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Instrumental variable applications using nursing home prescribing preferences in comparative effectiveness research.

Krista F Huybrechts1, Tobias Gerhard, Jessica M Franklin

  • 1Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.

Pharmacoepidemiology and Drug Safety
|March 26, 2014
PubMed
Summary

Instrumental variable methods using nursing home prescribing preference show promise for comparative effectiveness research in vulnerable populations. This approach helps reduce confounding in studies of psychotropic medications for dementia patients.

Keywords:
comparative effectivenessconfoundingepidemiologic methodsinstrumental variablenursing homepharmacoepidemiologyprescribing preference

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Area of Science:

  • Health Services Research
  • Comparative Effectiveness Research
  • Epidemiology

Background:

  • Nursing home residents are susceptible to adverse treatment effects and often excluded from clinical trials.
  • Conventional analytic methods risk residual confounding due to unmeasured health markers in this population.
  • Instrumental variable (IV) methods offer a potential solution to mitigate confounding.

Purpose of the Study:

  • To evaluate the validity of IV methods using nursing home prescribing preference.
  • To address confounding in comparative effectiveness research for nursing home residents.
  • To use psychotropic medications for dementia behavioral problems as a case study.

Main Methods:

  • Utilized linked data from Medicaid, Medicare, Minimum Data Set, and Online Survey, Certification and Reporting (2001-2004).
  • Selected dual-eligible patients aged 65+ initiating psychotropic medication post-admission.
  • Characterized nursing home prescribing preference and explored IV assumption plausibility.

Main Results:

  • High-prescribing and low-prescribing nursing homes differed significantly (factor of 2).
  • IV measures explained substantial variation in psychotropic medication choice (β(IV→treatment): 0.22-0.36).
  • Patient characteristics were well-balanced across instrument groups, with no association with quality of care markers.

Conclusions:

  • IV analyses leveraging nursing home prescribing preference appear valuable for comparative effectiveness studies.
  • This method can be extended to include untreated comparison groups, addressing significant confounding.
  • The approach shows potential for improving research validity in vulnerable populations.