient populations.
The authors acknowledged as limitations of the study its retrospective design and the fact that the majority of patients where white men.
Dr. Wojciechowski, an infectious diseases pharmacy resident, and Dr. Mergenhagen, a clinical infectious diseases pharmacist, said that they had no relevant conflicts of interest to disclose.
AT ICAAC 2013
Major finding: Use of corticosteroids during antibiotics treatment was associated with a significantly lower risk of Clostridium difficile–associated diarrhea among patients hospitalized for COPD exacerbations or CAP.
Data source: A study of 532 veterans hospitalized for respiratory infections between March 2006 and July 2012 who were treated with moxifloxacin or ceftriaxone plus azithromycin.
Disclosures: The researchers had no relevant financial conflicts of interest to disclose.
