Jennifer M Polinski

Brigham and Women's Hospital, Boston, Massachusetts, United States

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Publications (62)295.18 Total impact

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    ABSTRACT: Objective: The objective of this study was to compare treatment persistence and rates of seizure-related events in patients who initiate antiepileptic drug (AED) therapy with a generic versus a brand-name product. Methods: We used linked electronic medical and pharmacy claims data to identify Medicare beneficiaries who initiated one of five AEDs (clonazepam, gabapentin, oxcarbazepine, phenytoin, zonisamide). We matched initiators of generic versus brand-name versions of these drugs using a propensity score that accounted for demographic, clinical, and health service utilization variables. We used a Cox proportional hazards model to compare rates of seizure-related emergency room (ER) visit or hospitalization (primary outcome) and ER visit for bone fracture or head injury (secondary outcome) between the matched generic and brand-name initiators. We also compared treatment persistence, measured as time to first 14-day treatment gap, between generic and brand-name initiators. Results: We identified 19,760 AED initiators who met study eligibility criteria; 18,306 (93%) initiated a generic AED. In the matched cohort, we observed 47 seizure-related hospitalizations and ER visits among brand-name initiators and 31 events among generic initiators, corresponding to a hazard ratio of 0.53 (95% confidence interval, 0.30 to 0.96). Similar results were observed for the secondary clinical endpoint and across sensitivity analyses. Mean time to first treatment gap was 124.2days (standard deviation [sd], 125.8) for brand-name initiators and 137.9 (sd, 148.6) for generic initiators. Significance: Patients who initiated generic AEDs had fewer adverse seizure-related clinical outcomes and longer continuous treatment periods before experiencing a gap than those who initiated brand-name versions.
    Epilepsy & Behavior 09/2015; 52(Pt A):14-18. DOI:10.1016/j.yebeh.2015.08.014 · 2.26 Impact Factor
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    ABSTRACT: Background: Among patients with type 2 diabetes, insulin intensification to achieve glycemic targets occurs less often than clinically indicated. Barriers to intensification are not well understood. We present patients' baseline characteristics from MOSAIc, a study investigating patient-, physician-, and healthcare environment-based factors affecting insulin intensification and subsequent health outcomes. Methods: MOSAIc is a longitudinal, observational study following patients' diabetes care in 18 countries: United Arab Emirates (UAE), Argentina, Brazil, Canada, China, Germany, India, Israel, Italy, Japan, Mexico, Russia, Saudi Arabia, South Korea, Spain, Turkey, United Kingdom, United States. Eligible patients are age ≥18, have type 2 diabetes, and have used insulin for ≥3 months with/without other antidiabetic medications. Extensive baseline demographic, clinical, and psychosocial data are collected at baseline and regular intervals during the 24-month follow-up. We conducted descriptive analyses of baseline data. Results: Four thousand three hundred forty one patients met eligibility criteria. Patients received their type 2 diabetes diagnosis 12 ± 8 years prior to baseline visit, yet patients in developing countries were younger than in developed countries (e.g., UAE, 55 ± 10; Germany = 70 ± 10). Saudi Arabians had the highest HbA1c values (9.0 ± 2.2) and Germany (7.5 ± 1.4) among the lowest. Most patients in 5 (28 %) of the 18 countries did not use an oral antidiabetic drug. Over half of patients in fourteen (78 %) countries exclusively used basal insulin; most Indian and Chinese patients exclusively used mixed insulin. Conclusions: MOSAIc's baseline data highlight differences in patient characteristics across countries. These patterns, along with physician and healthcare environment differences, may contribute to the likelihood of insulin intensification and subsequent clinical outcomes.
    BMC Endocrine Disorders 09/2015; 15(1). DOI:10.1186/s12902-015-0044-z · 1.71 Impact Factor
  • JAMA Internal Medicine 09/2015; DOI:10.1001/jamainternmed.2015.4582 · 13.12 Impact Factor
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    ABSTRACT: One-quarter of U.S. patients do not have a primary care provider or do not have complete access to one. Work and personal responsibilities also compete with finding convenient, accessible care. Telehealth services facilitate patients' access to care, but whether patients are satisfied with telehealth is unclear. We assessed patients' satisfaction with and preference for telehealth visits in a telehealth program at CVS MinuteClinics. Cross-sectional patient satisfaction survey. Patients were aged ≥18 years, presented at a MinuteClinic offering telehealth in January-September 2014, had symptoms suitable for telehealth consultation, and agreed to a telehealth visit when the on-site practitioner was busy. Patients reported their age, gender, and whether they had health insurance and/or a primary care provider. Patients rated their satisfaction with seeing diagnostic images, hearing and seeing the remote practitioner, the assisting on-site nurse's capability, quality of care, convenience, and overall understanding. Patients ranked telehealth visits compared to traditional ones: better (defined as preferring telehealth), just as good (defined as liking telehealth), or worse. Predictors of preferring or liking telehealth were assessed via multivariate logistic regression. In total, 1734 (54 %) of 3303 patients completed the survey: 70 % were women, and 41 % had no usual place of care. Between 94 and 99 % reported being "very satisfied" with all telehealth attributes. One-third preferred a telehealth visit to a traditional in-person visit. An additional 57 % liked telehealth. Lack of medical insurance increased the odds of preferring telehealth (OR = 0.83, 95 % CI, 0.72-0.97). Predictors of liking telehealth were female gender (OR = 1.68, 1.04-2.72) and being very satisfied with their overall understanding of telehealth (OR = 2.76, 1.84-4.15), quality of care received (OR = 2.34, 1.42-3.87), and telehealth's convenience (OR = 2.87, 1.09-7.94) CONCLUSIONS: Patients reported high satisfaction with their telehealth experience. Convenience and perceived quality of care were important to patients, suggesting that telehealth may facilitate access to care.
    Journal of General Internal Medicine 08/2015; DOI:10.1007/s11606-015-3489-x · 3.42 Impact Factor
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    ABSTRACT: Several small studies have reported inconsistent findings about the safety of selective serotonin reuptake inhibitors (SSRIs) among patients undergoing coronary artery bypass grafting (CABG). We sought to investigate post-CABG bleeding and mortality outcomes related to antidepressant exposure. We identified patients who underwent CABG between 2004 and 2008 in the Premier Perspective Comparative Database. We determined whether they received SSRIs, other antidepressants, or no antidepressants on any pre-CABG hospital day and used Cox proportional hazards models to compare bleeding and mortality rates among the exposure groups while adjusting for potential confounders based on administrative data, pre-CABG charge codes, and discharge diagnosis codes. We identified 132,686 eligible patients: 7112 exposed to SSRIs, 1905 exposed to other antidepressants, and 123,668 unexposed. As compared with no exposure, neither SSRIs (hazard ratio [HR] 0.98; 95 % confidence interval [CI] 0.90-1.07) nor other antidepressants (HR 1.11; 95 % CI 0.96-1.28) increased major bleeds, and neither SSRIs (HR 0.93; 95 % CI 0.80-1.07) nor other antidepressants (HR 0.84; 95 % CI 0.62-1.14) increased mortality. Both SSRIs (HR 1.14; 95 % CI 1.10-1.18) and other antidepressants (HR 1.11; 95 % CI 1.03-1.19) were associated with a slight increase in receipt of one or more packed red blood cell (pRBC) units, but neither were associated with substantial increases in receipt of three or more pRBC units (HR 1.06; 95 % CI 0.96-1.17 for SSRIs; HR 1.09; 95 % CI 0.91-1.31 for other antidepressants). In this large cohort study, neither SSRIs nor other antidepressants were associated with elevated rates of major bleed, or in-hospital mortality.
    Drug Safety 07/2015; DOI:10.1007/s40264-015-0328-2 · 2.82 Impact Factor
  • Sarah-Jo Sinnott · Jennifer M. Polinski · Stephen Byrne · Joshua J. Gagne
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    ABSTRACT: To determine the concordance between two methods to measure drug exposure duration from pharmacy claim data. We conducted a cohort study using 2002-2007 US Medicaid data. Initiators of eight drug groups were identified: statins, metformin, atypical antipsychotics, warfarin, proton pump inhibitors (PPIs), angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (ns-NSAIDs), and coxibs. For each patient, we calculated two measures of exposure duration using (1) observed days' supply available in US pharmacy claims and (2) the World Health Organisation's Defined Daily Dose (DDD) methodology. We used Wilcoxon signed rank tests to compare medians and Spearman correlations to assess correlation between the two measures. Cohort sizes ranged from 143,885 warfarin users to >3,000,000 ns-NSAID users. Similar median exposure durations were observed for ACE inhibitors (70 days vs.75 days), PPIs (44 days vs. 45 days), and coxibs (44 days vs. 45 days). The DDD method overestimated exposure duration for ns-NSAIDs and underestimated for the remaining drug groups, relative to days' supply. Spearman correlation coefficients ranged from 0.2 to 0.8. Using DDDs to estimate drug exposure duration can result in misclassification. The magnitude of this misclassification might depend on doses used which can vary according to factors such as local prescribing practices, renal function, and age. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of Clinical Epidemiology 06/2015; DOI:10.1016/j.jclinepi.2015.05.026 · 3.42 Impact Factor
  • Value in Health 05/2015; 18(3):A9-A10. DOI:10.1016/j.jval.2015.03.064 · 3.28 Impact Factor
  • William H Shrank · Jennifer M Polinski
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    ABSTRACT: With so much recent change in the healthcare system, it is easy to forget that Medicare Part D was only implemented in 2006. At the time, it represented the largest expansion in coverage for seniors since the introduction of Medicare in 1965. For the first time, seniors could voluntarily enroll in a government-subsidized, privately offered insurance program to make medications affordable, and 37 million of our most vulnerable Americans have enrolled to date.1 The program is widely acknowledged as a great success, expanding access to treatment, helping to improve health outcomes, and likely even reducing the overall costs to Medicare by improving patient health and reducing the need for other, more expensive health care services.2-5 As many of our most common chronic conditions can now be managed entirely with highly effective and low-cost generic medications,6 there may be no more cost-effective way to enhance coverage that will meaningfully improve health and, at the same time, bend t ...
    Journal of General Internal Medicine 04/2015; 30(8). DOI:10.1007/s11606-015-3291-9 · 3.42 Impact Factor
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    ABSTRACT: Generic drugs are approved on the basis of pharmaceutical equivalence and bioequivalence. Some drug products have unique structural or functional attributes, necessitating modified approaches to bioequivalence determinations. The aim of this systematic review was to identify studies that evaluated laboratory or clinical outcomes of six drugs approved via modified bioequivalence approaches. We conducted a systematic review of articles published through February 2014 in MEDLINE, EMBASE, and International Pharmaceutical Abstracts related to six recent drugs subject to modified regulatory approaches: venlafaxine extended release tablet (Effexor XR), acarbose (Precose), enoxaparin (Lovenox), vancomycin capsules (Vancocin), sodium ferric gluconate (Ferrlecit), and calcitonin salmon nasal spray (Miacalcin NS). We included all empirical evaluations (whether in vivo or in vitro) and excluded case studies, qualitative analyses, and pharmacoeconomic evaluations. Studies were summarized and evaluated on their methodological quality and assessed for bias using the Cochrane Risk of Bias Assessment Tool. Articles were divided into studies of US FDA-approved generics and non-FDA-approved generics available in non-US locations. We extracted drug(s) studied, study design, setting, sample size, population characteristics, study endpoints and results, and source of funding. After retrieving 1408 articles and searching through the full text of 106 articles, we found 26 articles that met our inclusion criteria-8 examining FDA-approved versions and 18 examining non-FDA-approved versions. Among FDA-approved generics, five studies of enoxaparin showed minor variations in biologic activities of unclear clinical importance, and no publications involved acarbose, venlafaxine ER, or vancomycin capsules. Among non-FDA-approved generics, nine studies of enoxaparin supported generic bioequivalence, despite three showing minor variations in drug activity. Four of six studies of venlafaxine ER supported generic bioequivalence, while two found a lack of bioequivalence with a Canadian generic version of the drug. Most studies were either highly susceptible to bias (12/26) or were not able to be assessed for bias (13/26), in part because eight studies were abstracts/posters without full reports. Pharmaceutical manufacturers sometimes raise scientific concerns related to potential generic versions of their drugs; however, in the six cases we reviewed, these companies did not follow up the pre-approval concerns they raised with any methodologically rigorous post-approval testing using clinical endpoints. Despite their pre-approval controversy, experience with these generic drugs provides reassurance of their clinical interchangeability. Systematized post-approval study of certain generic drug bioequivalence determinations is needed.
    Drugs 03/2015; 75(6). DOI:10.1007/s40265-015-0382-1 · 4.34 Impact Factor
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    ABSTRACT: Background: With proliferating treatment options for anticoagulant therapy, physicians and patients must choose among them based on their benefits and risks. Using a Discrete Choice Experiment, we elicited patients' relative preferences for specific benefits and risks of anticoagulant therapy. Methods and results: We selected a sample of US patients with cardiovascular disease from an online panel and elicited their preferences for benefits and risks of anticoagulant therapy: nonfatal stroke, nonfatal myocardial infarction, cardiovascular death, minor bleeding, major bleeding, bleeding death, and need for monitoring. These attributes were used to design scenarios describing hypothetical treatments that were labeled as new drug, old drug, or no drug. Latent class analysis was used to identify groups of patients with similar preferences. A total of 341 patients completed all Discrete Choice Experiment questions. On average, patients valued a 1% increased risk of a fatal bleeding event the same as a 2% increase in nonfatal myocardial infarction, a 3% increase in nonfatal stroke, a 3% increase in cardiovascular death, a 6% increase in major bleeding, and a 16% increase in minor bleeding. The odds of choosing no drug or old drug versus new drug were 0.72 (95% confidence interval, 0.61-0.84) and 0.86 (95% confidence interval, 0.81-0.93), respectively. Previous stroke or myocardial infarction was associated with membership in the class with larger negative preferences for these outcomes. Conclusions: Patients' preferences for various outcomes of anticoagulant therapy vary and depend on their previous experiences with myocardial infarction or stroke. Incorporating these preferences into benefit risk calculation and treatment decisions can enhance patient-centered care.
    Circulation Cardiovascular Quality and Outcomes 11/2014; 7(6). DOI:10.1161/CIRCOUTCOMES.114.001013 · 5.66 Impact Factor
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    ABSTRACT: Objective: Disease-modifying antirheumatic drugs (DMARDs) are recommended for all patients with rheumatoid arthritis (RA). Some estimate that approximately one-half of patients with RA do not receive DMARDs. We hypothesized that patients with RA living farther from rheumatologists would be less likely to receive RA diagnoses and to receive DMARDs. Methods: US-based Medicare patients ages >65 years were study eligible. We calculated driving distance from patients' homes to the nearest rheumatologist. Using multivariable logistic regression, we assessed relationships between driving distance and RA diagnosis and between driving distance and DMARD receipt. In one set of analyses, distance was divided into quartiles: 0-2, 2.1-5, 5.1-15.9, and ≥16 miles. In a second set of analyses, we used predefined categories: 0-15, 15.1-30, 30.1-60, and >60 miles. Results: Among 59,426 Medicare beneficiaries, 918 had diagnosed RA. Compared to the first quartile, increased distance was associated with decreased odds of RA diagnosis (odds ratio [OR] 0.96 [95% confidence interval (95% CI) 0.80-1.16] in second quartile, OR 0.88 [95% CI 0.72-1.07] in third quartile, and OR 0.72 [95% CI 0.56-0.93] in fourth quartile; P < 0.01 for trend). Similar results were observed using predefined categories. Among those with RA, increased distance was associated with increased odds of DMARD receipt across quartiles (OR 1.15 [95% CI 1.06-1.25] in second quartile, OR 1.41 [95% CI 1.29-1.54] in third quartile, and OR 1.32 [95% CI 1.18-1.46] in fourth quartile; P = 0.001 for trend). There was no relationship between predefined categories and DMARD receipt (P = 0.45 for trend). Conclusion: Increased driving distance to rheumatologists was associated with decreased odds of RA diagnosis. Among those with diagnosed RA, the odds of DMARD receipt rose as distance increased from <2 to 16 miles, but not beyond. Urban residents living closer to rheumatologists may have barriers to DMARD use besides geographic access.
    11/2014; 66(11). DOI:10.1002/acr.22333
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    ABSTRACT: Background: Statins are effective in preventing cardiovascular events, but patients do not fully adhere to them. Objective: To determine whether patients are more adherent to generic statins versus brand-name statins (lovastatin, pravastatin, or simvastatin) and whether greater adherence improves health outcomes. Design: Observational, propensity score-matched, new-user cohort study. Setting: Linked electronic data from medical and pharmacy claims. Participants: Medicare beneficiaries aged 65 years or older with prescription drug coverage between 2006 and 2008. Intervention: Initiation of a generic or brand-name statin. Measurements: Adherence to statin therapy (measured as the proportion of days covered [PDC] up to 1 year) and a composite outcome comprising hospitalization for an acute coronary syndrome or stroke and all-cause mortality. Hazard ratios (HRs) and absolute rate differences were estimated. Results: A total of 90 111 patients who initiated a statin during the study was identified; 83 731 (93%) initiated a generic drug, and 6380 (7%) initiated a brand-name drug. The mean age of patients was 75.6 years, and most (61%) were female. The average PDC was 77% for patients in the generic group and 71% for those in the brand-name group (P < 0.001). An 8% reduction in the rate of the clinical outcome was observed among patients in the generic group versus those in the brand-name group (HR, 0.92 [95% CI, 0.86 to 0.99]). The absolute difference was -1.53 events per 100 person-years (CI, -2.69 to -0.19 events per 100 person-years). Limitation: Results may not be generalizable to other populations with different incomes or drug benefit structures. Conclusion: Compared with those initiating brand-name statins, patients initiating generic statins were more likely to adhere and had a lower rate of a composite clinical outcome.
    Annals of internal medicine 09/2014; 161(6):400-407. DOI:10.7326/M13-2942 · 17.81 Impact Factor
  • SJ Sinnott · JM Franklin · H. Whelton · JM Polinski
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    ABSTRACT: Background Generalisability has been reported as a barrier to using evidence in policy making. Little data are available on whether US and Canadian based evidence on cost-sharing and medication adherence is generalizable to international populations. To explore external validity, we compared the impact of two similar cost sharing policies, one in the US and one in Ireland, on medication adherence. Methods A repeated measures longitudinal study design was employed to measure individual drug adherence before and after the introduction of drug cost-sharing policies. The Irish policy introduced a 50 cent copayment/prescription item in a publicly insured population in 2010. A similar policy occurred in the Massachusetts Medicaid population in 2003. Prescription data were obtained from centrally held pharmacy claims databases; HSE-PCRS, in Ireland and Medicaid Analytical Extract in the US New users of anti-hypertensive, anti-hyperlipidaemic and anti-diabetes drugs entered the cohort 6 months prior to initiation of cost-sharing polices and were followed for 12 months post-policy change. Segmented regression with generalised estimating equations and an autoregressive correlation structure was used. Results The Irish policy change resulted in a 3.9% (95% CI, 2.91%-5.02%) immediate drop in adherence to anti-hypertensive drugs in Ireland, whereas the US policy did not affect anti-hypertensive adherence. Relative to the US, the Irish population had a 5.3% (95% CI, 3.68% - 6.92%) additional decrease in adherence to anti-hypertensive drugs immediately after the policy change. Adherence to anti-hyperlipidaemic drugs was insignificantly reduced (-0.6235%, 95% CI, - 2.41%-1.16%) immediately post-policy change in the U. S. However, adherence to anti-hyperlipidaemics was reduced in Ireland by 3.4% (95% CI, 2.25%-4.62%). Compared to the US, Irish patients decreased their adherence to anti-hyperlipidaemics by 2.8% (95% CI, 0.673%-4.945%). Adherence to anti-diabetic drugs did not differ internationally post-policy change. There was no evidence for international differences in the long-term impact (12 months) of policy changes. Conclusion Irish and US populations had different changes in adherence to anti-hypertensive and anti-hyperlipidaemic drugs directly after implementation of cost-sharing policies, with greater reductions in adherence in the Irish population. However, changes in adherence to anti-diabetic drugs were similar between the populations. This study suggests that North American and Canadian evidence may not be automatically internationally generalizable. Rather, the specific attributes of a setting should always be considered before applying evidence to policy. This novel study will be of interest to global policymakers as they seek to develop evidence based cost-sharing policies.
    Journal of Epidemiology &amp Community Health 09/2014; 68(Suppl 1):A65-A65. DOI:10.1136/jech-2014-204726.141 · 3.50 Impact Factor
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    ABSTRACT: PurposeType 2 diabetes mellitus has reached epidemic proportions worldwide. Many patients with type 2 diabetes mellitus will require insulin, and the evidence-based use of insulin is described in the prescription drug label. Product labels in different countries may provide inconsistent information. We evaluated the variability in drug label content for one brand of basal insulin across diverse settings.Methods We examined the drug label content pertinent to effective and safe use of insulin glargine across 17 countries: Abu Dhabi (United Arab Emirates), Argentina, Brazil, Canada, China, Germany, Israel, Italy, Japan, Mexico, Russia, Saudi Arabia, South Korea, Spain, Turkey, UK, and the USA. We compared label characteristics in settings where drug labels were governed by a local regulatory authority versus countries where labels were administered by a regional body or adopted from another locale.ResultsAll 17 labels cautioned that providers should consider age, illness, diet, and exercise when prescribing. Only two (12%) described care of the fasting patient. Caution was urged for patients with renal or hepatic impairment in 16 (94%) labels. Four (24%) did not describe responses to missed doses, and five (29%) failed to recommend patient counseling about the risk of hypoglycemia. Labels emerging from regional or adopted regulatory bodies reported fewer patients in efficacy studies than did labels from settings with their own drug regulatory agencies (365 ± 0 patients vs. 3560 ± 2938, p = 0.04).Conclusions There is substantial variation in the content of drug labels for glargine, which may lead to international inconsistency in quality of care for diabetic patients. Copyright © 2014 John Wiley & Sons, Ltd.
    Pharmacoepidemiology and Drug Safety 09/2014; 24(2). DOI:10.1002/pds.3704 · 2.94 Impact Factor
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    ABSTRACT: Primary medication adherence occurs when a patient properly fills the first prescription for a new medication. Primary adherence only occurs about three-quarters of the time for antihypertensive medications. We assessed patients’ barriers to primary adherence and attributes of patient–provider discussions that might improve primary adherence for antihypertensives. In total, 26 patients with incomplete primary adherence for an antihypertensive, identified using their retail pharmacy claims, participated in four focus groups. Following a moderators’ guide developed a priori, moderators led patients in a discussion of patients’ attitudes and experiences with hypertension and receiving an antihypertensive medication, barriers to primary adherence, and their preferences for shared decision making and communication with providers. Three authors analysed and organized data into salient themes, including patients’ anger about and suspicion of their hypertension diagnosis, the need for medication and providers’ credibility. A trusting patient–provider relationship, shared decision-making support, full disclosure of side effects and cost sensitivity were attributes that might enhance primary adherence. Developing decision support interventions that strengthen the patient–provider relationship by enhancing provider credibility and patient trust prior to prescribing may provide more effective approaches for improving primary adherence.
    Health Education Research 05/2014; 29(5). DOI:10.1093/her/cyu023 · 1.66 Impact Factor
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    ABSTRACT: Longitudinal healthcare claim databases are frequently used for studying the comparative safety and effectiveness of medications, but results from these studies may be biased due to residual confounding. It is unclear whether methods for confounding adjustment that have been shown to perform well in small, simple nonrandomized studies are applicable to the large, complex pharmacoepidemiologic studies created from secondary healthcare data. Ordinary simulation approaches for evaluating the performance of statistical methods do not capture important features of healthcare claims. A statistical framework for creating replicated simulation datasets from an empirical cohort study in electronic healthcare claims data is developed and validated. The approach relies on resampling from the observed covariate and exposure data without modification in all simulated datasets to preserve the associations among these variables. Repeated outcomes are simulated using a true treatment effect of the investigator’s choice and the baseline hazard function estimated from the empirical data. As an example, this framework is applied to a study of high versus low-intensity statin use and cardiovascular outcomes. Simulated data is based on real data drawn from Medicare Parts A and B linked with a prescription drug insurance claims database maintained by Caremark. Properties of the data simulated using this framework are compared with the empirical data on which the simulations were based. In addition, the simulated datasets are used to compare variable selection strategies for confounder adjustment via the propensity score, including high-dimensional approaches that could not be evaluated with ordinary simulation methods. The simulated datasets are found to closely resemble the observed complex data structure but have the advantage of an investigator-specified exposure effect.
    Computational Statistics & Data Analysis 04/2014; 72:219–226. DOI:10.1016/j.csda.2013.10.018 · 1.40 Impact Factor
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    ABSTRACT: Medication copayments can influence patient choices. We evaluated 2 copayment policies implemented by Massachusetts Medicaid incentivizing the use of selected generic medications. In 2009, Massachusetts Medicaid copayments were $1 for generics and $3 for brands. On February 1, 2009, copayments for generic antihypertensives, antihyperlipidemics, and hypoglycemics (target medications) remained at $1, whereas copayments for all nontarget generics increased to $2 (policy #1) and $3 on July 1, 2010 (policy #2). Using state-level, aggregate prescription data, we developed interrupted time-series models with controls to evaluate the impact of these policies on use of target generics, target brands, and nontarget essential medications (defined as medications required for ongoing treatment of serious medical conditions). After policy #1, target generic use increased by 0.93% (P<0.001) with a subsequent quarterly slope decrease of -0.16% (P<0.01); policy #2 led to a slope increase of 0.20% (P<0.01) for target generics; increase in target generics attributable to policy changes was 28,000 prescriptions per year. Neither policy affected target brand use. For nontarget essential generics, there was a -0.27% (P<0.001) quarterly slope decrease after policy #1 and a 0.32% (P<0.01) slope increase after policy #2 with total decrease attributable to policy changes of 127,300 prescriptions per year. For nontarget essential brands, there was a level increase of 0.91% (P<0.001) after policy #1 with increased use attributable to policy changes of 98,300 prescriptions per year. Two copayment policies designed to encourage use of selected generic medications modestly increased their use; however, there was a shift in other essential medications from generics to brands, which could increase Medicaid costs. When adjusting copayments, careful consideration must be given to unintended consequences of specific policy structures.
    Medical care 03/2014; 52(5). DOI:10.1097/MLR.0000000000000119 · 3.23 Impact Factor
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    ABSTRACT: Statin use has increased substantially in North America and Europe, with resultant reductions in cardiovascular mortality. However, little is known about statin use in lower-income countries. India is of interest because of its burden of cardiovascular disease, the unique nature of its prescription drug market, and the growing globalization of drug sales. We conducted an observational study using IMS Health data for the period February 2006-January 2010. During the period, monthly statin prescriptions increased from 45.8 to 84.1 per 1,000 patients with coronary heart disease-an increase of 0.80 prescriptions per month. The proportion of the Indian population receiving a defined daily statin dose increased from 3.35 percent to 7.78 percent. Nevertheless, only a fraction of those eligible for a statin appeared to receive the therapy, even though there were 259 distinct statin products available to Indian consumers in January 2010. Low rates of statin use in India may reflect problems with access to health care, affordability, underdiagnosis, and cultural beliefs. Because of the growing burden of cardiovascular disease in lower-income countries such as India, there is an urgent need to increase statin use and ensure access to safe products whose use is based on evidence. Policies are needed to expand insurance, increase medications' affordability, educate physicians and patients, and improve regulatory oversight.
    Health Affairs 02/2014; 33(2):273-82. DOI:10.1377/hlthaff.2013.0388 · 4.97 Impact Factor
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    ABSTRACT: Type 2 diabetes (T2DM) diagnoses are skyrocketing, making treatment of this disease an increasing focus of primary care visits. Guidelines recommend insulin intensification over time to achieve HbA1c targets. We conducted a systematic review regarding patterns and trends of insulin intensification and barriers to intensification. Providers across primary and specialty care settings often did not intensify insulin regimens despite patients' clinical status. Even among progressed patients, HbA1c values remained high. The paucity of available studies prevented a comprehensive understanding of patterns and trends in insulin intensification. Such information is needed to assess the quality of pharmacologic care for patients with T2DM.
    11/2013; 8(2). DOI:10.1016/j.pcd.2013.10.008
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    ABSTRACT: Many patients with type 2 diabetes eventually require insulin, yet little is known about the patterns and quality of pharmacologic care received following insulin initiation. Guidelines from the American Diabetes Association and the European Association for the Study of Diabetes recommend that insulin secretagogues such as sulfonylureas be discontinued at the time of insulin initiation to reduce the risk of hypoglycemia, and that treatment be intensified if HbA1c levels remain above-target 3 months after insulin initiation. To describe pharmacologic treatment patterns over time among adults initiating insulin and/or intensifying insulin treatment. Observational study. A large commercially insured population of adult patients without recorded type 1 diabetes who initiated insulin. We evaluated changes in non-insulin antidiabetic medication use during the 120 days immediately following insulin initiation, rates of increase in insulin dose and/or dosing frequency during the 270 days following an insulin initiation treatment period of 90 days, and rates of insulin discontinuation. Seven thousand, nine hundred and thirty-two patients initiated insulin during 2003-2008, with the majority (61 %) initiating basal insulin only. Metformin (55 %), sulfonylureas (39 %), and thiazolidinediones (30 %) were commonly used prior to insulin initiation. Metformin was continued by 64 % of patients following mixed or mealtime insulin initiation; the continuation rate was nearly as high for sulfonylureas (58 %). Insulin dose and/or dosing frequency increased among 22.9 % of patients. Insulin was discontinued by 27 % of patients. We found evidence of substantial departures from guideline-recommended pharmacotherapy. Insulin secretagogues were frequently co-prescribed with insulin. The majority of patients had no evidence of treatment intensification following insulin initiation, although this finding is difficult to interpret without HbA1c levels. While each patient's care should be individualized, our data suggest that the quality of care following insulin initiation can be improved.
    Journal of General Internal Medicine 10/2013; 29(2). DOI:10.1007/s11606-013-2643-6 · 3.42 Impact Factor

Publication Stats

792 Citations
295.18 Total Impact Points


  • 2007–2014
    • Brigham and Women's Hospital
      • • Division of Pharmacoepidemiology and Pharmacoeconomics
      • • Department of Medicine
      Boston, Massachusetts, United States
  • 2006–2014
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2005–2014
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States
  • 2009
    • Partners HealthCare
      Boston, Massachusetts, United States
  • 2008
    • Dana-Farber Cancer Institute
      Boston, Massachusetts, United States