Effectiveness of national provider prescription of PPI gastroprotection among elderly NSAID users
Effectiveness of national provider prescription of PPI gastroprotection among elderly NSAID users
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DOI：
10.1111/j.1572-0241.2007.01595.x
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发表时间：
2008-02-01
影响因子：
9.8
通讯作者：
Smalley, Walter
中科院分区：
文献类型：
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作者：
Abraham, Neena S.;Hartman, Christine;Smalley, Walter
目的：我们的目的是量化提供者依从性对 NSAID 相关上消化道事件 (UGIE) 风险的影响。 方法：我们从国家药房记录中确定了在任何退伍军人事务部 (VA) 机构（2000 年 1 月 1 日至 12 月 31 日， 2002）。处方填写数据以纵向方式与 VA 住院患者、门诊患者和死亡档案关联，并与 Medicare 的人口统计、住院患者、门诊患者和提供者数据合并。每个人日的随访均评估单独 NSAID、NSAID+质子泵抑制剂 (PPI)、考昔布或考昔布+PPI 的暴露情况。 UGIE 是使用我们发布的、经过验证的算法定义的。计算暴露后 365 天的未调整发病密度比。我们使用 Cox 比例风险模型评估 UGIE 风险，同时调整人口统计学、UGIE 风险因素、合并症、处方通道（即倾向评分）、地理位置和多个时间依赖性药理学协变量，包括阿司匹林、类固醇、抗凝剂、抗血小板、他汀类药物和选择性血清素再摄取抑制剂。 结果：在我们的 481,980 名队列中（97.8% 为男性，85.3% 为白人，平均年龄 73.9，标准差 5.6），为 19.8% 制定了更安全的策略，在 220,662 人年的随访中发生了 2,753 例 UGIE。当调整处方通道、混杂因素和与效果修改相关的 PPI 时，单独使用 NSAID 时 UGIE 的风险为 1.8（95% 置信区间 [CI] 1.6-2.0），单独使用昔布为 1.8（95% CI 1.5-2.0），NSAID+PPI 为 1.1（95% CI 0.7-4.6），以及 1.1 (0.6-5.2) 昔布+PPI。当根据 PPI 上花费的累积时间百分比调整分析时，UGIE 风险从 0-20% 的时间使用 PPI 时的 HR 3.0 (95% CI 2.6-3.7) 降至 80-100% 的时间使用 PPI 时的 1.1 (95% CI 1.0-1.3)。结论：提供者遵守更安全的 NSAID 处方策略与更少的风险相关。老年人中的UGIE。坚持策略可以降低但不能消除 NSAID 相关 UGIE 的风险。
OBJECTIVES: Our aim was to quantify the effect of provider adherence on the risk of NSAID-related upper gastrointestinal events (UGIE).METHODS: We identified from national pharmacy records veterans >= 65 yr prescribed an NSAID, a coxib, or salicylate (> 325 mg/day) at any Veterans Affairs (VA) facility (January 1, 2000 to December 31, 2002). Prescription fill data were linked in longitudinal fashion to VA inpatient, outpatient, and death files and merged with demographic, inpatient, outpatient, and provider data from Medicare. Each person-day of follow-up was assessed for exposure to NSAID alone, NSAID+proton pump inhibitor (PPI), coxib, or coxib+PPI. UGIE was defined using our published, validated algorithm. Unadjusted incidence density ratios were calculated for the 365 days following exposure. We assessed risk of UGIE using Cox proportional hazards models, while adjusting for demographics, UGIE risk factors, comorbidity, prescription channeling (i.e., propensity score), geographic location, and multiple time-dependent pharmacological covariates, including aspirin, steroids, anticoagulants, antiplatelets, statins, and selective serotonin reuptake inhibitors.RESULTS: In our cohort of 481,980 (97.8% male, 85.3% white, mean age 73.9, standard deviation 5.6), a safer strategy was prescribed for 19.8%, and 2,753 UGIE occurred in 220,662 person-years of follow-up. When adjusted for prescription channeling, confounders, and effect modification-associated PPI, risk of UGIE was 1.8 (95% confidence interval [CI] 1.6-2.0) on NSAID alone, :1.8 (95% CI 1.5-2.0) on coxib alone, 1.1 (95% CI 0.7-4.6) on NSAID+PPI, and 1.1 (0.6-5.2) on coxib+PPI. When the analysis was adjusted for cumulative percent time spent on a PPI, risk of UGIE decreased from HR 3.0 (95% CI 2.6-3.7) when a PPI was prescribed 0-20% of the time to 1.1 (95% CI 1.0-1.3) when a PPI was prescribed 80-100% of the time.CONCLUSIONS: Provider adherence to safer NSAID prescribing strategies is associated with fewer UGIE among the elderly. An adherent strategy lowers, but does not eliminate, risk of an NSAID-related UGIE.