title: The Role of Hemoglobin Laboratory Test Results for the Detection of Upper Gastrointestinal Bleeding Outcomes Resulting from the Use of Medications in Observational Studies.
abstract: The identification of upper gastrointestinal (UGI) bleeding and perforated ulcers in claims data typically relies on inpatient diagnoses. The use of hemoglobin laboratory results might increase the detection of UGI events that do not lead to hospitalization.
  
  
  
  Our objective was to evaluate whether hemoglobin results increase UGI outcome identification in electronic databases, using non-steroidal anti-inflammatory drugs (NSAIDs) as a test case.
  
  
  
  From three data partner sites within the Mini-Sentinel Distributed Database, we identified NSAID initiators aged ≥18 years between 2008 and 2013. Numbers of events and risks within 30 days after NSAID initiation were calculated for four mutually exclusive outcomes: (1) inpatient UGI diagnosis of bleeding or gastric ulcer (standard claims-based definition without laboratory results); (2) non-inpatient UGI diagnosis AND ≥3 g/dl hemoglobin decrease; (3) ≥3 g/dl hemoglobin decrease without UGI diagnosis in any clinical setting; (4) non-inpatient UGI diagnosis, without ≥3 g/dl hemoglobin decrease.
  
  
  
  We identified 2,289,772 NSAID initiators across three sites. Overall, 45.3% had one or more hemoglobin result available within 365 days before or 30 days after NSAID initiation; only 6.8% had results before and after. Of 7637 potential outcomes identified, outcome 1 accounted for 21.7%, outcome 2 for 0.8%, outcome 3 for 34.3%, and outcome 4 for 43.3%. Potential cases identified by outcome 3 were largely not suggestive of UGI events. Outcomes 1, 2, and 4 had similar distributions of specific UGI diagnoses.
  
  
  
  Using available hemoglobin result values combined with non-inpatient UGI diagnoses identified few additional UGI cases. Non-inpatient UGI diagnostic codes may increase outcome detection but would require validation.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street (Suite 3030), Boston, MA, 02120, USA. epatorno@partners.org.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Patorno
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street (Suite 3030), Boston, MA, 02120, USA.
authors.forename: Joshua J
authors.initials: JJ
authors.lastname: Gagne
authors.affiliation: Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
authors.forename: Christine Y
authors.initials: CY
authors.lastname: Lu
authors.affiliation: HealthCore, Wilmington, DE, USA.
authors.forename: Kevin
authors.initials: K
authors.lastname: Haynes
authors.affiliation: Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Sterrett
authors.affiliation: University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Jason
authors.initials: J
authors.lastname: Roy
authors.affiliation: University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Xingmei
authors.initials: X
authors.lastname: Wang
authors.affiliation: Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA.
authors.forename: Marsha A
authors.initials: MA
authors.lastname: Raebel
mesh_terms: D000328:Adult; D000368:Aged; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects*; D059019:Clinical Coding; D015331:Cohort Studies; D016208:Databases, Factual / Q000706:statistics & numerical data; D064420:Drug-Related Side Effects and Adverse Reactions / Q000175:diagnosis / Q000453:epidemiology; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000175:diagnosis; D006454:Hemoglobins / Q000032:analysis*; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D064887:Observational Studies as Topic; D018571:Sentinel Surveillance; D013276:Stomach Ulcer / Q000139:chemically induced* / Q000175:diagnosis; D013997:Time Factors
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D006454:Hemoglobins