title: Methodology to Estimate the Longitudinal Average Attributable Fraction of Guideline-recommended Medications for Death in Older Adults With Multiple Chronic Conditions.
abstract: Persons with multiple chronic conditions receive multiple guideline-recommended medications to improve outcomes such as mortality. Our objective was to estimate the longitudinal average attributable fraction for 3-year survival of medications for cardiovascular conditions in persons with multiple chronic conditions and to determine whether heterogeneity occurred by age.
  
  
  
  Medicare Current Beneficiary Survey participants (N = 8,578) with two or more chronic conditions, enrolled from 2005 to 2009 with follow-up through 2011, were analyzed. We calculated the longitudinal extension of the average attributable fraction for oral medications (beta blockers, renin-angiotensin system blockers, and thiazide diuretics) indicated for cardiovascular conditions (atrial fibrillation, coronary artery disease, heart failure, and hypertension), on survival adjusted for 18 participant characteristics. Models stratified by age (≤80 and >80 years) were analyzed to determine heterogeneity of both cardiovascular conditions and medications.
  
  
  
  Heart failure had the greatest average attributable fraction (39%) for mortality. The fractional contributions of beta blockers, renin-angiotensin system blockers, and thiazides to improve survival were 10.4%, 9.3%, and 7.2% respectively. In age-stratified models, of these medications thiazides had a significant contribution to survival only for those aged 80 years or younger. The effects of the remaining medications were similar in both age strata.
  
  
  
  Most cardiovascular medications were attributed independently to survival. The two cardiovascular conditions contributing independently to death were heart failure and atrial fibrillation. The medication effects were similar by age except for thiazides that had a significant contribution to survival in persons younger than 80 years.
authors.affiliation: Department of Medicine, Yale School of Medicine, New Haven, Connecticut. Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut. Heather.Allore@yale.edu.
authors.forename: Heather G
authors.initials: HG
authors.lastname: Allore
authors.affiliation: Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut. Department of Statistics and Biostatistics, Rutgers University, New Brunswick, New Jersey.
authors.forename: Yilei
authors.initials: Y
authors.lastname: Zhan
authors.affiliation: Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Cohen
authors.affiliation: Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Mary E
authors.initials: ME
authors.lastname: Tinetti
authors.affiliation: Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Mark
authors.initials: M
authors.lastname: Trentalange
authors.affiliation: Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
authors.forename: Gail
authors.initials: G
authors.lastname: McAvay
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000188:drug therapy* / Q000401:mortality*; D011307:Drug Prescriptions; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D006278:Medicare; D000071069:Multiple Chronic Conditions / Q000188:drug therapy* / Q000401:mortality*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D015996:Survival Rate; D049971:Thiazides / Q000627:therapeutic use*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D000319:Adrenergic beta-Antagonists; D049971:Thiazides
keywords: Average attributable fraction; Chronic disease; Longitudinal study; Medications; Mortality; Multimorbidity