Increasing attention focuses on cardiovascular disease (CVD) among persons with SMI. We examined, among persons with SMI, whether co-occurring substance use disorder (SUD) elevates the risk of CVD death. We linked 2002-2007 Medicaid claims data on 121,817 persons with SMI to cause and date of death information. We applied a proportional hazards model that controls for co-morbidity at baseline, atypical antipsychotic prescription medications, age, gender and race/ethnicity. Results among persons with co-occurring SUD indicate a 24 % increased risk of CVD death (hazard ratio 1.24; 95 % confidence interval 1.17-1.33). We encourage further coordination of services for this population.

Objectives

To estimate and compare the risk of emergent bradycardia associated with starting immediate-release (IR) and slow-release (SR) formulations of metoprolol.

Design

Retrospective analysis of administrative claims data.

Data source

State of California Medicaid program (Medi-Cal) claims database.

Patients

A total of 31,574 adults beginning metoprolol between May 1, 2004, and November 1, 2009, without a pharmacy claim for a β blocker within the previous 6 months of metoprolol initiation; patients with a primary or secondary diagnosis of symptomatic bradycardia, pacemaker, or implantable cardioverter-defibrillator placement before metoprolol initiation were excluded.

Measurements and main results

The study outcome was the time to first occurrence of emergent bradycardia, measured at an emergency department visit or hospitalization due to diagnosis of symptomatic bradycardia, after metoprolol initiation. We calculated the incidence and compared the risk of emergent bradycardia by using a proportional hazards model that included the metoprolol formulation with adjustment for total daily metoprolol dose and the use of other drugs as time-varying covariates, as well as demographics and comorbidities. Among 31,574 patients starting metoprolol, 18,516 (58.6%) used the IR formulation. The incidence of emergent bradycardia was 19.1/1000 person-years overall but was nearly twice as common in patients using the IR versus the SR formulation (24.1/1000 person-yrs in the IR group versus 12.9/1000 person-yrs in the SR group, unadjusted hazard ratio [HR] 1.81, 95% confidence interval [CI] 1.28-2.56). Adjustment for other drugs also associated with symptomatic bradycardia (cytochrome P450 2D6 inhibitors, class I or III antiarrhythmics, and atrioventricular node-blocking agents), metoprolol dose, and other participant characteristics somewhat attenuated the association (adjusted HR 1.48, 95% CI 1.03-2.13).

Conclusion

The risk of emergent bradycardia associated with metoprolol initiation was higher with the IR formulation than the SR formulation, although the absolute risk was low.

Study objectives

To describe patterns of outpatient antibacterial use among California Medicaid (Medi-Cal) fee-for-service system beneficiaries, and to investigate the influence of demographic factors-age, race/ethnicity, state county, and population density-on those patterns.

Design

Retrospective analysis of administrative claims data.

Data source

Medi-Cal fee-for-service system claims database.

Patients

All outpatient Medi-Cal fee-for-service system beneficiaries enrolled between 2006 and 2011 who had at least one systemic antibacterial claim.

Measurements and main results

Rates of antibacterial prescribing and the proportion of broad-spectrum antibacterial use were measured over the study period and among age, racial/ethnic, and geographic (county) groups. Of the 10,018,066 systemic antibacterial claims selected for analysis, antibacterial prescribing rates decreased from 542 claims/1000 beneficiaries in 2006 to 461 claims/1000 beneficiaries in 2011 (r = -0.971, p=0.0012; τ-b = -1.00, p=0.009). Among age groups, children had the highest rate of use (605 claims/1000 beneficiaries, χ(2) (2) = 320,000, p<0.001); among racial/ethnic groups, Alaskan Natives and Native Americans had the highest rate of use (1086/1000 beneficiaries, χ(2) (5) = 197,000, p<0.001). Broad-spectrum antibacterial prescribing increased from 28.1% (95% confidence interval [CI] 28.1-28.2%) to 32.7% (95% CI 32.6-32.8%) over the study period. Senior age groups and whites received the highest proportions of broad-spectrum agents (53.4% [95% CI 52.5-54.3%] and 36.6% [95% CI 36.6-36.7%], respectively). Population density was inversely related to both overall antibacterial use (ρ = -0.432, p=0.0018) and broad-spectrum antibacterial prescribing (ρ = -0.359, p<0.001). The rate of prescribing decreased over the study period for all antibacterial classes with the exception of macrolides and sulfonamides. Amoxicillin was the most frequently prescribed agent.

Conclusion

Overall and broad-spectrum antibacterial use in the Medi-Cal fee-for-service program are less than that observed nationally. Significant variations in prescribing exist between age and racial/ethnic groups, and heavily populated areas are associated with both less antibacterial use and less broad-spectrum antibacterial prescribing. Studies are needed to determine the reasons for the observed differences in antibacterial use among demographic groups.