ingest cdrApp 2018-03-15T16:19:42.640Z d591f2cd-3da7-4b31-9dd8-ee27dcb6a3ee modifyDatastreamByValue RELS-EXT fedoraAdmin 2018-03-15T16:20:33.977Z Setting exclusive relation addDatastream MD_TECHNICAL fedoraAdmin 2018-03-15T16:20:45.134Z Adding technical metadata derived by FITS addDatastream MD_FULL_TEXT fedoraAdmin 2018-03-15T16:21:07.658Z Adding full text metadata extracted by Apache Tika modifyDatastreamByValue RELS-EXT fedoraAdmin 2018-03-15T16:21:29.537Z Setting exclusive relation modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2018-05-17T17:00:09.759Z modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2018-07-11T03:48:25.150Z modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2018-07-18T00:05:57.391Z modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2018-08-15T20:14:20.316Z modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2018-09-21T20:31:24.581Z modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2018-09-26T23:51:18.929Z modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2018-10-12T00:25:47.010Z modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2019-03-20T18:20:49.421Z Magdalene Assimon Author Department of Epidemiology Gillings School of Global Public Health INVESTIGATING THE LONGITUDINAL PATTERNS OF USE AND COMPARATIVE EFFECTIVENESS OF BETA BLOCKER THERAPY IN THE HEMODIALYSIS POPULATION United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. Winter 2017 2017 Epidemiology Adherence, Beta blocker, Hemodialysis, Mortality, Patterns of use eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text Magdalene Assimon Creator Department of Epidemiology Gillings School of Global Public Health INVESTIGATING THE LONGITUDINAL PATTERNS OF USE AND COMPARATIVE EFFECTIVENESS OF BETA BLOCKER THERAPY IN THE HEMODIALYSIS POPULATION United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. 2017-12 2017 Epidemiology Adherence, Beta blocker, Hemodialysis, Mortality, Patterns of use eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text Magdalene Assimon Creator Department of Epidemiology Gillings School of Global Public Health INVESTIGATING THE LONGITUDINAL PATTERNS OF USE AND COMPARATIVE EFFECTIVENESS OF BETA BLOCKER THERAPY IN THE HEMODIALYSIS POPULATION United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. 2017-12 2017 Epidemiology Adherence, Beta blocker, Hemodialysis, Mortality, Patterns of use eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text Magdalene Assimon Creator Department of Epidemiology Gillings School of Global Public Health INVESTIGATING THE LONGITUDINAL PATTERNS OF USE AND COMPARATIVE EFFECTIVENESS OF BETA BLOCKER THERAPY IN THE HEMODIALYSIS POPULATION United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. 2017-12 2017 Epidemiology Adherence, Beta blocker, Hemodialysis, Mortality, Patterns of use eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text Magdalene Assimon Creator Department of Epidemiology Gillings School of Global Public Health INVESTIGATING THE LONGITUDINAL PATTERNS OF USE AND COMPARATIVE EFFECTIVENESS OF BETA BLOCKER THERAPY IN THE HEMODIALYSIS POPULATION United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. 2017-12 2017 Epidemiology Adherence, Beta blocker, Hemodialysis, Mortality, Patterns of use eng Doctor of Philosophy Dissertation Epidemiology M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text University of North Carolina at Chapel Hill Degree granting institution Magdalene Assimon Creator Department of Epidemiology Gillings School of Global Public Health INVESTIGATING THE LONGITUDINAL PATTERNS OF USE AND COMPARATIVE EFFECTIVENESS OF BETA BLOCKER THERAPY IN THE HEMODIALYSIS POPULATION United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. 2017-12 2017 Epidemiology Adherence, Beta blocker, Hemodialysis, Mortality, Patterns of use eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text Magdalene Assimon Creator Department of Epidemiology Gillings School of Global Public Health INVESTIGATING THE LONGITUDINAL PATTERNS OF USE AND COMPARATIVE EFFECTIVENESS OF BETA BLOCKER THERAPY IN THE HEMODIALYSIS POPULATION United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. 2017-12 2017 Epidemiology Adherence; Beta blocker; Hemodialysis; Mortality; Patterns of use eng Doctor of Philosophy Dissertation Epidemiology M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text University of North Carolina at Chapel Hill Degree granting institution Magdalene Assimon Creator Department of Epidemiology Gillings School of Global Public Health INVESTIGATING THE LONGITUDINAL PATTERNS OF USE AND COMPARATIVE EFFECTIVENESS OF BETA BLOCKER THERAPY IN THE HEMODIALYSIS POPULATION United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. 2017-12 2017 Epidemiology Adherence, Beta blocker, Hemodialysis, Mortality, Patterns of use eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Epidemiology M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text Magdalene Assimon Creator Department of Epidemiology Gillings School of Global Public Health United States hemodialysis patients experience high rates of cardiovascular mortality. Approximately 50% of deaths are due to cardiovascular disease. In the general population, beta blocker treatment improves clinical outcomes in a range of cardiovascular conditions. However, the cardioprotective benefit of beta blocker therapy has never been evaluated by large randomized trials in individuals receiving maintenance hemodialysis therapy, a population with special drug dosing considerations. Pharmacologic and pharmacokinetic differences across individual beta blockers may alter drug efficacy and safety profiles in the setting of end-stage renal disease. Using the clinical research database of a large United States dialysis provider linked with the United States Renal Data system registry we assembled a cohort of maintenance hemodialysis with Medicare insurance coverage who initiated beta blocker therapy from 2007 – 2012 to: 1) assess long-term beta blocker utilization patterns in the hemodialysis population, 2) examine the association between beta blocker adherence versus non-adherence (proportion of days covered (PDC) ≥ 80% versus PDC < 80%) and all-cause mortality, and 3) evaluate the association between carvedilol versus metoprolol initiation and 1-year all-cause and cardiovascular mortality. First, we found that carvedilol and metoprolol were the most commonly initiated beta blockers (79.7% of all beta blocker new-users). After beta blocker initiation, therapy cessation (i.e. discontinuation) and re-initiation were relatively common. Second, we found that beta blocker adherence (versus non-adherence) was associated with lower all-cause mortality (PDC ≥ 80% versus < 80% measured using pharmacy claims: adjusted hazard ratio (HR) [95% confidence interval (CI)] = 0.84 [0.79, 0.90]). Finally, we found that carvedilol (versus metoprolol) initiation was associated with higher all-cause (adjusted HR [95% CI] = 1.09 [1.02, 1.16]) and cardiovascular mortality (adjusted HR [95% CI] = 1.19 [1.08, 1.30]). The potential mechanism for the observed mortality association may be the increased rate of intradialytic hypotension observed after carvedilol (versus metoprolol) initiation. Our findings provide insights into: 1) the longitudinal patterns of beta blocker utilization among individuals receiving maintenance hemodialysis therapy, 2) the association between beta blocker adherence and all-cause mortality, and most importantly, 3) provide important evidence to guide beta blocker prescribing in hemodialysis population the absence of clinical trial data. 2017-12 2017 Epidemiology Adherence; Beta blocker; Hemodialysis; Mortality; Patterns of use eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution M. Alan Brookhart Thesis advisor Jason Fine Thesis advisor Jennifer Flythe Thesis advisor Gerardo Heiss Thesis advisor J. Bradley Layton Thesis advisor text Assimon_unc_0153D_17461.pdf uuid:034f5a03-c237-4d24-bfa9-a4a2dfdee78b 2019-12-31T00:00:00 2017-12-02T20:07:10Z proquest application/pdf 2568267