In this large population-based cohort of older adults, we found a 16% increased hospitalization risk associated with PIM exposure.

The few studies comparing poststroke outcomes indicated better outcomes (with higher costs) for patients in IRFs versus those in SNFs. Contemporary research on the role of the postacute care setting and its attributes in determining health outcomes should be prioritized to inform reimbursement system reform.

Background Nursing home residents with atrial fibrillation are at high risk for ischemic stroke and bleeding events. The most recent national estimate (2004) indicated less than one third of this high‐risk population was anticoagulated. Whether direct‐acting oral anticoagulant ( DOAC ) use has disseminated into nursing homes and increased anticoagulant use is unknown. Methods and Results A repeated cross‐sectional design was used to estimate the point prevalence of oral anticoagulant use on July 1 and December 31 of calendar years 2011 to 2016 among Medicare fee‐for‐service beneficiaries with atrial fibrillation residing in long‐stay nursing homes. Nursing home residence was determined using Minimum Data Set 3.0 records. Medicare Part D claims for apixaban, dabigatran, edoxaban, rivaroxaban, and warfarin were identified and point prevalence was estimated by determining if the supply from the most recent dispensing covered each point prevalence date. A Cochran‐Armitage test was performed for linear trend in prevalence. On December 31, 2011, 42.3% of 33 959 residents (median age: 85; Q1 79, Q3 90) were treated with an oral anticoagulant, of whom 8.6% used DOAC s. The proportion receiving treatment increased to 47.8% of 37 787 residents as of December 31, 2016 ( P <0.01); 48.2% of 18 054 treated residents received DOAC s. Demographic and clinical characteristics of residents using DOAC s and warfarin were similar in 2016. Half of the 8734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016. Conclusions Increases in anticoagulant use among US nursing home residents with atrial fibrillation coincided with declining warfarin use and increasing DOAC use.

IntroductionThe objective of the study was to determine the relative importance (RI) of treatment attributes psoriasis patients and physicians consider when choosing between biologic therapies based on psoriasis severity.MethodsA discrete choice experiment (DCE) weighting preference for eight sets of hypothetical treatments for moderate or severe psoriasis was conducted. DCE hypothetical treatments were defined and varied on combinations of efficacy, safety, and dosing attributes [frequency/setting/route of administration (ROA)].ResultsWhen assuming moderate psoriasis in the patient DCE, ROA (RI 29%) and efficacy (RI 27%) drive treatment choices. When assuming severe disease in the DCE, patients preferred treatments with higher efficacy (RI 36%); ROA was relatively less important (RI 15%). From the physician perspective, ROA (RI 32%) and efficacy (RI 26%) were most important for moderate psoriasis patients. In the physician model for severe psoriasis, efficacy (RI 42%) was the predominant driver followed by ROA (RI 22%). Regardless of severity, probability of loss of response within 1 year was the least important factor.ConclusionsThe severity of disease is a critical element in psoriasis treatment selection. There are high levels of alignment between physician- and patient-derived preferences in biologic treatment choice selection for psoriasis.FundingJanssen Pharmaceuticals.

BACKGROUND: Research comparing direct-acting oral anticoagulants (DOACs) to warfarin has excluded nursing home residents, a vulnerable and high-risk population. OBJECTIVE: To compare the safety and effectiveness of DOACs versus warfarin. DESIGN: New-user cohort study (2011)(2012)(2013)(2014)(2015)(2016). PATIENTS: US nursing home residents aged > 65 years with non-valvular atrial fibrillation enrolled in fee-forservice Medicare for > 6 months. EXPOSURES: Initiators of DOACs (2881 apixaban, 1289 dabigatran, 3735 rivaroxaban) were 1:1 propensity matched to warfarin initiators. MAIN MEASURES: Outcomes included ischemic stroke or transient ischemic attack (i.e., ischemic cerebrovascular event), bleeding (extracranial or intracranial), other vascular events, death, and a composite of all outcomes. Absolute rate differences (RD) and cause-specific hazard ratios (HR) with 95% confidence intervals (CI) were estimated. Subgroup analyses were performed by alignment of DOAC dosing with labeling. KEY RESULTS: Median age (84 years), CHA 2 DS 2 -Vasc (5), and ATRIA risk scores (3) were similar across medications. Clinical outcome rates were similar for dabigatran and rivaroxaban users versus warfarin users. However, ischemic cerebrovascular event rates were higher among dabigatran and rivaroxaban users that received reduced dosages without an indication. Overall, apixaban users had higher ischemic cerebrovascular event rates (HR 1.86; 95% CI 1.00-3.45) and lower bleeding rates (HR 0.66; 95% CI 0.49-0.88), but outcome rates varied by dosing alignment. Mortality rates (per 100 person-years) were lower for apixaban (RDs − 9.30; 95% CI − 13.18 to − 5.42), dabigatran (RDs − 10.79; 95% CI − 14.98 to − 6.60), and rivaroxaban (RDs − 8.92; 95% CI − 12.01 to − 5.83) versus warfarin; composite outcome findings were similar.CONCLUSIONS: Among US nursing home residents, the DOACs were each associated with lower mortality versus warfarin. Misaligned DOAC dosing was common in nursing homes and was associated with clinical and mortality outcomes. Overall, DOAC users had lower rates of adverse outcomes including mortality compared with warfarin users.

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Summary What is known and objective Observational clinical studies of metformin for prevention and treatment of several cancer types have reported mixed findings. Although preclinical studies have suggested metformin may reduce head and neck cancer (HNC) proliferation, clinical evidence is limited. The objective of this large population‐based study was to evaluate the relationship between metformin exposure following HNC diagnosis and all‐cause mortality. Methods We conducted a retrospective cohort study using the Italian Emilia‐Romagna Regional administrative healthcare database, which includes demographic, hospital and outpatient prescription information for ~4.5 million residents. Included patients were followed from the first hospital discharge (index) during the study period (01/2003‐12/2012) with a diagnosis of HNC. Metformin exposure and select covariates were operationalized in a time‐dependent manner during follow‐up. Cox proportional hazards models estimated the covariate‐adjusted time‐dependent association between metformin exposure and all‐cause mortality. Results and discussion Among 7872 patients diagnosed with HNC, 708 (9.0%) were exposed to metformin after HNC diagnosis, and 3626 (46.1%) died during follow‐up (median follow‐up: 35.2 months). In the covariate‐adjusted model, the all‐cause mortality rate appeared lower (HR: 0.81, 95% CI: 0.61‐1.09) among metformin exposed patients during the 2 years post‐diagnosis, while the all‐cause mortality rate appeared higher (HR: 1.20, 95% CI: 0.94‐1.53) among exposed patients after 2 years post‐diagnosis. Metformin was protective among patients ≤60 years of age (HR for the period of 0‐2 years post‐diagnosis: 0.22, 95% CI 0.09‐0.56; HR for the period ≥2 years post‐diagnosis: 0.56, 95% CI 0.26‐1.22) but not in those >60 years. What is new and conclusion In this population‐based study of metformin in HNC, we found a modest protective association between metformin exposure and all‐cause mortality in the 2‐year post‐diagnosis period. Age appeared to modify the association between metformin and HNC survival.