2024 – 2025
PRINCIPAL Investigator:
Jiha Lee, MD, MHS – University of Michigan
Pilot award:
Sustained Anti-Tumor Necrosis Factor De-Escalation in Older Adults with Rheumatoid Arthritis
Evidence Gap This Study Seeks to Address: Biologic disease-modifying anti-rheumatic drugs (bDMARDs), such as anti-tumor necrosis factor medications (anti-TNFs), improve outcomes in rheumatoid arthritis (RA). However, their use is associated with dose- and age-dependent adverse effects. Current guidelines recommend de-escalating (or deprescribing) bDMARDs in RA patients with low disease activity or in remission. Anti-TNFs are de-escalated in 21% of Medicare beneficiaries with RA in usual care. It remains unclear how often and which sub-group of older adults sustain de-escalation, and whether this is associated with increases in potentially problematic substitutes, such as glucocorticoids (GCs) and opioids.
Primary Study Aims:
Aim 1: To evaluate the frequency of, and factors associated with, sustained anti-TNF de-escalation among older adults with RA.
Aim 2: To assess whether sustained de-escalation is associated with compensatory increases in the use of GCs and opioids.
Study Design: This study will use 20% Medicare claims data from 2007–2021 to identify adults aged ≥66 years with RA who were on anti-TNF therapy for at least 6–7 months (a proxy for stable disease). Sustained (12 months) de-escalation, including dose reduction and dosing interval increase, will be analyzed. Multivariable analyses will explore factors associated with sustained de-escalation. Long-term GC and opioid use will be compared between older adults with sustained de-escalation and those with escalation or resumption of bDMARD therapy. Members of the Turner Geriatric Patient and Family Advisory Committee will provide feedback on the study, review results, and help interpret findings.
PRINCIPAL Investigator:
Aimee Pickering, MD, MS – University of Pittsburgh
Pilot award:
Racial and Ethnic Disparities in Prescribing and Deprescribing Low-Value Medications in Older U.S. Veterans
Evidence Gap This Study Seeks to Address: Racial and ethnic disparities in medication use are associated with various adverse health outcomes. Prior research has primarily focused on disparities in the underuse of appropriate medications among the broader adult population. However, little is known about how race and ethnicity influence the prescribing and deprescribing of unsafe, ineffective, or low-value medications in older adults.
Primary Study Aims:
Aim 1: To characterize racial and ethnic disparities in prescribing low-value medications among U.S. Veterans aged 65 and older.
Aim 2: To characterize racial and ethnic disparities in deprescribing low-value medications among U.S. Veterans aged 65 and older.
Study Design: This study will use a national cohort of older Veterans and apply a claims-based metric of low-value medication use (EVOLV-Rx). Multi-level mixed-effects logistic regression models will compare the receipt of low-value practices across racial/ethnic groups (non-Hispanic White, non-Hispanic Black, Hispanic, Asian, American Indian/Alaska Native), with and without adjustments for sociodemographic, clinical, and health center covariates. Deprescribing will be defined using a 90-day gap in medication supply, and similar regression models will evaluate deprescribing patterns across racial and ethnic groups. A stakeholder group of older patients and caregivers will provide feedback on study design, data interpretation, and manuscript preparation.
