Publications

2013
Desai RJ, Williams CE, Greene SB, Pierson S, Caprio AJ, Hansen RA. Exploratory evaluation of medication classes most commonly involved in nursing home errors. J Am Med Dir Assoc 2013;14(6):403-8.Abstract
BACKGROUND: Medication errors may potentially pose significant risk of harmful outcomes in vulnerable nursing home residents. Current literature lacks data regarding the drug classes most frequently involved in errors in this population and their risk relative to underlying drug class utilization rates. OBJECTIVES: This study (1) describes the frequency and error characteristics for the drug classes most commonly involved in medication errors in nursing homes, and (2) examines the correlation between drug class utilization rates and their involvement in medication errors in nursing home residents. DESIGN: A cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2010 to 2011 was conducted. PARTICIPANTS: All nursing home residents in the state of North Carolina. MAIN MEASURES: The 10 drug classes most frequently involved in medication errors were identified. Characteristics and patient impact of these medication errors were further examined as frequencies and proportions within each drug class. Medication error data were combined with data from the 2004 National Nursing Home Survey to capture nationally representative estimates of medication use by drug class in nursing home patients. The correlation between medication utilization and error involvement was assessed. RESULTS: There were 32,176 individual medication errors reported to Medication Error Quality Initiative in years 2010-2011. The 10 drug classes most commonly involved in medication errors were analgesics (12.27%), anxiolytics/sedative/hypnotics (8.39%), antidiabetic agents (5.86%), anticoagulants (5.04%), anticonvulsants (4.05%), antidepressants (4.05%), laxatives (3.13%), ophthalmic preparations (2.77%), antipsychotics (2.47%), and diuretics (2.34%). The correlation between utilization and medication error involvement was not statistically significant (P value for spearman correlation coefficient = .88), suggesting certain drug classes are more likely to be involved in medication errors in nursing home patients regardless of the extent of their use. CONCLUSIONS: The drug classes frequently and disproportionately involved in errors in nursing homes include anxiolytics/sedatives/hypnotics, antidiabetic agents, anticoagulants, anticonvulsants, and ophthalmic preparations. Better understanding of the causes and prevention strategies to reduce these errors may improve nursing home patient safety.
2012
Desai RJ, Ashton CM, Deswal A, Morgan RO, Mehta HB, Chen H, Aparasu RR, Johnson ML. Comparative effectiveness of individual angiotensin receptor blockers on risk of mortality in patients with chronic heart failure. Pharmacoepidemiol Drug Saf 2012;21(3):233-40.Abstract
OBJECTIVE: There is little evidence on comparative effectiveness of individual angiotensin receptor blockers (ARBs) in patients with chronic heart failure (CHF). This study compared four ARBs in reducing risk of mortality in clinical practice. METHODS: A retrospective analysis was conducted on a national sample of patients diagnosed with CHF from 1 October 1996 to 30 September 2002 identified from Veterans Affairs electronic medical records, with supplemental clinical data obtained from chart review. After excluding patients with exposure to ARBs within the previous 6 months, four treatment groups were defined based on initial use of candesartan, valsartan, losartan, and irbesartan between the index date (1 October 2000) and the study end date (30 September 2002). Time to death was measured concurrently during that period. A marginal structural model controlled for sociodemographic factors, comorbidities, comedications, disease severity (left ventricular ejection fraction), and potential time-varying confounding affected by previous treatment (hospitalization). Propensity scores derived from a multinomial logistic regression were used as inverse probability of treatment weights in a generalized estimating equation to estimate causal effects. RESULTS: Among the 1536 patients identified on ARB therapy, irbesartan was most frequently used (55.21%), followed by losartan (21.74%), candesartan (15.23%), and valsartan (7.81%). When compared with losartan, after adjusting for time-varying hospitalization in marginal structural model, candesartan (OR = 0.79, 95%CI = 0.42-1.50), irbesartan (OR = 1.17, 95%CI = 0.72-1.90), and valsartan (OR =  0.98, 95%CI = 0.45-2.14) were found to have similar effectiveness in reducing mortality in CHF patients. CONCLUSION: Effectiveness of ARBs in reducing mortality is similar in patients with CHF in everyday clinical practice.
Desai RJ, Hansen RA, Rao JK, Wilkins TM, Harden EA, Yuen A, Jonas DE, Roubey R, Jonas B, Gartlehner G, Lux L, Donahue KE. Mixed treatment comparison of the treatment discontinuations of biologic disease-modifying antirheumatic drugs in adults with rheumatoid arthritis. Ann Pharmacother 2012;46(11):1491-505.Abstract
BACKGROUND: Introduction of biologic disease-modifying antirheumatic drugs (DMARDs) has considerably changed treatment options for rheumatoid arthritis (RA) over the past decade. Very little information is available on comparative discontinuation rates of the biologics. OBJECTIVE: To compare treatment discontinuations for 9 biologic DMARDs in adults with RA. METHODS: We searched electronic databases through May 2012 to retrieve randomized controlled trials (RCTs) of patients with RA that compared biologic DMARDs with placebo or another biologic DMARD. The primary outcome was treatment discontinuation during the blinded phase of the trials, measured as overall withdrawals, withdrawals resulting from lack of efficacy, and withdrawals resulting from adverse events. Random-effects meta-analysis estimated the effect size for individual agents, and adjusted indirect comparisons were made between biologics using mixed treatment comparisons (MTC) meta-analysis. RESULTS: Forty-four trials were included in the analysis. In comparison with placebo, biologics were less likely to be withdrawn because of lack of efficacy (OR 0.22, 95% CI 0.17 to 0.27) and more likely to be withdrawn because of an adverse event (OR 1.41, 95% CI 1.16 to 1.70). Based on the MTC, certolizumab had the most favorable overall withdrawal profile, followed by etanercept and rituximab. Certolizumab had lower relative withdrawal rates resulting from lack of efficacy than adalimumab, anakinra, and infliximab. Anakinra had higher relative withdrawal rates resulting from lack of efficacy than most other biologics. Certolizumab and infliximab had more, while etanercept had fewer, withdrawals because of adverse events than most other drugs. CONCLUSIONS: Based on MTC using data from RCTs, differences in discontinuation rates were observed, generally favoring certolizumab, etanercept, and rituximab over other biologic DMARDs. These potential differences need to be further explored in head-to-head trials or well-conducted observational studies.
2011
Desai RJ, Agarwal SJ, Aparasu RR. Drug use trends for arthritis and other rheumatic conditions and effect of patient's age on treatment choice. N C Med J 2011;72(6):432-8.Abstract
BACKGROUND: Little is known about the influence of the patient's age on selection of treatment for arthritis and other rheumatic conditions (AORCs). The aim of the present study was to examine drug use trends in patients with AORCs in ambulatory care and to study age-specific drug use. METHODS: Data from the National Ambulatory Medical Care Survey and the outpatient department component of the National Hospital Ambulatory Medical Care Survey were used to examine ambulatory visits for AORCs during 2001-2005. Use of nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics (narcotics and nonnarcotics), steroids, and disease-modifying antirheumatoid drugs (DMARDs) was measured as the proportion of visits that resulted in a prescription. Age-specific drug use trends were determined separately for adult (19-64 years) and for elderly (> or = 65 years) patients. RESULTS: According to the national surveys, there were 208 million ambulatory visits for AORCs during the study period. Use of NSAIDs, analgesics, steroids, and DMARDs was found to be 33.3%, 23.5%, 15.7%, and 4.3%, respectively. Analgesic use increased from 18.3% in 2001 to 26.7% in 2005. DMARDs and NSAIDs were prescribed 1.2 times more to adult patients than to elderly patients. Steroids and analgesics were prescribed 1.3 and 1.2 times more, respectively, to elderly patients than to adult patients. LIMITATION: The findings do not translate to population-based prevalence measures, as the unit of analysis was the patient visit. CONCLUSIONS: NSAIDs remain the most frequently prescribed drug class for AORCs; however, there has been increased use of analgesics in recent years. The study findings suggest that the patient's age plays a role in the choice of drugs prescribed for AORCs.

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