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Uptake and Outcomes Associated with Cyclooxygenase (COX-2) Inhibitors in Ontario’S Elderly

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Uptake and Outcomes Associated with Cyclooxygenase (COX-2) Inhibitors in Ontario’S Elderly Enhancing the effectiveness of health care for Ontarians through research Uptake and outcomes associated with cyclooxygenase (COX-2) inhibitors in Ontario’s elderly ICES Investigative Report July 2005 Uptake and Outcomes Associated with Cyclooxgenase (COX-2) Inhibitors in Ontario’s Elderly ICES Investigative Report Authors Muhammad Mamdani, PharmD, MA, MPH Alex Kopp, BA Andreas Laupacis, MD, MSC, FRCPC Paula A. Rochon, MD, MPH, FRCPC David N. Juurlink, BPhm, MD, PhD, FRCPC Geoffrey N. Anderson, MD, PhD Gary Naglie, MD Peter C. Austin, PhD Douglas S. Lee, MD Thérèse Stukel, PhD Institute for Clinical Evaluative Sciences July 2005 Uptake and Outcomes Associated with Cyclooxygenase (COX-2) Inhibitors in Ontario’s Elderly Publication Information Publication Information Published by the Institute for Clinical Evaluative Sciences (ICES) © 2005 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the proper written permission of the publisher. How to cite this publication Mamdani M, Kopp A, Laupacis A. Uptake and outcomes associated with cyclooxygenase (COX-2) inhibitors in Ontario’s elderly. Toronto: Institute for Clinical Evaluative Sciences; 2005. Institute for Clinical Evaluative Sciences (ICES) G1 06, 2075 Bayview Avenue Toronto, ON M4N 3M5 Telephone: 416-480-4055 www.ices.on.ca Institute for Clinical Evaluative Sciences i July 2005 Uptake and Outcomes Associated with Cyclooxygenase (COX-2) Inhibitors in Ontario’s Elderly Authors’ Affiliations Authors’ Affiliations Muhammad Mamdani, PharmD, MA, MPH Scientist, Institute for Clinical Evaluative Sciences Associate Professor, Department of Health Policy, Management and Evaluation, Faculty of Medicine and Faculty of Pharmacy, University of Toronto Alex Kopp, BA Programmer/Analyst, Institute for Clinical Evaluative Sciences David N. Juurlink, BPhm, MD, PhD, FRCPC Scientist, Institute for Clinical Evaluative Sciences Assistant Professor, Departments of Medicine and Pediatrics, University of Toronto Staff physician, Divisions of General Internal Medicine and Clinical Pharmacology, Sunnybrook and Women's College Health Sciences Centre Clinical Toxicologist, Ontario Regional Poison Information Centre, Hospital for Sick Children Peter C. Austin, PhD Scientist, Institute for Clinical Evaluative Sciences Associate Professor, Department of Public Health Sciences, University of Toronto Geoffrey N. Anderson, MD, PhD Senior Adjunct Scientist, Institute for Clinical Evaluative Sciences Liberty Health Chair and Professor, Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto Paula A. Rochon, MD, MPH, FRCPC Scientist, Institute for Clinical Evaluative Sciences Assistant Director and Senior Scientist, Kunin-Lunenfeld Applied Research Unit, and Staff Geriatrician, Baycrest Centre for Geriatric Care Gary Naglie, MD Mary Trimmer Chair, Geriatric Medicine and Associate Professor, Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto Geriatrician, University Health Network Clinical Researcher, Toronto Rehabilitation Institute Senior Scientist, Toronto General Research Institute Douglas S. Lee, MD Research Fellow, Institute for Clinical Evaluative Sciences Thérèse Stukel, PhD Senior Scientist, Institute for Clinical Evaluative Sciences Professor, Biostatistics and Evaluative Clinical Sciences at Dartmouth Medical School, Hanover, NH Adjunct Professor, Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto Andreas Laupacis, MD, MSC, FRCPC President and CEO, and Senior Scientist, Institute for Clinical Evaluative Sciences Professor, Departments of Health Policy Management and Evaluation, Faculty of Medicine, University of Toronto General Internist, Sunnybrook and Women's College Health Sciences Centre Institute for Clinical Evaluative Sciences ii July 2005 Uptake and Outcomes Associated with Cyclooxygenase (COX-2) Inhibitors in Ontario’s Elderly Acknowledgments Acknowledgments Knowledge Transfer Paula McColgan Vice President, Policy and External Relations, Institute for Clinical Evaluative Sciences Editor Carolynne Varney Institute for Clinical Evaluative Sciences Layout Shelley Drennan Institute for Clinical Evaluative Sciences Critical Review The authors would like to thank Dr. E.R. Greenberg for his extremely useful suggestions for Chapter 3. Financial contribution Canadian Institutes of Health Research (CIHR) The New Emerging Team program receives joint sponsorship from the Canadian Diabetes Association, the Kidney Foundation of Canada, the Heart and Stroke Foundation of Canada and the CIHR Institutes of Nutrition, Metabolism & Diabetes and Circulatory & Respiratory Health. The sponsors had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript. Institute for Clinical Evaluative Sciences iii July 2005 Uptake and Outcomes Associated with Cyclooxygenase (COX-2) Inhibitors in Ontario’s Elderly About ICES About the Institute for Clinical Evaluative Sciences (ICES) Ontario’s resource for informed health care decision-making ICES is an independent, non-profit organization that conducts health services evaluations on a broad range of topical issues to enhance the effectiveness of health care for Ontarians. Internationally recognized for its innovative use of population-based health information, ICES knowledge provides evidence to support health policy development and changes to the organization and delivery of health care services. Unbiased ICES evidence offers fact-based measures of health system performance; a clearer understanding of the shifting health care needs of Ontarians; and a stimulus for discussion of practical solutions to optimize scarce resources. Key to ICES' work is our ability to link anonymous population-based health information on an individual patient basis, using unique encrypted identifiers that ensure privacy and confidentiality. This allows scientists to obtain a more comprehensive view of specific health care issues than would otherwise be possible. Linked databases reflecting 12 million of 30 million Canadians allow researchers to follow patient populations through diagnosis and treatment, and to evaluate outcomes. ICES brings together the best and the brightest talent under one roof. Many of our faculty are not only internationally recognized leaders in their fields, but are also practising clinicians who understand the grassroots of health care delivery, making ICES knowledge clinically-focused and useful in changing practice. Other team members have statistical training, epidemiological backgrounds, project management or communications expertise. The variety of skill sets and educational backgrounds ensures a multi-disciplinary approach to issues management and creates a real-world mosaic of perspectives that is vital to shaping Ontario’s future health care. ICES collaborates with experts from a diverse network of institutions, government agencies, professional organizations and patient groups to ensure that its findings are relevant. Institute for Clinical Evaluative Sciences iv July 2005 Uptake and Outcomes Associated with Cyclooxygenase (COX-2) Inhibitors in Ontario’s Elderly Contents Contents Foreword .................................................................................................................................................................. 1 Executive Summary................................................................................................................................................. 3 Introduction ............................................................................................................................................................ 3 Key messages........................................................................................................................................................ 3 Study overview....................................................................................................................................................... 4 Discussion.............................................................................................................................................................. 9 Chapter 1. Selective COX-2 Inhibitors and Nonselective NSAIDs: Upper Gastrointestinal Hemorrhage in an Elderly Cohort................................................................................................................................................... 10 Abstract ................................................................................................................................................................ 11 Findings................................................................................................................................................................ 12 Exhibits................................................................................................................................................................. 15 Appendix 1.A How the Research was Done........................................................................................................ 19 Appendix 1.B Detailed Analytic Methods............................................................................................................. 21 References..........................................................................................................................................................
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