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- Title
Association of Different Prescribing Patterns for Oral Corticosteroids With Fracture Preventive Care Among Older Adults in the UK and Ontario.
- Authors
Matthewman, Julian; Tadrous, Mina; Mansfield, Kathryn E.; Thiruchelvam, Deva; Redelmeier, Donald A.; Cheung, Angela M.; Lega, Iliana C.; Prieto-Alhambra, Daniel; Cunliffe, Lawrence A.; Mulick, Amy; Henderson, Alasdair; Langan, Sinéad M.; Drucker, Aaron M.
- Abstract
Key Points: Question: Are prescribing patterns for older people receiving high cumulative doses of oral corticosteroids associated with adequate fracture preventive care? Findings: This cohort study of 65 195 older adults in the UK and 28 674 older adults in Ontario, Canada, found that individuals who were prescribed high cumulative oral corticosteroid doses gradually or intermittently across multiple prescriptions were about half as likely as individuals prescribed a similar dose in 1 prescription or within a short period of time to receive guideline-indicated fracture preventive care. Meaning: Increasing attention to individuals receiving prescriptions for high cumulative oral corticosteroid doses discontinuously may help close an identified gap in fracture preventive care. Importance: Identifying and mitigating modifiable gaps in fracture preventive care for people with relapsing-remitting conditions such as eczema, asthma, and chronic obstructive pulmonary disease who are prescribed high cumulative oral corticosteroid doses may decrease fracture-associated morbidity and mortality. Objective: To estimate the association between different oral corticosteroid prescribing patterns and appropriate fracture preventive care, including treatment with fracture preventive care medications, among older adults with high cumulative oral corticosteroid exposure. Design, Setting, and Participants: This cohort study included 65 195 participants with UK electronic medical record data from the Clinical Practice Research Datalink (January 2, 1998, to January 31, 2020) and 28 674 participants with Ontario, Canada, health administrative data from ICES (April 1, 2002, to September 30, 2020). Participants were adults 66 years or older with eczema, asthma, or chronic obstructive pulmonary disease receiving prescriptions for oral corticosteroids with cumulative prednisolone equivalent doses of 450 mg or higher within 6 months. Data were analyzed October 22, 2020, to September 6, 2022. Exposures: Participants with prescriptions crossing the 450-mg cumulative oral corticosteroid threshold in less than 90 days were classified as having high-intensity prescriptions, and participants crossing the threshold in 90 days or more as having low-intensity prescriptions. Multiple alternative exposure definitions were used in sensitivity analyses. Main Outcomes and Measures: The primary outcome was prescribed fracture preventive care. A secondary outcome was major osteoporotic fracture. Individuals were followed up from the date they crossed the cumulative oral corticosteroid threshold until their outcome or the end of follow-up (up to 1 year after index date). Rates were calculated for fracture preventive care and fractures, and hazard ratios (HRs) were estimated from Cox proportional hazards regression models comparing high- vs low-intensity oral corticosteroid prescriptions. Results: In both the UK cohort of 65 195 participants (mean [IQR] age, 75 [71-81] years; 32 981 [50.6%] male) and the Ontario cohort of 28 674 participants (mean [IQR] age, 73 [69-79] years; 17 071 [59.5%] male), individuals with high-intensity oral corticosteroid prescriptions had substantially higher rates of fracture preventive care than individuals with low-intensity prescriptions (UK: 134 vs 57 per 1000 person-years; crude HR, 2.34; 95% CI, 2.19-2.51, and Ontario: 73 vs 48 per 1000 person-years; crude HR, 1.49; 95% CI, 1.29-1.72). People with high- and low-intensity oral corticosteroid prescriptions had similar rates of major osteoporotic fractures (UK: crude rates, 14 vs 13 per 1000 person-years; crude HR, 1.07; 95% CI, 0.98-1.15 and Ontario: crude rates, 20 vs 23 per 1000 person-years; crude HR, 0.87; 95% CI, 0.79-0.96). Results from sensitivity analyses suggested that reaching a high cumulative oral corticosteroid dose within a shorter time, with fewer prescriptions, or with fewer or shorter gaps between prescriptions, increased fracture preventive care prescribing. Conclusions: The results of this cohort study suggest that older adults prescribed high cumulative oral corticosteroids across multiple prescriptions, or with many or long gaps between prescriptions, may be missing opportunities for fracture preventive care. This cohort study conducted in the UK and Ontario, Canada, assesses the association between oral corticosteroid prescribing patterns and appropriate fracture preventive care among older adults with high cumulative oral corticosteroid exposure.
- Publication
JAMA Dermatology, 2023, Vol 159, Issue 9, p961
- ISSN
2168-6068
- Publication type
Article
- DOI
10.1001/jamadermatol.2023.2495