Nivedita M Patkar

Oregon Health and Science University, Los Angeles, CA, United States

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Publications (35)170.79 Total impact

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    ABSTRACT: Background The comparative risk of infection associated with non anti-TNF biologics are not well established. Our objective was to compare risk for hospitalized infections between anti-TNF and non-anti-TNF biologics in U.S. veterans with rheumatoid arthritis (RA). Methods Using 1998-2011 data from the U.S. Veteran's Health Administration, we studied RA patients initiating rituximab, abatacept or anti-TNF therapy.. Exposure was based upon days supplied (injections) or usual dosing intervals (infusions). Treatment episodes were defined as new biologic use. Hazard ratios (HR, 95% CI) for hospitalization for a bacterial infection were estimated from Cox proportional hazards models, adjusting for potential confounders. Results Among 3152 unique RA patients contributing 4158 biologic treatment episodes to rituximab (n=596), abatacept (n=451), and anti-TNF (n-3111); patient mean age was 60 years, 87% were male. The most common infections were pneumonia(37%), skin/soft tissue(22%), urinary tract(9%), and bacteremia/sepsis(7%). Hospitalized infection rates/100 person-years (95% CI) were 4.4 (3.1, 6.4) for rituximab, 2.8 (1.7, 4.7) for abatacept and 3.0 (2.5, 3.5) for anti-TNF. Compared to etanercept, the adjusted rate of hospitalized infection was not different for adalimumab (HR 1.4, 0.9-2.2), abatacept (HR 1.1, 0.6-2.1), or rituximab (HR 1.4, 0.8-2.6) although was increased for infliximab (HR 2.3, 1.3-4.0). Infection risk was greater for those taking prednisone >7.5mg/day (HR=1.8, 1.3-2.7) and in the highest quartile of C-reactive protein (HR=2.3, 1.4-3.8) and ESR rate (HR= 4., 2.3-7.2)) compared to the lowest quartile. Conclusions In older, predominantly male US veterans with RA, the risk of hospitalized bacterial infections associated with rituximab or abatacept was similar to etanercept. © 2014 American College of Rheumatology.
    Arthritis care & research. 01/2014;
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    ABSTRACT: To determine among patients with autoimmune diseases in the USA whether the risk of non-viral opportunistic infections (OI) was increased among new users of tumour necrosis factor α inhibitors (TNFI), when compared to users of non-biological agents used for active disease. We identified new users of TNFI among cohorts of rheumatoid arthritis (RA), inflammatory bowel disease and psoriasis-psoriatic arthritis-ankylosing spondylitis patients during 1998-2007 using combined data from Kaiser Permanente Northern California, two pharmaceutical assistance programmes for the elderly, Tennessee Medicaid and US Medicaid/Medicare programmes. We compared incidence of non-viral OI among new TNFI users and patients initiating non-biological disease-modifying antirheumatic drugs (DMARD) overall and within each disease cohort. Cox regression models were used to compare propensity-score and steroid- adjusted OI incidence between new TNFI and non-biological DMARD users. Within a cohort of 33 324 new TNFI users we identified 80 non-viral OI, the most common of which was pneumocystosis (n=16). In the combined cohort, crude rates of non-viral OI among new users of TNFI compared to those initiating non-biological DMARD was 2.7 versus 1.7 per 1000-person-years (aHR 1.6, 95% CI 1.0 to 2.6). Baseline corticosteroid use was associated with non-viral OI (aHR 2.5, 95% CI 1.5 to 4.0). In the RA cohort, rates of non-viral OI among new users of infliximab were higher when compared to patients newly starting non-biological DMARD (aHR 2.6, 95% CI 1.2 to 5.6) or new etanercept users (aHR 2.9, 95% CI 1.5 to 5.4). In the USA, the rate of non-viral OI was higher among new users of TNFI with autoimmune diseases compared to non-biological DMARD users.
    Annals of the rheumatic diseases 07/2013; · 8.11 Impact Factor
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    ABSTRACT: Herpes zoster reactivation disproportionately affects patients with rheumatoid arthritis (RA). It is unclear whether anti-tumor necrosis factor (anti-TNF) therapy elevates herpes zoster risk. To ascertain whether initiation of anti-TNF therapy compared with nonbiologic comparators is associated with increased herpes zoster risk. We identified new users of anti-TNF therapy among cohorts of patients with RA, inflammatory bowel disease, and psoriasis, psoriatic arthritis, or ankylosing spondylitis from 1998 through 2007 within a large US multi-institutional collaboration combining data from Kaiser Permanente Northern California, Pharmaceutical Assistance Contract for the Elderly, Tennessee Medicaid, and national Medicaid/Medicare programs. We compared herpes zoster incidence between new anti-TNF users (n=33,324) and patients initiating nonbiologic disease-modifying antirheumatic drugs (DMARDs) (n=25,742) within each inflammatory disease cohort (last participant follow-up December 31, 2007). Within these cohorts, we used Cox regression models to compare propensity score-adjusted herpes zoster incidence between new anti-TNF and nonbiologic DMARD users while controlling for baseline corticosteroid use. Incidence of herpes zoster cases occurring after initiation of new anti-TNF or nonbiologic DMARD therapy. Among 33,324 new users of anti-TNF therapy, we identified 310 herpes zoster cases. Crude incidence rates among anti-TNF users were 12.1 per 1000 patient-years (95% CI, 10.7-13.6) for RA, 11.3 per 1000 patient-years (95% CI, 7.7-16.7) for inflammatory bowel disease, and 4.4 per 1000 patient-years (95% CI, 2.8-7.0) for psoriasis, psoriatic arthritis, or ankylosing spondylitis. Baseline use of corticosteroids of 10 mg/d or greater among all disease indications was associated with elevated risk (adjusted hazard ratio [HR], 2.13 [95% CI, 1.64-2.75]) compared with no baseline use. For patients with RA, adjusted incidence rates were similar between anti-TNF and nonbiologic DMARD initiators (adjusted HR, 1.00 [95% CI, 0.77-1.29]) and comparable between all 3 anti-TNF therapies studied. Across all disease indications, the adjusted HR was 1.09 (95% CI, 0.88-1.36). CONCLUSION AND RELEVANCE: Among patients with RA and other inflammatory diseases, those who initiated anti-TNF therapies were not at higher risk of herpes zoster compared with patients who initiated nonbiologic treatment regimens.
    JAMA The Journal of the American Medical Association 03/2013; 309(9):887-95. · 29.98 Impact Factor
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    ABSTRACT: OBJECTIVE: To compare incidence rates of selected opportunistic infections (OI) among children with and without juvenile idiopathic arthritis (JIA). METHODS: Using United States national Medicaid administrative claims data from 2000 through 2005, we identified a cohort of children with JIA based on physician diagnosis codes and dispensed medications. We defined a non-JIA comparator cohort of children diagnosed with attention deficit hyperactivity disorder (ADHD). We defined 15 types of OI using physician diagnosis or hospital discharge codes, and 7 of these types also required evidence of treatment with specific antimicrobials. We calculated infection incidence rates (IR). The rates in the ADHD comparator cohort were standardized to the age, sex, and race distribution of the JIA cohort. We calculated incidence rate ratios (IRR) to compare infection rates. RESULTS: The JIA cohort included 8,503 children with 13,990 person-years (p-y) of follow-up. The ADHD comparator cohort included 360,362 children with 477,050 p-y of follow-up. When all OI were considered together as a single outcome, there were 42 infections in the JIA cohort (IR 300 per 100,000 p-y; IRR 2.4 [1.7-3.3] versus ADHD). The most common OI among children with JIA were 3 Coccidioides (IR 21 per 100,000 p-y; IRR 101 [8.1-5319] versus ADHD); 5 Salmonella (IR 35 per 100,000 p-y; IRR 3.8 [1.2-9.5]); and 32 herpes zoster (IR 225 per 100,000 p-y; IRR 2.1 [1.4-3.0]). CONCLUSIONS: OI are rare among children with JIA. Nevertheless, children with JIA had a higher rate of OI, including Coccidioides, Salmonella, and herpes zoster, than children with ADHD. © 2013 American College of Rheumatology.
    Arthritis & Rheumatology 03/2013; · 7.48 Impact Factor
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    ABSTRACT: PURPOSE: To evaluate the incidence of optic neuritis (ON) in patients using anti-tumor necrosis factor (TNF) alpha therapy. DESIGN: Retrospective, population-based cohort study. METHODS: We identified new users of anti-TNF therapy (etanercept, infliximab, or adalimumab) or nonbiologic disease-modifying antirheumatic drugs (DMARDs) during 2000-2007 from the following data sources: Kaiser Permanente Northern California, Pharmaceutical Assistance Contract for the Elderly, Tennessee Medicaid, and National Medicaid/Medicare. Within this cohort, we used validated algorithms to identify ON cases occurring after onset of new drug exposure. We then calculated and compared ON incidence rates between exposure groups. RESULTS: We identified 61 227 eligible inflammatory disease patients with either new anti-TNF or new nonbiologic DMARD use. Among this cohort, we found 3 ON cases among anti-TNF new users, occurring a median of 123 days (range, 37-221 days) after anti-TNF start. The crude incidence rate of ON across all disease indications among anti-TNF new users was 10.4 (95% CI 3.3-32.2) cases per 100 000 person-years. In a sensitivity analysis considering current or past anti-TNF or DMARD use, we identified a total of 6 ON cases: 3 among anti-TNF users and 3 among DMARD users. Crude ON rates were similar among anti-TNF and DMARD groups: 4.5 (95% CI 1.4-13.8) and 5.4 (95% CI 1.7-16.6) per 100 000 person-years, respectively. CONCLUSION: Optic neuritis is rare among those who initiate anti-TNF therapy and occurs with similar frequency among those with nonbiologic DMARD exposure.
    American Journal of Ophthalmology 09/2012; · 4.02 Impact Factor
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    ABSTRACT: To compare the incidence of hospitalized bacterial infections among children with and children without juvenile idiopathic arthritis (JIA) and to examine the effects of selected medications. Using national Medicaid data from 2000 through 2005, we identified a cohort of children with JIA and a comparator cohort of children with attention deficit hyperactivity disorder (ADHD). Exposures to methotrexate (MTX), TNF inhibitors, and oral glucocorticoids (GCs) were determined using pharmacy claims. Patients hospitalized with bacterial infections were identified using coded discharge diagnoses. We calculated adjusted hazard ratios (HR(adj) ) to compare infection incidence rates while adjusting for relevant covariates. We identified 8,479 JIA patients with 13,003 person-years of followup; 36% took MTX and 16% took TNF inhibitors. Compared with ADHD patients, JIA patients who were not currently taking MTX or TNF inhibitors had an increased rate of infection (HR(adj) 2.0 [95% confidence interval (95% CI) 1.5, 2.5]). Among JIA patients not receiving TNF inhibitor therapy, MTX users had a similar rate of infection as those not currently taking MTX (HR(adj) 1.2 [95% CI 0.9, 1.7]). TNF inhibitor use (irrespective of MTX) resulted in a similar rate of infection as use of MTX without a TNF inhibitor (HR(adj) 1.2 [95% CI 0.8, 1.8]). Use of high-dose GCs (≥10 mg/day of prednisone or equivalent) increased the rate of infection as compared with no GC use, after adjustment for MTX and TNF inhibitor use (HR(adj) 3.1 [95% CI 2.0, 4.7]). Children with JIA had an increased rate of infection compared to children with ADHD. Among children with JIA, the rate of infection was not increased with MTX or TNF inhibitor use, but was significantly increased with high-dose GC use.
    Arthritis & Rheumatology 05/2012; 64(8):2773-80. · 7.48 Impact Factor
  • Arthritis care & research. 05/2012; 64(5):625-39.
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    ABSTRACT: To ascertain the incidence of progressive multifocal leukoencephalopathy (PML) in patients with selected rheumatic diseases, to describe the characteristics of PML cases occurring in this setting, and to evaluate the extent to which such cases occurred in the context of biologic therapies such as rituximab or tumor necrosis factor antagonists. We conducted a large population-based study to describe the incidence and risk factors for PML among patients with rheumatoid arthritis, psoriatic arthritis, psoriasis, juvenile idiopathic arthritis, inflammatory bowel disease, and ankylosing spondylitis using national inpatient and outpatient administrative data from the entire Center for Medicare and Medicaid Services from 2000-2009. Suspected PML cases were identified using hospital discharge diagnosis codes. Risk factors for PML were evaluated using outpatient data ≥6 months prior to PML diagnosis. Among 2,030,578 patients with autoimmune diseases of interest, a total of 53 PML cases were identified (2.6 per 100,000 patients). Most PML cases had human immunodeficiency virus (HIV) and/or cancer. Nine PML cases had evidence for biologic use prior to PML hospitalization, of which 3 had neither HIV nor malignancy and were exposed to biologics within 12 (rituximab) or 6 months (all other biologics) prior to PML diagnosis. PML occurred at an estimated incidence of 0.2 per 100,000 patients with autoimmune diseases who did not have HIV or malignancy. PML occurs at a very low incidence among patients with rheumatic diseases but can occur even in the absence of HIV or malignancy.
    Arthritis care & research. 12/2011; 64(4):612-5.
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    ABSTRACT: Administrative claims databases have large samples and high generalizability. They have been used to evaluate associations of atypical femoral fractures with bisphosphonates. We developed and assessed accuracy of claims-based algorithms with hospital and physician diagnosis codes for these fractures. Medical records and radiology reports of all adults admitted at University of Alabama at Birmingham Health System from 2004 to 2008 with International Classification of Diseases, Ninth Revision hospital discharges and surgeons' fracture repair codes for subtrochanteric femoral fractures and random sample of other femoral fractures were reviewed. We identified 137 persons with suspected subtrochanteric femoral fractures and randomly selected 50 persons with either suspected diaphyseal femoral fractures or hip fractures other than subtrochanteric and diaphyseal femoral fractures (typical hip fractures). Eleven patients had radiographic features indicative of atypical femoral fractures. The positive predictive value (PPV) of claims-based algorithms varied with primary or secondary positions on discharge diagnoses and the sources of diagnosis codes. The PPV for fractures ranged 69-89% for subtrochanteric femoral, 89-98% for diaphyseal femoral, and 85-98% for typical hip fractures. The PPV of administrative codes for defining a femoral fracture as atypical was low and imprecise. Claims-based algorithms combining hospital discharges with surgeon's diagnosis codes had high PPV to identify the site of subtrochanteric or diaphyseal femoral fractures vs typical hip fractures. However, claims-based data were not accurate in identifying atypical femoral fractures. These claims algorithms will be useful in future population-based observational studies to evaluate associations between osteoporosis medications and subtrochanteric and diaphyseal femoral fractures.
    Journal of Clinical Densitometry 11/2011; 15(1):92-102. · 1.71 Impact Factor
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    ABSTRACT: Although tumor necrosis factor (TNF)-α antagonists are increasingly used in place of nonbiologic comparator medications, their safety profile remains incomplete. To determine whether initiation of TNF-α antagonists compared with nonbiologic comparators is associated with an increased risk of serious infections requiring hospitalization. Within a US multi-institutional collaboration, we assembled retrospective cohorts (1998-2007) of patients with rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and psoriasis, psoriatic arthritis, or ankylosing spondylitis (psoriasis and spondyloarthropathies) combining data from Kaiser Permanente Northern California, New Jersey and Pennsylvania Pharmaceutical Assistance programs, Tennessee Medicaid, and national Medicaid/Medicare. TNF-α antagonists and nonbiologic regimens were compared in disease-specific propensity score (PS)-matched cohorts using Cox regression models with nonbiologics as the reference. Baseline glucocorticoid use was evaluated as a separate covariate. Infections requiring hospitalization (serious infections) during the first 12 months after initiation of TNF-α antagonists or nonbiologic regimens. Study cohorts included 10,484 RA, 2323 IBD, and 3215 psoriasis and spondyloarthropathies matched pairs using TNF-α antagonists and comparator medications. Overall, we identified 1172 serious infections, most of which (53%) were pneumonia and skin and soft tissue infections. Among patients with RA, serious infection hospitalization rates were 8.16 (TNF-α antagonists) and 7.78 (comparator regimens) per 100 person-years (adjusted hazard ratio [aHR], 1.05 [95% CI, 0.91-1.21]). Among patients with IBD, rates were 10.91 (TNF-α antagonists) and 9.60 (comparator) per 100 person-years (aHR, 1.10 [95% CI, 0.83-1.46]). Among patients with psoriasis and spondyloarthropathies, rates were 5.41 (TNF-α antagonists) and 5.37 (comparator) per 100 person-years (aHR, 1.05 [95% CI, 0.76-1.45]). Among patients with RA, infliximab was associated with a significant increase in serious infections compared with etanercept (aHR, 1.26 [95% CI, 1.07-1.47]) and adalimumab (aHR, 1.23 [95% CI, 1.02-1.48]). Baseline glucocorticoid use was associated with a dose-dependent increase in infections. Among patients with autoimmune diseases, compared with treatment with nonbiologic regimens, initiation of TNF-α antagonists was not associated with an increased risk of hospitalizations for serious infections.
    JAMA The Journal of the American Medical Association 11/2011; 306(21):2331-9. · 29.98 Impact Factor
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    ABSTRACT: Background: Newer biologic therapies such as TNF-alpha inhibitors represent important treatment advances for inflammatory and autoimmune diseases; however, risk of opportunistic infections (OIs) other than mycobacterial disease has been poorly characterized. Methods: We identified new users of anti-TNF therapy from a cohort of patients with rheumatoid arthritis (RA), inflammatory bowel disease (IBD), psoriasis (PsO), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) from 2000-2007 from Kaiser Permanente Northern California, Pharmaceutical Assistance Contract for the Elderly, Tennessee Medicaid and national Medicaid/Medicare. Cases of non-mycobacterial OIs were identified by use of ICD-9 codes and OI rates were estimated among initiators of TNF-alpha inhibitors and initiators of methotrexate or other non-biologic immunosuppressive agents (e.g. azathioprine, sulfasalazine). Follow-up was truncated at exposure discontinuation, death, study end or OI, whichever came first. The rate of OIs was compared between anti-TNF users and non-biologic comparator drugs in disease specific cohorts. Confounding was controlled through adjustment for the quintile of the propensity score and steroid use with Cox proportional hazards models. Results: We identified 47235 new episodes of anti-TNF use among patients with inflammatory diseases. Among RA patients, the crude rate of non-mycobacterial, non-zoster OIs in new anti-TNF users was 236 per 100,000 person-years (adjusted hazard ratio 1.47; 95% CI: 0.73-3.3). Lower rates were seen in new anti-TNF users with PsO, PsA and AS (pooled rate, 121 per 100,000) and IBD (rate, 172 per 100,000). The crude rate of zoster in new anti-TNF users with RA was 541 per 100,000 person-years (adjusted hazard ratio 1.16; 95% CI: 0.77-1.8) and lower in patients with PsO, PsA and AS (pooled rate, 145 per 100,000) and IBD (rate, 129 per 100,000). Conclusion: In a cohort of US patients with inflammatory diseases, overall rates for non-mycobacterial OIs are low and not significantly higher in new users of TNF drugs when compared to non-biologic comparators. Among new anti-TNF users, OI rates were lowest in patients with non-RA inflammatory diseases.
    Infectious Diseases Society of America 2011 Annual Meeting; 10/2011
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    ABSTRACT: Background: Cryptococcosis (crypto) is an opportunistic fungal infection caused by C. neoformans and the emerging species C. gattii. Incidence and risk factor data for cryptococcosis in older Americans are limited. Methods: We evaluated a 5% sample of national Medicare data for years 1999-2008 to determine incidence and risk factors for crypto. Cases were identified by ICD-9 code 117.5 and required one inpatient claim or at least two outpatient claims at least 7 days apart but within 90 days. Co-morbidities were identified by ICD-9 codes and defined as one physician claim within 6-months prior to the case date. We calculated national, regional and state-based incidence rates (per 100,000 person-years). Multivariable Poisson regression was used to determine risk factors for crypto. Results: One hundred ninety-four cases of crypto were identified from a sample of 1,913,294 Medicare patients 65-years-of age or older. Mean age among cases was 79.6 years, 55.4% were male and 80.8% white. Ninety-day mortality among cases was 36.3%. Overall US incidence rate was 1.83/100,000 p-years and greatest in the South (2.65) and Western (1.75) regions. Incidence was highest in Arkansas (8.3) and Arizona (5.1). National and regional IR decreased during the study period (US 2.23 in 2000 to 1.09 in 2008). Multivariable regression analyses identified neutropenia (IRR 4.6), rheumatologic disease (IRR 2.6), chronic liver disease (IRR 2.4), chronic kidney disease (IRR 2.2), malignancy (IRR 2.2), COPD (IRR 2.2), diabetes (IRR 2.0), South region (IRR 2.6) and Western region (IRR 1.7) when compared to North; black race (IRR 1.6) and male gender (IRR 1.4) as significant risk factors for cryptococcosis. Conclusion: Cryptococcosis is an uncommon infection in older Americans. Geographic variation in crypto IR was evident, with South and Western regions having increased incidence. As older Americans continue to comprise a greater proportion of the US population, identification of risk factors for cryptococcosis may aid surveillance and prevention strategies. Despite the reported emergence of C. gattii in some parts of the country, overall crypto incidence decreased during the study period.
    Infectious Diseases Society of America 2011 Annual Meeting; 10/2011
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    ABSTRACT: Administrative claims data have not commonly been used to study the clinical effectiveness of medications for rheumatoid arthritis (RA) because of the lack of a validated algorithm for this outcome. We created and tested a claims-based algorithm to serve as a proxy for the clinical effectiveness of RA medications. We linked Veterans Health Administration (VHA) medical and pharmacy claims for RA patients participating in the longitudinal Department of Veterans Affairs (VA) RA registry (VARA). Among individuals for whom treatment with a new biologic agent or nonbiologic disease-modifying agent in rheumatic disease (DMARD) was being initiated and with registry follow-up at 1 year, VARA and administrative data were used to create a gold standard for the claims-based effectiveness algorithm. The gold standard outcome was low disease activity (LDA) (Disease Activity Score using 28 joint counts (DAS28) ≤ 3.2) or improvement in DAS28 by > 1.2 units at 12 ± 2 months, with high adherence to therapy. The claims-based effectiveness algorithm incorporated biologic dose escalation or switching, addition of new disease-modifying agents, increase in oral glucocorticoid use and dose as well as parenteral glucocorticoid injections. Among 1,397 patients, we identified 305 eligible biologic or DMARD treatment episodes in 269 unique individuals. The patients were primarily men (94%) with a mean (± SD) age of 62 ± 10 years. At 1 year, 27% of treatment episodes achieved the effectiveness gold standard. The performance characteristics of the effectiveness algorithm were as follows: positive predictive value, 76% (95% confidence interval (95% CI) = 71% to 81%); negative predictive value, 90% (95% CI = 88% to 92%); sensitivity, 72% (95% CI = 67% to 77%); and specificity, 91% (95% CI = 89% to 93%). Administrative claims data may be useful in evaluating the effectiveness of medications for RA. Further validation of this effectiveness algorithm will be useful in assessing its generalizability and performance in other populations.
    Arthritis research & therapy 09/2011; 13(5):R155. · 4.27 Impact Factor
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    ABSTRACT: Although biologic treatments have excellent efficacy for many autoimmune diseases, safety concerns persist. Understanding the absolute and comparative risks of adverse events in patient and disease subpopulations is critical for optimal prescribing of biologics. The Safety Assessment of Biologic Therapy collaborative was federally funded to provide robust estimates of rates and relative risks of adverse events among biologics users using data from national Medicaid and Medicare plus Medicaid dual-eligible programs, Tennessee Medicaid, Kaiser Permanente, and state pharmaceutical assistance programs supplementing New Jersey and Pennsylvania Medicare programs. This report describes the organizational structure of the collaborative and the study population and methods. This retrospective cohort study (1998-2007) examined risks of seven classes of adverse events in relation to biologic treatments prescribed for seven autoimmune diseases. Propensity scores were used to control for confounding and enabled pooling of individual-level data across data systems while concealing personal health information. Cox proportional hazard modeling was used to analyze study hypotheses. The cohort was composed of 159,000 subjects with rheumatic diseases, 33,000 with psoriasis, and 46,000 with inflammatory bowel disease. This report summarizes demographic characteristics and drug exposures. Separate reports will provide outcome definitions and estimated hazard ratios for adverse events. This comprehensive research will improve understanding of the safety of these treatments. The methods described may be useful to others planning similar evaluations.
    Pharmacoepidemiology and Drug Safety 09/2011; 20(11):1199-209. · 2.90 Impact Factor
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    ABSTRACT: To investigate the epidemiology and geographic distribution of histoplasmosis, coccidioidomycosis, and blastomycosis in older persons in the United States, we evaluated a random 5% sample of national Medicare data from 1999 through 2008. We calculated national, regional, and state-based incidence rates and determined 90-day postdiagnosis mortality rates. We identified 776 cases (357 histoplasmosis, 345 coccidioidomycosis, 74 blastomycosis). Patient mean age was 75.7 years; 55% were male. Histoplasmosis and blastomycosis incidence was highest in the Midwest (6.1 and 1.0 cases/100,000 person-years, respectively); coccidioidomycosis incidence rate was highest in the West (15.2). On the basis of available data, for 86 (11.1%) cases, there was no patient exposure to a traditional disease-endemic area. Knowledge of areas where endemic mycosis incidence is increased may affect diagnostic or prevention measures for older adults at risk.
    Emerging Infectious Diseases 09/2011; 17(9):1664-9. · 6.79 Impact Factor
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    ABSTRACT: Osteoporosis is a leading health problem worldwide due to the morbidity and mortality associated with fractures. However, a large number of fractures occur in persons without osteoporosis, when defined by bone mineral density alone. Numerous studies have shown that the risk of subsequent fracture is increased following fractures at most sites, and the increased risk is not limited to prior hip and vertebral fractures only. In addition, the amount of trauma present at the time of a fracture event appears to have limited impact on future fracture risk. Thus, even fractures that occur in the presence of high trauma should be recognized as evidence of possible bone fragility. Further methods to better identify persons at risk of future fracture are needed, such as through evaluation of other indicators of bone strength or recognition of modifiable, non-bone factors. Any initial fracture event is important for patients and caregivers to recognize as an implication for future fracture risk.
    Current Osteoporosis Reports 06/2011; 9(3):122-8.
  • Arthritis care & research. 06/2011;
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    Arthritis care & research. 04/2011; 63(4):465-82.
  • Nivedita M Patkar, Jeffrey R Curtis, Kenneth Saag
    Journal of clinical epidemiology 02/2011; · 5.48 Impact Factor
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    ABSTRACT: Determining anatomic sites and circumstances under which a fracture may be a consequence of osteoporosis is a topic of ongoing debate and controversy that is important to both clinicians and researchers. We conducted a systematic literature review and generated an evidence report on fracture risk based on specific anatomic bone sites and fracture diagnosis codes. Using the Research and Development/University of California at Los Angeles appropriateness process, we convened a multidisciplinary panel of 11 experts who rated fractures according to their likelihood of being because of osteoporosis based on the evidence report. Fracture sites (as determined by International Classification of Diseases Clinical Modification codes) were stratified by four clinical risk factor categories based on age, sex, race/ethnicity (African American and Caucasian), and presence or absence of trauma. Consistent with current clinical experience, the fractures rated most likely because of osteoporosis were the femoral neck, pathologic fractures of the vertebrae, and lumbar and thoracic vertebral fractures. The fractures rated least likely because of osteoporosis were open proximal humerus fractures, skull, and facial bones. The expert panel rated open fractures of the arm (except proximal humerus) and fractures of the tibia/fibula, patella, ribs, and sacrum as being highly likely because of osteoporosis in older Caucasian women but a lower likelihood in younger African American men. Osteoporosis attribution scores for all fracture sites were determined by a multidisciplinary expert panel to provide an evidence-based continuum of the likelihood of a fracture being associated with osteoporosis.
    Journal of clinical epidemiology 01/2011; 64(1):46-53. · 5.48 Impact Factor

Publication Stats

1k Citations
170.79 Total Impact Points


  • 2012–2013
    • Oregon Health and Science University
      • Department of Public Health & Preventive Medicine
      Los Angeles, CA, United States
  • 2006–2013
    • University of Alabama at Birmingham
      Birmingham, Alabama, United States
  • 2011
    • Kaiser Permanente
      Oakland, California, United States
    • Vanderbilt University
      • Department of Preventive Medicine
      Nashville, MI, United States
  • 2010
    • University of California, Los Angeles
      • Division of Rheumatology
      Los Angeles, California, United States