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JANUARY 2015–VOL. 63, NO. 1
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Cheung: concept and design, acquisition of subjects and data, preparation of manuscript. Cheung, Ho, Chou: analysis and interpretation of data, critical review and approval. Sponsor’s Role: None.
LETTERS TO THE EDITOR
203
Thomas E. Finucane, MD Johns Hopkins Geriatrics Center, Baltimore, Maryland
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Dr. Finucane is the sole author of this paper. Sponsor’s Role: N/A.
REFERENCES 1. Achem SR, Devault KR. Dysphagia in aging. J Clin Gastroenterol 2005;39:357–371. 2. Patti MG, Herbella FA. Achalasia and other esophageal motility disorders. J Gastrointest Surg 2011;15:703–707. 3. Schechter RB, Lemme EM, Novais P et al. Achalasia in the elderly patient: A comparative study. Arq Gastroenterol 2011;48:19–23. 4. Parshad R, Devana SK, Panchanatheeswaran K et al. Clinical, radiological and functional assessment of pulmonary status in patients with achalasia cardia before and after treatment. Eur J Cardiothorac Surg 2012;42:e90–e95. 5. Makharia GK, Seith A, Sharma SK et al. Structural and functional abnormalities in lungs in patients with achalasia. Neurogastroenterol Motil 2009;21:603–608 e20. 6. Fisichella PM, Raz D, Palazzo F et al. Clinical, radiological, and manometric profile in 145 patients with untreated achalasia. World J Surg 2008;32:1974–1979. 7. Lahbabi M, Ihssane M, Sidi Adil I et al. Pseudoachalasia secondary to metastatic breast carcinoma mimicking radiation stenosis. Clin Res Hepatol Gastroenterol 2012;36:e117–e121. 8. Paladini F, Cocco E, Cascino I et al. Age-dependent association of idiopathic achalasia with vasoactive intestinal peptide receptor 1 gene. Neurogastroenterol Motil 2009;21:597–602. 9. Al-Habbal Y. Cough from megaoesophagus. Aust Fam Physician 2011;40:299–300. 10. Lewandowski A. Diagnostic criteria and surgical procedure for megaesophagus—a personal experience. Dis Esophagus 2009;22: 305–309. 11. Ladizinski B, Rukhman ED, Sankey C. Failure to yield: Refractory achalasia. Am J Med 2014;127:34–35.
COMMENTS/ RESPONSES COHERENT PATIENTS AND GOOD OUTCOMES To the Editor: Cooper and colleagues show that “Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD [coronary artery disease] hospitalizations at follow-up than those with less than 80% adherence.”1 In 1980, the Coronary Drug Project showed that “This analysis [multiple linear regression] yielded adjusted 5-year mortality figures of 16.4 per cent for good adherers (80% or greater) and 25.8 per cent for poor adherers, among subjects receiving placebo.” They note that “[s]ince this difference cannot be due to a pharmacologic effect of the placebo, one must surmise that it is due to differences in patient characteristics in the two adherence subgroups.”2 Do Cooper and colleagues think that adherence bias may have affected their results? Might they then weaken the suggestion that enhanced efforts to improve adherence might have a benefit in CAD outcomes?
REFERENCES 1. Cooper D, Trivedi R, Nelson K. Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression. J Am Geriatr Soc 2014;62:1238–1245. 2. Coronary Drug Project Research Group. Influence of adherence to treatment and response of cholesterol on mortality in the Coronary Drug Project. N Engl J Med 1980;303:1038–1041.
RESPONSE TO THOMAS E. FINUCANE, MD To the Editor: Citing an analysis that found better outcomes for individuals who were more adherent to placebo in a randomized clinical trial of cholesterol treatment,1 Finucane asked about the possible influence of participant characteristics and adherence bias on the findings of our study.2 We agree with Finucane that such factors can influence studies of medication adherence. However, it is likely that our study’s design and adjusted analyses reduced the effects of these potential confounders on the results, which we believe suggested that better antidepressant medication adherence might benefit coronary artery disease (CAD) outcomes. We derived the data from a large ongoing quality review program that randomly abstracted the medical records of individuals throughout the Veterans Health Administration (VHA) nationwide. Because this quality review program was unrelated to our study and did not focus on antidepressant adherence, it seems unlikely that the program inadvertently oversampled individuals with adequate antidepressant adherence. Although our approach has uncertain generalizability to individuals outside of the VHA,2 it limited the bias that can be introduced in clinical trials when recruitment at clinics results in an overrepresentation of volunteers with good treatment adherence. The potential effect of costs on adherence also was limited because the VHA provides medications free of charge or with a small copayment.3 In addition, our analyses were adjusted for many participant-related variables that can affect treatment adherence, including sociodemographic characteristics, comorbid psychiatric conditions, and substance abuse, and number of outpatient visits.4 Depression itself is an important risk factor for poor self-management and nonadherence.5 As we noted,2 there is strong evidence that treatment of depression in individuals with poorly controlled chronic illness improves the management of those diseases.6 Therefore, we believe our findings that older adults with adequate antidepressant
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adherence had 26% lower odds of hospitalizations for CAD warranted the suggestion that better antidepressant adherence could be associated with better CAD outcomes. Denise C. Cooper, PhD Veteran Affairs Puget Sound Health Care System, Seattle, Washington Department of Health Services, University of Washington, Seattle, Washington Ranak B. Trivedi, PhD Veterans Affairs Palo Alto Health Care System, Palo Alto, California Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California Karin M. Nelson, MD, MSHS Veteran Affairs Puget Sound Health Care System, Seattle, Washington Department of Medicine, University of Washington, Seattle, Washington Gayle E. Reiber, MPH, PhD Veteran Affairs Puget Sound Health Care System, Seattle, Washington Department of Health Services, University of Washington, Seattle, Washington Evercita C. Eugenio, MS Kristine A. Beaver, MPH Veteran Affairs Puget Sound Health Care System, Seattle, Washington Vincent S. Fan, MD Veteran Affairs Puget Sound Health Care System, Seattle, Washington Department of Medicine, University of Washington, Seattle, Washington
ACKNOWLEDGMENTS This study was supported by the Department of Veterans Affairs Quality Enhancement Research Initiative Rapid Response Project (RRP 10–105) (VSF). The views expressed in this article are solely those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Conflict of Interest: All authors report no conflicts of interest. Author Contributions: Drafting and final approval of the manuscript: Cooper, Trivedi, Nelson, Reiber, Eugenio, Beaver, and Fan. Sponsor’s Role: The Department of Veterans Affairs Quality Enhancement Research Initiative Rapid Response Project funded this study but had no role in the design, methods, analysis, or preparation of the paper.
REFERENCES 1. Influence of adherence to treatment and response of cholesterol on mortality in the Coronary Drug Project. N Engl J Med 1980;303:1038–1041.
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2. Cooper D, Trivedi R, Nelson K et al. Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression. J Am Geriatr Soc 2014;62:1238–1245. 3. Stroupe KT, Smith BM, Lee TA et al. Effect of increased copayments on pharmacy use in the Department of Veterans Affairs. Med Care 2007;45:1090–1097. 4. Julius RJ, Novitsky MA Jr, Dubin WR. Medication adherence: A review of the literature and implications for clinical practice. J Psychiatr Pract 2009;15:34–44. 5. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160:2101–2107. 6. Katon WJ, Lin EH, Von Korff M et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363:2611– 2620.
LEARNING FROM EXPERIENCE AND MAKING PLANS? To the Editor: Amjad et al.1 studied a group of 304 individuals with a mean age of 74 and measured readiness to participate in advance care planning as well as prior experience with any of seven illness and end-of-life care situations. Lack of prior experience was associated with less readiness to plan. Never having had experience with decision-making for others was particularly strongly associated with lack of readiness to plan. These findings, they say, “suggest that there is something particularly important about witnessing actual end-of-life care.” Another explanation could be that 74-year-olds who have never been involved in any of these situations are somehow different from those who have. Perhaps there is a group of people who are strongly resistant to or even repelled by matters of illness and death. This group would tend to avoid involvement in the process of dying as it occurs in their relatives and friends and might tend to avoid involvement in thinking about their own deaths as well. Thomas E. Finucane, MD Department of Medicine, Johns Hopkins Geriatrics Center, Baltimore, Maryland
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Dr. Finucane is the sole author of this paper. Sponsor’s Role: N/A.
REFERENCE 1. Amjad H, Towle V, Fried T. Association of experience with illness and endof-life care with advance care planning in older adults. J Am Geriatr Soc 2014;62:1304–1309.
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
JANUARY 2015–VOL. 63, NO. 1
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Cheung: concept and design, acquisition of subjects and data, preparation of manuscript. Cheung, Ho, Chou: analysis and interpretation of data, critical review and approval. Sponsor’s Role: None.
LETTERS TO THE EDITOR
203
Thomas E. Finucane, MD Johns Hopkins Geriatrics Center, Baltimore, Maryland
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Dr. Finucane is the sole author of this paper. Sponsor’s Role: N/A.
REFERENCES 1. Achem SR, Devault KR. Dysphagia in aging. J Clin Gastroenterol 2005;39:357–371. 2. Patti MG, Herbella FA. Achalasia and other esophageal motility disorders. J Gastrointest Surg 2011;15:703–707. 3. Schechter RB, Lemme EM, Novais P et al. Achalasia in the elderly patient: A comparative study. Arq Gastroenterol 2011;48:19–23. 4. Parshad R, Devana SK, Panchanatheeswaran K et al. Clinical, radiological and functional assessment of pulmonary status in patients with achalasia cardia before and after treatment. Eur J Cardiothorac Surg 2012;42:e90–e95. 5. Makharia GK, Seith A, Sharma SK et al. Structural and functional abnormalities in lungs in patients with achalasia. Neurogastroenterol Motil 2009;21:603–608 e20. 6. Fisichella PM, Raz D, Palazzo F et al. Clinical, radiological, and manometric profile in 145 patients with untreated achalasia. World J Surg 2008;32:1974–1979. 7. Lahbabi M, Ihssane M, Sidi Adil I et al. Pseudoachalasia secondary to metastatic breast carcinoma mimicking radiation stenosis. Clin Res Hepatol Gastroenterol 2012;36:e117–e121. 8. Paladini F, Cocco E, Cascino I et al. Age-dependent association of idiopathic achalasia with vasoactive intestinal peptide receptor 1 gene. Neurogastroenterol Motil 2009;21:597–602. 9. Al-Habbal Y. Cough from megaoesophagus. Aust Fam Physician 2011;40:299–300. 10. Lewandowski A. Diagnostic criteria and surgical procedure for megaesophagus—a personal experience. Dis Esophagus 2009;22: 305–309. 11. Ladizinski B, Rukhman ED, Sankey C. Failure to yield: Refractory achalasia. Am J Med 2014;127:34–35.
COMMENTS/ RESPONSES COHERENT PATIENTS AND GOOD OUTCOMES To the Editor: Cooper and colleagues show that “Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD [coronary artery disease] hospitalizations at follow-up than those with less than 80% adherence.”1 In 1980, the Coronary Drug Project showed that “This analysis [multiple linear regression] yielded adjusted 5-year mortality figures of 16.4 per cent for good adherers (80% or greater) and 25.8 per cent for poor adherers, among subjects receiving placebo.” They note that “[s]ince this difference cannot be due to a pharmacologic effect of the placebo, one must surmise that it is due to differences in patient characteristics in the two adherence subgroups.”2 Do Cooper and colleagues think that adherence bias may have affected their results? Might they then weaken the suggestion that enhanced efforts to improve adherence might have a benefit in CAD outcomes?
REFERENCES 1. Cooper D, Trivedi R, Nelson K. Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression. J Am Geriatr Soc 2014;62:1238–1245. 2. Coronary Drug Project Research Group. Influence of adherence to treatment and response of cholesterol on mortality in the Coronary Drug Project. N Engl J Med 1980;303:1038–1041.
RESPONSE TO THOMAS E. FINUCANE, MD To the Editor: Citing an analysis that found better outcomes for individuals who were more adherent to placebo in a randomized clinical trial of cholesterol treatment,1 Finucane asked about the possible influence of participant characteristics and adherence bias on the findings of our study.2 We agree with Finucane that such factors can influence studies of medication adherence. However, it is likely that our study’s design and adjusted analyses reduced the effects of these potential confounders on the results, which we believe suggested that better antidepressant medication adherence might benefit coronary artery disease (CAD) outcomes. We derived the data from a large ongoing quality review program that randomly abstracted the medical records of individuals throughout the Veterans Health Administration (VHA) nationwide. Because this quality review program was unrelated to our study and did not focus on antidepressant adherence, it seems unlikely that the program inadvertently oversampled individuals with adequate antidepressant adherence. Although our approach has uncertain generalizability to individuals outside of the VHA,2 it limited the bias that can be introduced in clinical trials when recruitment at clinics results in an overrepresentation of volunteers with good treatment adherence. The potential effect of costs on adherence also was limited because the VHA provides medications free of charge or with a small copayment.3 In addition, our analyses were adjusted for many participant-related variables that can affect treatment adherence, including sociodemographic characteristics, comorbid psychiatric conditions, and substance abuse, and number of outpatient visits.4 Depression itself is an important risk factor for poor self-management and nonadherence.5 As we noted,2 there is strong evidence that treatment of depression in individuals with poorly controlled chronic illness improves the management of those diseases.6 Therefore, we believe our findings that older adults with adequate antidepressant
204
LETTERS TO THE EDITOR
adherence had 26% lower odds of hospitalizations for CAD warranted the suggestion that better antidepressant adherence could be associated with better CAD outcomes. Denise C. Cooper, PhD Veteran Affairs Puget Sound Health Care System, Seattle, Washington Department of Health Services, University of Washington, Seattle, Washington Ranak B. Trivedi, PhD Veterans Affairs Palo Alto Health Care System, Palo Alto, California Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California Karin M. Nelson, MD, MSHS Veteran Affairs Puget Sound Health Care System, Seattle, Washington Department of Medicine, University of Washington, Seattle, Washington Gayle E. Reiber, MPH, PhD Veteran Affairs Puget Sound Health Care System, Seattle, Washington Department of Health Services, University of Washington, Seattle, Washington Evercita C. Eugenio, MS Kristine A. Beaver, MPH Veteran Affairs Puget Sound Health Care System, Seattle, Washington Vincent S. Fan, MD Veteran Affairs Puget Sound Health Care System, Seattle, Washington Department of Medicine, University of Washington, Seattle, Washington
ACKNOWLEDGMENTS This study was supported by the Department of Veterans Affairs Quality Enhancement Research Initiative Rapid Response Project (RRP 10–105) (VSF). The views expressed in this article are solely those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Conflict of Interest: All authors report no conflicts of interest. Author Contributions: Drafting and final approval of the manuscript: Cooper, Trivedi, Nelson, Reiber, Eugenio, Beaver, and Fan. Sponsor’s Role: The Department of Veterans Affairs Quality Enhancement Research Initiative Rapid Response Project funded this study but had no role in the design, methods, analysis, or preparation of the paper.
REFERENCES 1. Influence of adherence to treatment and response of cholesterol on mortality in the Coronary Drug Project. N Engl J Med 1980;303:1038–1041.
JANUARY 2015–VOL. 63, NO. 1
JAGS
2. Cooper D, Trivedi R, Nelson K et al. Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression. J Am Geriatr Soc 2014;62:1238–1245. 3. Stroupe KT, Smith BM, Lee TA et al. Effect of increased copayments on pharmacy use in the Department of Veterans Affairs. Med Care 2007;45:1090–1097. 4. Julius RJ, Novitsky MA Jr, Dubin WR. Medication adherence: A review of the literature and implications for clinical practice. J Psychiatr Pract 2009;15:34–44. 5. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160:2101–2107. 6. Katon WJ, Lin EH, Von Korff M et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363:2611– 2620.
LEARNING FROM EXPERIENCE AND MAKING PLANS? To the Editor: Amjad et al.1 studied a group of 304 individuals with a mean age of 74 and measured readiness to participate in advance care planning as well as prior experience with any of seven illness and end-of-life care situations. Lack of prior experience was associated with less readiness to plan. Never having had experience with decision-making for others was particularly strongly associated with lack of readiness to plan. These findings, they say, “suggest that there is something particularly important about witnessing actual end-of-life care.” Another explanation could be that 74-year-olds who have never been involved in any of these situations are somehow different from those who have. Perhaps there is a group of people who are strongly resistant to or even repelled by matters of illness and death. This group would tend to avoid involvement in the process of dying as it occurs in their relatives and friends and might tend to avoid involvement in thinking about their own deaths as well. Thomas E. Finucane, MD Department of Medicine, Johns Hopkins Geriatrics Center, Baltimore, Maryland
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Dr. Finucane is the sole author of this paper. Sponsor’s Role: N/A.
REFERENCE 1. Amjad H, Towle V, Fried T. Association of experience with illness and endof-life care with advance care planning in older adults. J Am Geriatr Soc 2014;62:1304–1309.
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
