-
[show abstract]
[hide abstract]
ABSTRACT: Recent data suggest that statin use may be associated with a reduced risk of advanced prostate cancer. However, the influence of statins on prostate-specific antigen (PSA) levels and what effect this could potentially have on prostate cancer diagnosis are unknown.
We conducted a longitudinal study of 1214 men who were prescribed a statin between 1990 and 2006 at the Durham Veterans Affairs Medical Center who were free of prostate cancer, had not undergone prostate surgery or taken medications known to alter androgen levels and who had at least one PSA value within 2 years before and at least one PSA value within 1 year after starting a statin. The change in PSA from before to after statin treatment was analyzed as a continuous variable using the Wilcoxon signed rank test. The association between change in PSA and change in cholesterol parameters (low-density lipoprotein [LDL], high-density lipoprotein [HDL], and total cholesterol) was analyzed using multivariate linear regression. All statistical tests were two-sided.
Mean (SD) age when starting statins was 60.3 (8.3) years; median prestatin PSA concentration was 0.9 (1.9) ng/mL; and mean prestatin LDL cholesterol concentration was 144 (34) mg/dL. After starting a statin, the median LDL decline was 27.5%, and the median PSA decline was 4.1% (P < .001, for both comparisons). Changes in PSA concentration were strongly associated with statin dose and changes in LDL levels. For every 10% decrease in LDL after starting a statin, PSA levels declined by 1.64 (95 % confidence interval [CI] = 0.64% to 2.65%, p = .001). Among men most likely to be under consideration for prostate biopsy (prestatin PSA levels > or =2.5 ng/mL, n = 188), those with >41% declines in LDL (highest quartile) after starting a statin experienced a 17.4% (95% CI = 10.0% to 24.9%) decline in serum PSA.
PSA levels declined by a statistically significant extent after initiation of statin treatment. The reduction was most pronounced among men with the largest LDL declines and those with PSA levels that would make them candidates for prostate biopsy. By lowering PSA levels, statins may complicate cancer detection, although further studies are needed to quantify the clinical significance of this effect.
CancerSpectrum Knowledge Environment 11/2008; 100(21):1511-8. · 14.07 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine whether suboptimal pharmacotherapy increases the risk of adverse outcomes in older adults discharged from the emergency department (ED).
Retrospective, cohort study.
Academically affiliated Veterans Affairs Medical Center.
Nine hundred forty-two veterans aged 65 and older discharged from the ED.
The primary independent variable, suboptimal pharmacotherapy, was based on drugs-to-avoid criteria, drug-drug interactions, drug-disease interactions, or failure to satisfy explicit quality indicators (QIs). An adverse outcome was defined as one or more repeat ED visits or hospitalizations or death within 90 days of ED discharge.
Four hundred twenty-one patients were prescribed a new medication at ED discharge. Of these, 134 (31.8%) had suboptimal pharmacotherapy; 49 (11.6%) were prescribed a drug to avoid, 53 (12.6%) received a drug that introduced a new drug-drug interaction, 24 (5.7%) were given a drug that introduced a drug-disease interaction, and 74 (17.6%) did not have a QI satisfied. Overall, 320 patients (34.0%) experienced an adverse outcome within 90 days. Multivariable analyses suggested a trend toward greater risk of adverse outcomes in patients with suboptimal pharmacotherapy (hazard ratio=1.32, 95% confidence interval=0.95, 1.84).
A substantial number of older male veterans discharged from the ED may be at risk for adverse events due to suboptimal prescribing and inadequate medication monitoring. Efforts to improve the quality of pharmacotherapy in this vulnerable population are warranted.
Journal of the American Geriatrics Society 06/2008; 56(5):875-80. · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: An Emergency Department (ED) visit represents a time of significant risk for an older adult; however, little is known about adverse outcomes after an ED visit in the VA system.
1) To describe the frequency and type of adverse health outcomes among older veterans discharged from the ED, and 2) To determine risk factors associated with adverse outcomes.
Retrospective, cohort study at an academically affiliated VA medical center.
A total of 942 veterans > or = 65 years old discharged from the ED.
Primary dependent variable was adverse outcome, defined as a repeat VA ED visit, hospitalization, and/or death within 90 days. Overall, 320 (34.0%) patients experienced an adverse outcome: 245 (26%) returned to the VA ED but were not admitted, 125 (13.3%) were hospitalized, and 23 (2.4%) died. In adjusted analyses, higher score on the Charlson Comorbidity Index (hazard ratio [HR] 1.11; 95% CI 1.03, 1.21), ED visit within the previous 6 months (HR 1.64; 95% CI 1.30, 2.06), hospitalization within the previous 6 months (HR 1.70, 95% CI 1.30, 2.22), and triage to the emergency unit (compared to urgent care clinic) (HR 1.76, 95% CI 1.32, 2.36) were independently associated with higher risk of adverse outcomes.
More than 1 in 3 older veterans discharged from the ED experienced a significant adverse outcome within 90 days of ED discharge. Identifying veterans at greatest risk for adverse outcomes after ED discharge can inform the design and targeting of interventions to reduce morbidity and costs in this group.
Journal of General Internal Medicine 11/2007; 22(11):1527-31. · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the prevalence and type of suboptimal pharmacotherapy that older veterans discharged from the emergency department (ED) or urgent care clinic (UCC) receive and to examine factors associated with suboptimal pharmacotherapy in this population.
Retrospective, cohort study.
An academically affiliated Department of Veterans' Affairs (VA) Medical Center.
Four hundred twenty-one veterans aged 65 and older who were prescribed a new medication at the time of discharge from the ED or UCC.
The primary dependent variable, suboptimal pharmacotherapy, was a composite measure defined as one or more drug-related problems, based on drugs-to-avoid criteria, drug-drug interactions, drug-disease interactions, and failure to satisfy an explicit quality indicator for prescribing or medication monitoring.
A total of 757 drugs were prescribed to the 421 patients at the time of discharge from the ED or UCC (mean number+/-standard deviation per patient 1.65+/-1.1). The most frequently prescribed medications were nonsteroidal antiinflammatory drugs (n=59), opioid analgesics (n=47), and fluoroquinolone antibiotics (n=46). Overall, 134 (31.8%) subjects were found to have suboptimal pharmacotherapy with regard to their discharge medications; 49 (11.6%) were prescribed a drug to avoid, 53 (12.6%) received a drug that introduced a new drug-drug interaction, 24 (5.7%) were given a drug that introduced a drug-disease interaction, and 74 (17.6%) did not have a quality indicator satisfied (61% of these evaluated prescribing and 39% evaluated medication monitoring). No consistent associations between patient or visit characteristics and suboptimal pharmacotherapy were identified in multivariable models.
A substantial number of older adults discharged from the ED or UCC may be at risk for adverse events due to suboptimal prescribing and inadequate medication monitoring. Further study is needed to examine the relationship between suboptimal pharmacotherapy and adverse clinical outcomes.
Journal of the American Geriatrics Society 10/2007; 55(9):1339-48. · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To improve lipid management of high-risk patients in a large academic primary care practice.
Educational intervention with historical controls.
We determined the likelihood of providers within an academic Veterans Affairs primary care practice to adjust simvastatin doses before and after a low-cost educational intervention. Study patients were enrolled during a 2-year preintervention period, had an indication to achieve a low-density lipoprotein cholesterol (LDL-C) level of <100 mg/dL, and were taking simvastatin but not at the maximum dose. We explored factors that might affect dose changing, including patient demographics, diabetes, coronary disease, patient medication adherence, and a threshold effect where LDL-C values just above the target might lead to provider inaction.
Initially, 49% of 4048 patients met their LDL-C target. Before the intervention, the simvastatin dose was changed at only 16% of 2103 patient visits where the patient was not at treatment target and was on less than the maximum dose. Providers were more likely to adjust the dose for patients with high LDL-C and those who were compliant, and less likely to adjust it for older or diabetic patients. After the intervention, 62% of 1414 patients met their treatment target. Compared with the preintervention period, providers were more likely to increase the simvastatin dose for patients not yet at their target (P = .023).
Following a low-cost intervention, providers more aggressively treated high LDL-C in high-risk patients, and more patients reached their treatment target goal.
The American journal of managed care 09/2007; 13(9):530-4. · 2.46 Impact Factor
-
Kenneth C Goldberg
North Carolina medical journal 69(1):31-4.
