1000-person Years Research Articles

Outcomes following feeding gastrostomy (FG) insertion in patients with learning disability: a retrospective cohort study using the health improvement network (THIN) database

ObjectivesTo measure the rates of lower respiratory tract infection (LRTI) and mortality following feeding gastrostomy (FG) placement in patients with learning disability (LD). Following this to compare these rates between...

Combined effect of work stress and impaired sleep on coronary and cardiovascular mortality in hypertensive workers: The MONICA/KORA cohort study.

Although work stress and impaired sleep are established risk factors for cardiovascular disease (CVD) among healthy individuals, their impact on hypertensive workers is largely unknown. Prospective cohort study design. Hypertensive workers (N = 1959), derived from the population-based MONICA/KORA study in Southern Germany, who were free of any cardiovascular disease and diabetes were interviewed at baseline for work stress (high demand plus low control) and impaired sleep (difficulties falling asleep and/or maintaining sleep). Hazard ratios and 95% confidence intervals (CIs) were estimated by multivariate Cox proportional hazards models with adjustment for relevant covariates. During a mean follow-up of 17.8 years covering 34,900 person-years, 134 fatal CVD and 73 coronary heart disease (CHD) events were observed. In comparison to participants with low work stress and non-impaired sleep, participants with work stress (hazard ratio (HR) 1.56, 95% CI 0.81-2.98), or impaired sleep (HR 1.76, 95% CI 0.96-3.22) had an increased risk of CVD, while participants with both work stress and impaired sleep had the highest risk of CVD mortality (HR 2.94, 95% CI 1.18-7.33). Participants with both risk conditions had an absolute CVD mortality risk of 7.13 cases per 1000 person-years in comparison to 3.05 cases per 1000-person years in the reference group. Similar risk patterns were found for CHD mortality. Our findings add a new piece of evidence that work stress together with impaired sleep increase risk of coronary and cardiovascular mortality in hypertensive workers.

The Clinical and Economic Effects of Switching Medicare Beneficiaries with Type 2 Diabetes from Analog to Human Insulin

Objective: To evaluate the clinical and economic effects of a managed care organization’s conversion program switching Medicare beneficiaries with type 2 diabetes mellitus from analog to human insulin. Methods: A consecutive sample of 14,635 participants who filled insulin prescriptions between January 2014 and December 2016 were identified from a Medicare Advantage and prescription drug plan operating in 4 U.S. states (CA, AZ, NV, VA). Outcomes were mean hemoglobin A1c (%), rates of severe hypoglycemia or hyperglycemia events and risk of reaching the Part D coverage gap. Data were analyzed using interrupted time series and segmented regression with cut points at the beginning and end of 2015. Results: 14,635 members (mean age=72.5) filled 221,866 insulin prescriptions. Insulin conversion decreased the proportion of scripts filled by analog insulins from 90% to 30%. The baseline mean hemoglobin A1c was 8.46% and decreased at a rate of -0.02% per month during 2014. The beginning of the conversion program in 2015 was associated with a level change of +0.14% (p<0.01) and a slope change of 0.02% (p<0.01). The baseline rate of severe hypoglycemia was 4.21 per 1000-person years (py) and increased at a rate of 0.36/1000py during 2014. The baseline rate of severe hyperglycemia was 22.33/1000py and increased at a rate of 0.30/1000py. For both hypoglycemia and hyperglycemia, the level and slope changes in the 12-month intervention and post-intervention segments were not statistically significant. The intervention reduced the risk of reaching the coverage gap by 55% (HR 0.45, nominal 95% CI: 0.43-0.48, p<0.001). Conclusions: Switching Medicare beneficiaries with diabetes from analog to human insulin did not change the rates of hospitalization for hypoglycemia or hyperglycemia, slightly increased mean A1c, and reduced the risk of reaching the Part D coverage gap. Disclosure J. Luo: Consultant; Self; Alosa Health, Inc.. N.F. Khan: None. T. Manetti: None. J.J. Rose: None. A. Kaloghlian: None. B. Gadhe: None. S.H. Jain: Employee; Self; CareMore Health. J. Gagne: Research Support; Self; Eli Lilly and Company, Novartis Pharmaceuticals Corporation. A. Kesselheim: None.

Predictors of falls and fractures leading to hospitalization in people with schizophrenia spectrum disorder: A large representative cohort study

AimTo investigate predictors of falls/fractures leading to hospitalisation in people with schizophrenia-spectrum disorders. MethodsA historical cohort of people with schizophrenia-spectrum disorders (ICD F20-29) from 01/2006–12/2012 was assembled using data from the South London and Maudsley NHS Biomedical Research Centre Case Register. Falls/fractures were ascertained from a linkage to national hospitalisation data. Separate multivariate Cox regression analyses were employed to identify predictors of falls and fractures. ResultsOf 11,567 people with schizophrenia-spectrum disorders (mean age 42.6 years, 43% female), 579 (incidence rate 12.79 per 1000 person-years) and 528 (11.65 per 1000 person-years) had at least one reported hospital admission due to a fall or fracture respectively and 822 patients had at least either a recorded fall or a fracture during this period (i.e. 7.1% of sample). Overall, 6.69 and 10.74 years of inpatient hospital stay per 1000-person years of follow-up occurred due to a fall and fracture respectively. 14(0.12%) and 28(0.24%) died due to a fall and fracture respectively. In Multivariable analysis, increasing age, white ethnicity, analgesics, cardiovascular disease, hypertension, diseases of the genitourinary system, visual disturbance and syncope were significant risk factor for both falls and fractures. A previous fracture (HR 2.05, 95% CI 1.53–2.73) and osteoporosis (HR 6.79, 95% CI 4.71–9.78) were strong risk factors for consequent fractures. ConclusionComorbid physical health conditions and analgesic medication prescription were associated with higher risk of falls and fractures. Osteoporosis and previous fracture were strong predictors for subsequent fractures. Interventions targeting bone health and falls/fractures need to be developed and evaluated in these populations.

Abstract MP28: Cardiorespiratory Fitness Attenuates Risk of Cancer in Obese

Introduction: An association exists between being overweight and obese and an increased risk of certain types of cancers. In recent years even though there has been a decline in cancer rates in the general population, cancer rates in the overweight and obese have increased. Specific factors that may protect obese individuals against cancer have not been identified. Hypothesis: We assessed the hypothesis that improved cardiorespiratory fitness (CRF) will attenuate the risk of obesity associated cancer. Methods: We studied a total of 6,830 obese Veterans aged 56.2 ±10.4 years, of whom 67.2% (6471 of 6830) were African-American, 94.7% (4581 of 6830) males, 57.4% (3921 of 6830 smokers, 94.4% (6439 of 6830) with a past history of alcohol or drug use and 60.0% (4100 of 6830) were on statins. Obesity was defined as body mass index (BMI) ≥30.0 kg/m 2 and mean BMI for the cohort was 34.4±4.2 kg/m 2 . None of the patients had a diagnosis of cancer at baseline. Participants completed a maximal exercise tolerance test (ETT) as a part of clinical evaluation at either the Department of Veterans Affairs Medical Centers in Washington, DC or Palo Alto, CA and metabolic equivalents (METs) were estimated based on peak exercise time and treadmill grade. Based on these METs achieved on ETT, patients were divided into 4 age-based CRF categories (mean ± SD): least-fit (4.8±1.3 METs; n=1978), low-fit (6.8±1.2 METs; n=2210), moderately-fit (8.3±1.2 METs; n=1674), and high-fit (11.1±2.2 METs; n=968). Multivariable Cox models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for incidence of cancer across these age-based fitness categories for the entire obese cohort, using least-fit as the reference group. The models were adjusted for age, race, gender, smoking, alcohol and drug use. Results: During a median follow-up of 11.1 years, 9.5% (646 of 6830) of the cohort developed cancer with an event rate of 8.0 per 1000-person years of follow-up. An inverse and graded association was observed between CRF and cancer rates. The adjusted risk of cancer was 15% lower for each 1-MET increase in exercise capacity (HR=0.85; CI: 0.82-0.89). When incidence rates were assessed across CRF categories using the least fit as the referent group, the incidence of cancer was 31% lower in the moderately-fit group (HR=0.69; 95% CI: 0.56-0.86) and 81% lower in the high-fit group (HR=0.19; 95% CI: 0.12-0.29). Conclusions: CRF was inversely associated with rate of cancer in obese Veterans. For each 1-MET increase in fitness, cancer rate was 15% lower.

849: The association between Maternal GroupB Streptococcus colonization and offspring Gastro-Intestinal morbidity

Maternal Group B Streptococcus (GBS) colonization is associated with peripartum complications. We sought to evaluate the association between maternal GBS colonization and long-term gastrointestinal (GI) morbidity in the offspring. A population based retrospective cohort study was conducted in a tertiary medical center, serving a population of one million inhabitants. The risk for pediatric GI morbidity of offspring (up to the age of 18 years) was compared among two study groups: exposed and unexposed to maternal rectovaginal GBS colonized mothers, based on perinatal hospitalization databases. All singleton vaginal deliveries occurring between the years 1991-2014 were included. Offspring with congenital malformations were excluded. GI morbidities were based on a pre defined set of ICD-9 codes, as recorded in the hospital computerized files. Kaplan Meier survival curves were used to compare the cumulative risks among the two study groups, and Cox multivariable survival models were used to adjusted for confounding variables. During the study period, 195,457 newborns met the inclusion criteria; 4820 parturient had a proven diagnosis of GBS colonization. Selected categories of GI morbidity are presented in the Table. Total GI morbidity rate was higher in the GBS positive group as compared with the comparison group (7.69 vs. 5.03/ 1000-person years; Table). Offspring of GBS positive mothers had significantly higher rates of gastroduodenal diseases (0.69 vs. 0.51/1000-person years, p=0.005; Table) and of inflammatory bowel diseases (IBD), 3.03 vs. 1.26/1000 person years, p=0.023). The Kaplan-Meier survival curve demonstrated GBS positive offspring to have a significantly higher cumulative incidence of total GI morbidity (log rank, p=0.002; Figure). The association between maternal GBS and offspring GI morbidity remained significant in the Cox model, which adjusted for maternal age, diabetes, hypertensive disorders and gestational age (adjusted HR=1.2; 95% CI 1.1- 1.2). Maternal GBS colonization is an independent risk factor for long-term GI morbidity in the offspring, and specifically for gastroduodenal diseases and IBD. The exact mechanism leading to these findings, whether fetal microbiome changes or immunological alterations due to peripartum antibiotic exposure, awaits further investigations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Update on the Effect of Region-Wide Incorporation of an Algorithm Based on 2012 International Consensus Guideline on the Practice Pattern for the Management of Pancreatic Cystic Neoplasms in an Integrated Health System: 2017 Presidential Poster Award

Introduction: Pancreatic cystic neoplasms (PCN) have become a challenging entity for primary/acute care physicians, gastroenterologists, radiologists and surgeons. International consensus guideline was developed to assist in the management of PCNs. Based on the 2012 revision, Kaiser Permanente Southern California (KPSC) published an algorithm in October 2013, including a summary of recommendations in radiology reports. We examined the practice pattern in KPSC, i.e. gastroenterology (GI)/surgery referrals and endoscopic ultrasound (EUS), for PCNs after the region-wide dissemination of this algorithm. Methods: Retrospective review was performed; patients with PCN diagnosis given between April 2012 and April 2015 (18 months before and after the publication of the algorithm) in KPSC (integrated health system with 15 hospitals and 202 medical offices in Southern California) were identified. Results: 2694 (1087 pre- and 1607 post-algorithm) received a new diagnosis of PCN in the study period. There was no difference in the mean cyst size (pre- 19.2 mm vs post-18.6 mm, P=0.38). A smaller percentage of PCNs resulted in EUS after the implementation of the algorithm (pre- 43.8% vs post- 34.9%, P<0.0001). A smaller proportion of patients were referred for GI (pre- 62.84% vs post- 53.29%, P<0.0001) and surgery consultations (pre- 21.53% vs post- 15.71%, P=0.0003) for PCN after the implementation. There was no significant change in operations for PCNs. Cost of care was reduced after the implementation by 20%, 16%, and 27% for EUS, GI, and surgery consultations, respectively (table 1). All calculations were based on expected cost for 1,000 patients (KPSC has approximately 1,000 new PCN cases each year). The incidence rate of pancreatic cancer after diagnosis of PCN was 4.79 per 1000-person years (95% CI: 2.93, 7.43) for pre-algorithm, 5.98 per 1000-person years (95% CI: 3.71, 9.17) for post-algorithm, and 4.95 per 1000-person years for combined (95% CI: 4.95, 9.46). Conclusion: In current healthcare climate, there is increased need to optimize resource utilization. Dissemination of an algorithm for PCN management in an integrated health system resulted in fewer EUS and GI/surgery referrals, possibly due to increasing the confidence level of physicians ordering imaging studies. This translated to cost saving of 20%, 16%, and 27% for EUS, GI, and surgical consultations, respectively. Incidence rate of pancreatic cancer after cyst diagnosis was 4.95 per 1000-person years in this population.Table: Table. Cost of care for pancreatic cystic neoplasms pre- and post-algorithm implementation

Race and Sex Differences in the Incidence and Prognostic Significance of Silent Myocardial Infarction in the Atherosclerosis Risk in Communities (ARIC) Study.

Race and sex differences in silent myocardial infarction (SMI) are not well established. The analysis included 9498 participants from the Atherosclerosis Risk in Communities (ARIC) study who were free of cardiovascular disease at baseline (visit 1, 1987-1989). Incident SMI was defined as ECG evidence of MI without clinically documented MI (CMI) after the baseline until ARIC visit 4 (1996-1998). Coronary heart disease and all-cause deaths were ascertained starting from ARIC visit 4 until 2010. During a median follow-up of 8.9 years, 317 participants (3.3%) developed SMI and 386 (4.1%) developed CMI. The incidence rates of both SMI and CMI were higher in men (5.08 and 7.96 per 1000-person years, respectively) than in women (2.93 and 2.25 per 1000-person years, respectively; P<0.0001 for both). Blacks had a nonsignificantly higher rate of SMI than whites (4.45 versus 3.69 per 1000-person years; P=0.217), but whites had higher rate of CMI than blacks (5.04 versus 3.24 per 1000-person years; P=0.002). SMI and CMI (compared with no MI) were associated with increased risk of coronary heart disease death (hazard ratio, 3.06 [95% confidence interval, 1.88-4.99] and 4.74 [95% confidence interval, 3.26-6.90], respectively) and all-cause mortality (hazard ratio, 1.34 [95% confidence interval, 1.09-1.65] and 1.55 [95% confidence interval, 1.30-1.85], respectively). However, SMI and CMI were associated with increased mortality among both men and women, with potentially greater increased risk among women (interaction P=0.089 and 0.051, respectively). No significant interactions by race were detected. SMI represents >45% of incident MIs and is associated with poor prognosis. Race and sex differences in the incidence and prognostic significance of SMI exist that may warrant considering SMI in personalized assessments of coronary heart disease risk.

ASSOCIATION BETWEEN PRIMARY PREVENTION INDICATORS AND REGIONAL VARIATIONS IN THE INCIDENCE OF MAJOR CARDIOVASCULAR EVENTS: THE CANHEART STUDY

The burden of cardiovascular disease varies across Canada but it is unknown whether variations in health system performance are associated with these differences. As part of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) ‘big data’ initiative, we studied the association between several modifiable primary prevention indicators and the incidence of major cardiovascular events across Ontario, Canada. We constructed a population-based cohort of 5.9 million primary prevention patients aged 40 to 105 in Ontario as of January 1, 2008, by linking together information from multiple population-based databases (health survey, physician billing, hospital discharge, electronic medical record, laboratory, and vital statistics; see www.canheart.ca). A set of primary prevention indicators (family doctor visits, risk factor screening, prevalence, management, and control) and the 3-year age and sex-standardized incidence rate of major cardiovascular disease events (i.e. myocardial infarction, stroke, cardiovascular death) were measured between January 1, 2008 and December 31, 2010 across Ontario’s 14 health service regions, known as Local Health Integration Networks (LHINs). Pearson correlation coefficients and p-values were calculated for the association of each indicator with the incidence of CVD events. The age and sex-standardized incidence rate of major cardiovascular events varied nearly 2-fold from a low of 4.3 (95% CI 4.2 to 4.4) events per 1000-person years in the Central LHIN to a high of 7.5 events per 1000 person-years in the North East (95% CI 7.3 to 7.7) and North West LHINs (95% CI 7.2 to 7.8).(Table and Figure) Residents living in lower CVD risk regions had a higher mean number of family doctor visits/year (p=0.004), a greater likelihood of receiving lipid and diabetes screening as recommended in Canadian practice guidelines (p<0.001), and higher blood pressure control rates among hypertensive patients (p=0.005). Higher smoking rates were found in regions with higher CVD event rates (p<0.001) but rates of formal smoking cessation counselling provided by family doctors were not associated with CVD event rates (p=0.261). The proportion of patients aged 65 and over prescribed statins (p=0.341) and glycemic control rates (HbA1c ≤7%) among diabetics (p=0.348) were not associated with regional variations in CVD event rates. Residents of Ontario’s health regions with the lowest incidence of CVD events had more family doctors visits each year, were more likely to be screened for dyslipidemia and diabetes, and had more hypertensive patients with controlled blood pressures. Opportunities exist across Ontario to further improve the prevention of CVD events.View Large Image Figure ViewerDownload (PPT)

Risk of deaths, AIDS-defining and non-AIDS defining events among Ghanaians on long-term combination antiretroviral therapy.

Combination antiretroviral therapy (cART) has been widely available in Ghana since 2004. The aim of this cohort study was to assess the incidences of death, AIDS-defining events and non-AIDS defining events and associated risk factors amongst patients initiating cART in a large treatment centre. Clinical and laboratory data were extracted from clinic and hospital case notes for patients initiating cART between 2004 and 2010 and clinical events graded according to recognised definitions for AIDS, non-AIDS events (NADE) and death, with additional events not included in such definitions such as malaria also included. The cumulative incidence of events was calculated using Kaplan Meier analysis, and association of risk factors with events by Cox proportional hazards regression. Data were closed for analysis on 31st December, 2011 after a median follow-up of 30 months (range, 0–90 months). Amongst 4,039 patients starting cART at a median CD4 count of 133 cells/mm3, there were 324 (8%) confirmed deaths, with an event rate of 28.83 (95% CI 25.78–32.15) deaths per 1000-person follow-up years; the commonest established causes were pulmonary TB and gastroenteritis. There were 681 AIDS-defining events (60.60 [56.14–65.33] per 1000 person years) with pulmonary TB and chronic diarrhoea being the most frequent causes. Forty-one NADEs were recorded (3.64 [2.61–4.95] per 1000 person years), of which hepatic and cardiovascular events were most common. Other common events recorded outside these definitions included malaria (746 events) and respiratory tract infections (666 events). Overall 24% of patients were lost-to-follow-up. Alongside expected risk factors, stavudine use was associated with AIDS [adjusted HR of 1.08 (0.90–1.30)] and death (adjusted HR of 1.60 [1.21–2.11]). Whilst frequency of AIDS and deaths in this cohort were similar to those described in other sub-Saharan African cohorts, rates of NADEs were lower and far exceeded by events such as malaria and respiratory tract infections.

AB0279 Incidence of diabetes and effect of etanercept and adalimumab on hba1c over 1 year: data from a randomised trial in patients with rheumatoid arthritis

BackgroundInflammation such as that which occurs in rheumatoid arthritis (RA) is associated with insulin resistance and risk of diabetes mellitus (DM). Some DMARDs including TNF inhibitors (TNFi) may improve insulin...

Examining a Bidirectional Association Between Depressive Symptoms and Diabetes

Depressive symptoms are associated with development of type 2 diabetes, but it is unclear whether type 2 diabetes is a risk factor for elevated depressive symptoms. To examine the bidirectional association between depressive symptoms and type 2 diabetes. Multi-Ethnic Study of Atherosclerosis, a longitudinal, ethnically diverse cohort study of US men and women aged 45 to 84 years enrolled in 2000-2002 and followed up until 2004-2005. Elevated depressive symptoms defined by Center for Epidemiologic Studies Depression Scale (CES-D) score of 16 or higher, use of antidepressant medications, or both. The CES-D score was also modeled continuously. Participants were categorized as normal fasting glucose (< 100 mg/dL), impaired fasting glucose (100-125 mg/dL), or type 2 diabetes (> or = 126 mg/dL or receiving treatment). Analysis 1 included 5201 participants without type 2 diabetes at baseline and estimated the relative hazard of incident type 2 diabetes over 3.2 years for those with and without depressive symptoms. Analysis 2 included 4847 participants without depressive symptoms at baseline and calculated the relative odds of developing depressive symptoms over 3.1 years for those with and without type 2 diabetes. In analysis 1, the incidence rate of type 2 diabetes was 22.0 and 16.6 per 1000 person-years for those with and without elevated depressive symptoms, respectively. The risk of incident type 2 diabetes was 1.10 times higher for each 5-unit increment in CES-D score (95% confidence interval [CI], 1.02-1.19) after adjustment for demographic factors and body mass index. This association persisted following adjustment for metabolic, inflammatory, socioeconomic, or lifestyle factors, although it was no longer statistically significant following adjustment for the latter (relative hazard, 1.08; 95% CI, 0.99-1.19). In analysis 2, the incidence rates of elevated depressive symptoms per 1000-person years were 36.8 for participants with normal fasting glucose; 27.9 for impaired fasting glucose; 31.2 for untreated type 2 diabetes, and 61.9 for treated type 2 diabetes. Compared with normal fasting glucose, the demographic-adjusted odds ratios of developing elevated depressive symptoms were 0.79 (95% CI, 0.63-0.99) for impaired fasting glucose, 0.75 (95% CI, 0.44-1.27) for untreated type 2 diabetes, and 1.54 (95% CI, 1.13-2.09) for treated type 2 diabetes. None of these associations with incident depressive symptoms were materially altered with adjustment for body mass index, socioeconomic and lifestyle factors, and comorbidities. Findings in both analyses were comparable across ethnic groups. A modest association of baseline depressive symptoms with incident type 2 diabetes existed that was partially explained by lifestyle factors. Impaired fasting glucose and untreated type 2 diabetes were inversely associated with incident depressive symptoms, whereas treated type 2 diabetes showed a positive association with depressive symptoms. These associations were not substantively affected by adjustment for potential confounding or mediating factors.