Microsoft PowerPoint - 高雅慧.pptx

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齐序湛
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1 全民健康保險研究資料庫開發與應用研討會 Improving medical care from observing clinical practice 高雅慧國立成功大學醫學院臨床藥學與藥物科技研究所 2011/09/08 Improving Health Outcome Rational drug use Right drug to the right patient in the right dose at the right time with the right route Sub Optimal prescribing Overuse, underuse or misuse Prescribing for prevention Prophylactic use of antibiotics to prevent infection Prophylactic use of anticoagulant to prevent stroke in atrial fibrillation Prophylactic use of anticoagulant to prevent venous thromboembolism (VTE)

Annual incidence in Caucasian: 71 117 cases per 100 000 persons < 5 cases per 100 000 in

on the epidemiology of venous thromboembolism (VTE) in Asian populations, including

2 Annual incidence in Caucasian: cases per persons < 5 cases per in young people (< 15 years) 500 cases per at the age of 80 years Little information on the epidemiology of venous thromboembolism (VTE) in Asian populations, including Taiwan. The incidence and recurrence rate of VTE may be lower in Taiwanese than in Caucasians.

3 Methods -1 Study Design Cohort: to estimate incidence and recurrence rate Nested case control: to identify potential VTE risk factors of recurrence Inclusion of VTE cohort Discharge diagnosis with DVT or PE (ICD 9 CM code: 453.*, 415.1) between 1 Jan ~ 31 Dec Treated with sc or iv anticoagulation therapy or surgical thrombectomy, and continued oral warfarin therapy after discharge Received peripheral venous duplex or/and chest computed tomography examinations during the hospitalization The length of stay must have been at least 3 days Endpoint: recurrence of VTE, censored at 31 Dec run-in Nested case control study 583 cases 2993 controls 5347 Analyzed for VTE incidence 328 excluded 62 without admission 67 admission length below 3 days 26 incomplete data 173 no CT or duplex images 230 excluded due to In-hospital mor tality Follow-up 5117 analyzed for VTE cumulative rate and 585 recurrent VTE cases

4 Methods -2 Comorbidities Retrieved from both the inpatient and outpatient claims databases for 1 year before and during the index VTE hospitalization Potential risk factors Prior VTE, pregnancy, major surgery, major extremity trauma, major spine trauma and hormone therapy Documented within 3 months preceding the recurrent VTE event or the censored date Matched control in 4 : 1 Admission year, age (±5), gender, follow up duration Crude incidence of VTE Taiwan: 15.9/100,000 Caucasians: /

5 Cumulative rates of VTE recurrence Similar with Caucasians: 6 10% at 6 months 7 13% at 1 year Identifying Risk Factors

6 Limitations Potential disease misclassification bias The true incidence of VTE in Taiwan may be underestimated Patients with PE die suddenly without accurate diagnosis Patients have asymptomatic VTE No information about travel, smoking history and body mass index Effectiveness of Treatment

$Background Patients with prior osteoporotic fractures 2 X higher risk of future fractures Secondary prevention of osteoporotic fractures standard practice worldwide Bisphosphonates the primary$

7 Background Patients with prior osteoporotic fractures 2 X higher risk of future fractures Secondary prevention of osteoporotic fractures standard practice worldwide Bisphosphonates the primary pharmacological therapy for secondary prevention of osteoporotic hip fractures Long term compliance is necessary to ensure optimal therapeutic efficacy <50% of the patients were compliant during the first year after initiation of treatment Method: Cohort Inclusion Excluded fractures of highimpact trauma

$Covariates Patient demographic information and index osteoporotic fractures at treatment initiation$ $non vertebral fractures except hip fracture Comorbid conditions that could increase fracture risk:$ arthritis Co medications: antiepileptics, β blockers, benzodiazepines, glucocorticoids, hormone

arthritis Co medications: antiepileptics, β blockers, benzodiazepines, glucocorticoids, hormone

8 Covariates Patient demographic information and index osteoporotic fractures at treatment initiation Other covariates included Kyphosis, history of any other fracture: radius/ulna, humerus, and other non vertebral fractures except hip fracture Comorbid conditions that could increase fracture risk: Alzheimer's disease, asthma, diabetes mellitus, ischemic stroke, history of falls, and rheumatic arthritis Co medications: antiepileptics, β blockers, benzodiazepines, glucocorticoids, hormone replacement therapy, COX 2 agents, selective serotonin reuptake inhibitors, thyroid drugs, and sleep/hypnotic agents

Discussion - Limitations The inherent weakness of an observational study and the

confounding by lifestyle Body mass index, smoking status, and caffeine intake

inpatient, outpatient, and contracted pharmacies Patients who received HRT may have

9 Discussion - Limitations The inherent weakness of an observational study and the administrative database residual confounders Lack of socioeconomic covariates confounding by lifestyle Body mass index, smoking status, and caffeine intake Misclassification of compliance Comprehensively captured prescription claims from inpatient, outpatient, and contracted pharmacies Patients who received HRT may have benefited from its protective effect Consistent results were found even after excluding data for those kinds of patients

10 Challenges in Medical Care Chronic illness Multiple drug use Guidelines Multiple medical consultations Unmet needs

11 Thank you and Happy Moon Festival

ADR ADR ADR : 2

ADR ADR ADR : 2 8 2000 10 2001 5 ADR ADR 415 ADR44 ADR 10.6% 2661 ADR105 ADR 3.9% P