Propensity score estimation: neural networks, support vector machines, decision trees (CART), and meta-classifiers as alternatives to logistic regression

Propensity scores for the analysis of observational data are typically estimated using logistic regression. Our objective in this Review was to assess machine learning alternatives to logistic regression which may accomplish the same goals but with fewer assumptions or greater accuracy

Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality

OBJECTIVE: Previous studies examining opioid dose and overdose risk provide limited granularity by milligram strength and instead rely on thresholds. We quantify dose-dependent overdose mortality over a large spectrum of clinically common doses. We also examine the contributions of benzodiazepines and extended release opioid formulations to mortality. DESIGN: Prospective observational cohort with one year follow-up. SETTING: One year in one state (NC) using a controlled substances prescription monitoring program, with name-linked mortality data. SUBJECTS: Residential population of North Carolina (n = 9,560,234), with 2,182,374 opioid analgesic patients. METHODS: Exposure was dispensed prescriptions of solid oral and transdermal opioid analgesics; person-years calculated using intent-to-treat principles. Outcome was overdose deaths involving opioid analgesics in a primary or additive role. Poisson models were created, implemented using generalized estimating equations. RESULTS: Opioid analgesics were dispensed to 22.8% of residents. Among licensed clinicians, 89.6% prescribed opioid analgesics, and 40.0% prescribed ER formulations. There were 629 overdose deaths, half of which had an opioid analgesic prescription active on the day of death. Of 2,182,374 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). Mortality rates increased gradually across the range of average daily milligrams of morphine equivalents. 80.0% of opioid analgesic patients also received benzodiazepines. Rates of overdose death among those co-dispensed benzodiazepines and opioid analgesics were ten times higher (7.0 per 10,000 person-years, 95 percent CI: 6.3, 7.8) than opioid analgesics alone (0.7 per 10,000 person years, 95 percent CI: 0.6, 0.9). CONCLUSIONS: Dose-dependent opioid overdose risk among patients increased gradually and did not show evidence of a distinct risk threshold. There is urgent need for guidance about combined classes of medicines to facilitate a better balance between pain relief and overdose risk

Trends in the Surgical Management of Stress Urinary Incontinence

To estimate the rates of stress urinary incontinence (SUI) surgery from 2000-2009 by type of procedure, year, age, and region of the country

Using Poison Center Exposure Calls to Predict Methadone Poisoning Deaths

PurposeThere are more drug overdose deaths in the Untied States than motor vehicle fatalities. Yet the US vital statistics reporting system is of limited value because the data are delayed by four years. Poison centers report data within an hour of the event, but previous studies suggested a small proportion of poisoning deaths are reported to poison centers (PC). In an era of improved electronic surveillance capabilities, exposure calls to PCs may be an alternate indicator of trends in overdose mortality.MethodsWe used PC call counts for methadone that were reported to the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS®) System in 2006 and 2007. US death certificate data were used to identify deaths due to methadone. Linear regression was used to quantify the relationship of deaths and poison center calls.ResultsCompared to decedents, poison center callers tended to be younger, more often female, at home and less likely to require medical attention. A strong association was found with PC calls and methadone mortality (b = 0.88, se = 0.42, t = 9.5, df = 1, p<0.0001, R2 = 0.77). These findings were robust to large changes in a sensitivity analysis assessing the impact of underreporting of methadone overdose deaths.ConclusionsOur results suggest that calls to poison centers for methadone are correlated with poisoning mortality as identified on death certificates. Calls received by poison centers may be used for timely surveillance of mortality due to methadone. In the midst of the prescription opioid overdose epidemic, electronic surveillance tools that report in real-time are powerful public health tools

Rotavirus Vaccine Schedules and Vaccine Response Among Infants in Low- and Middle-Income Countries: A Systematic Review

Rotavirus vaccine schedules may impact vaccine response among children in low- and middle-income countries (LMICs). Our objective was to review the literature evaluating the effects of monovalent (RV1) or pentavalent rotavirus vaccines schedules on vaccine response

The proportion of patients in the United States receiving postsurgical opioids exceeding recommended thresholds increased between 2006 and 2015

Background: Studies have found that patients routinely receive more opioids than medically necessary for adequate postsurgical pain management. This excess prescribing contributes to unused supply, increasing the risk of diversion and nonmedical use. In response to the US opioid crisis, opioid prescription (Rx) limits have been implemented on a state-by-state basis beginning in 2016, with 32 states currently enforcing prescribing limits. Objectives: Among a broad cohort of opioid-naïve surgical patients in the US, examine trends in 1) the proportion filling opioid Rxs for postsurgical pain, and 2) the initial volume prescribed. Methods: We identified patients undergoing surgery in MarketScan (2006–2015) and Medicare (2007–2015) claims. We defined the index opioid Rx for postsurgical pain as the first opioid filled in the week surrounding surgery following 180 days with no prior use. To reflect recent policy recommendations, we examined the proportion of patients whose index opioid Rx exceeded 7 days supply, 40 quantity dispensed (QTY), or 300 morphine milligram equivalents (MME). Results: We identified 5,148,485 opioid-naïve surgical patients in MarketScan (mean age = 45), of whom 2,957,115 (55%) received an index opioid (median: days supply = 5; QTY = 30; MME = 240). The proportion of all patients with an index opioid Rx increased from 51% in 2006 to 62% in 2013, followed by a decline to 42% in 2015. Among patients receiving an index opioid, the proportion receiving >7 days supply increased monotonically, nearly doubling between 2006 (11%) and 2015 (19%). Similarly, the proportion of patients receiving >40 QTY more than doubled throughout the study period, rising from 14% in 2006 to 29% in 2015, and the proportion receiving >300 MME rose from 21% in 2006 to 34% in 2015. Parallel analyses in Medicare found that the proportion receiving post-op opioids continued to increase through 2015, with parallel trends of increasing proportions of patients filling index opioid Rxs above defined thresholds throughout the study period. Conclusions: Between 2005 and 2013, there was an increase in both the probability of opioid receipt for postsurgical pain, and the proportion of Rxs exceeding recommended thresholds. While the proportion of patients filling opioids began to decline in 2014 among the MarketScan population, the proportion of high threshold Rxs continued to increase. Understanding trends in post-surgical prescribing are vital in informing and evaluating policies aimed at reducing unnecessary opioid exposure and curbing the opioid crisis in the US

Long-Term Outcomes After Stress Urinary Incontinence Surgery

To compare the long-term risk of repeat stress urinary incontinence (SUI) surgery after different types of initial SUI surgery and to identify predictors of time to repeat SUI surgery in a large, population-based cohort

National Diabetes Data Group vs Carpenter-Coustan criteria to diagnose gestational diabetes

To compare perinatal outcomes among women diagnosed with gestational diabetes by National Diabetes Data Group (NDDG) with women only meeting Carpenter-Coustan criteria

Racial Disparities in Perinatal Outcomes Among Women with Gestational Diabetes

We sought to evaluate perinatal outcomes by race/ethnicity among women with gestational diabetes mellitus (GDM)

Comparison of diagnostic evaluations for cough among initiators of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: Diagnostic Workup in Antihypertensive Drug Initiators

Differential diagnostic evaluation associated with a drug may bias effect estimates due to an increased detection of preclinical outcomes. Persistent cough is a common side effect with angiotensin-converting enzyme inhibitors (ACEI) and we hypothesized that ACEI initiators would undergo more diagnostic evaluations, potentially leading to diagnosis of preclinical lung cancer. We compared the incidence of cough-related diagnostic evaluations and lung cancer among ACEI versus angiotensin receptor blockers (ARB) initiators