Context More than 1.5 million US adults use stimulants and other medications labeled for treatment of attention deficit hyperactivity disorder (ADHD). These agents can increase heart rate and blood pressure, raising concerns about their cardiovascular safety. Objective Examine whether current use of medications used primarily to treat ADHD is associated with increased risk of serious cardiovascular events in young and middle-aged adults. Design Retrospective, population-based cohort study Setting Computerized health records from 4 study sites (OptumInsight Epidemiology, Tennessee Medicaid, Kaiser Permanente California, and the HMO Research Network), starting in 1986 at one site and ending in 2005 at all sites, with additional covariate assessment using 2007 survey data. Participants Adults aged 25–64 years with dispensed prescriptions for methylphenidate, amphetamine, or atomoxetine at baseline. Each medication user (n=150,359) was matched to two non-users on study site, birth year, sex, and calendar year (total users and non-users=443,198). Main Outcome Serious cardiovascular events, including myocardial infarction (MI), sudden cardiac death (SCD), or stroke. Comparison between current or new users and remote users to account for potential healthy user bias. Results During 806,182 person-years of follow-up (median 1.3 years per person), 1357 cases of MI, 296 cases of SCD, and 575 cases of stroke occurred. There were 107,322 person-years of current use (median 0.33 years), with a crude incidence per 1000 person-years of 1.34 (95% CI, 1.14–1.57) for MI, 0.30 (95% CI, 0.20–0.42) for SCD, and 0.56 (95% CI, 0.43–0.72) for stroke. The multivariable adjusted rate ratio (RR) of serious cardiovascular events for current use vs non-use of ADHD medications was 0.83 (95% CI 0.72–0.96). Among new users of ADHD medications, the adjusted RR was 0.77 (95% CI 0.63–0.94). The adjusted RR was 1.03 (95% CI, 0.86–1.24) for current use vs remote use, and was 1.02 (95% CI, 0.82–1.28) for new use vs remote use. Conclusion Among young and middle-aged adults, current or new use of ADHD medications, compared with non-use or remote use, was not associated with an increased risk of serious cardiovascular events. Apparent protective associations likely represent healthy user bias.

Both nonadherence and lack of treatment intensification occur frequently in patients above target for CVD risk factor levels; however, lack of therapy intensification was somewhat more common. Quality improvement efforts should focus on these modifiable barriers to CVD risk factor control.

BackgroundPatient–physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient–physician communication.ObjectiveTo examine the association of patient race/ethnicity and language and patient–physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system.DesignWe studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient and physician race/ethnicity and language on adherence to CVD medications, after controlling for patient and physician characteristics.ResultsTen percent of African American, 11 % of Hispanic, 63% of Asian, and 47% of white patients had same race/ethnicity physicians. 24% of Spanish-speaking patients were linguistically concordant with their physicians. African American (46%), Hispanic (49%) and Asian (52%) patients were significantly less likely than white patients (58%) to be in good adherence to all of their CVD medications (p < 0.001). Spanish-speaking patients were less likely than English speaking patients to be in good adherence (51% versus 57%, p < 0.001). Race concordance for African American patients was associated with adherence to all their CVD medications (53% vs. 50%, p < 0.05). Language concordance was associated with medication adherence for Spanish-speaking patients (51% vs. 45%, p < 0.05).ConclusionIncreasing opportunities for patient–physician race/ethnicity and language concordance may improve medication adherence for African American and Spanish-speaking patients, though a similar effect was not observed for Asian patients or English-proficient Hispanic patients.

TO THE EDITOR: Long-term use of estrogen-or progestincontaining hormone therapies (HT) is well recognized to be associated with increased risk of breast cancer both in observational studies and the Women's Health Initiative (WHI) randomized trial. 1 After the early termination of the trial in July 2002 and the subsequent media coverage, reports from clinical series indicated immediate declines of 28% to 46% in prevalences of HT and estrogen-only (ET) use. 2,3 The population-level impact of these declines on breast cancer are uncertain given the 2-to 3-year lag time between diagnosis and data availability in cancer registries.To better understand the possible impact from changes in HT on breast cancer in larger populations, we compared recent secular trends in HT use and breast cancer incidence in available clinical and population-based data resources, including recently released cancer registry data for the year 2004. We calculated the annual prevalence of HT use and the annual incidence of invasive breast cancer for the period from 1994 to 2003 for women ages 50 to 74 years in Kaiser Permanente's (Oakland, CA) Northern California region (KPNC), a large integrated health-delivery system from which computerized pharmacy, membership, and hospital cancer registry data were obtained. Women filling at least two prescriptions (generally constituting 90 days per prescription) of HT or ET in any calendar year were considered users for that year. First primary invasive breast cancer (International Classification of Disease-Oncology, 3rd edition [ICD-O-3] 4 site 50.0-50.9) diagnoses were identified, with histologic subtypes defined as ductal (ICD-O-3 codes 8500), or "with lobular component" (ICD-O-3 codes 8520, 8522, 8524). Yearly denominators included women who were KPNC members for at least 11 months of the year, and excluded those with unknown age or county of residence. Population-based breast cancer incidence rates for the 13-county catchment area for KPNC and for the state of California were obtained from the California Cancer Registry for the same ICD-O-3 specifications and age group, but for the time period including 2004, which was the most recent year for which data were available. All rates were age-adjusted to the 2000 US standard. Figure 1 illustrates that between 2001 and 2003, the calendar years before and after the WHI announcement, age-adjusted rates of HT and ET use in KPNC members declined 68% and 36%, respectively. For the same time period, breast cancer incidence declined 10% in KPNC members, 11% in the catchment population, and 11% in the state. For 2004, breast cancer incidence rates in the catchment population and the state were lower than the rates for 2003. Comparable patterns of decline were observed for both the ductal and lobular histologic subtypes (data not shown).These recent decreases in breast cancer incidence, evident in both clinical and population-based groups, are temporally consistent with substantial changes in HT and ET use. Furthermore, these patterns are consistent with (1) report...

Systematically collecting exercise information during outpatient visits is associated with small but significant changes in exercise-related clinical processes and outcomes, and represents a valuable first step towards addressing the problem of inadequate physical activity.

This cohort study uses data clustering methods and clinical stakeholder assessment to identify clinical profiles in a population of medically complex patients.

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