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For example, the adjusted hazard ratio for β blockers was 0.59 (95% confidence interval 0.48 to 0.72) for people with atrial fibrillation and 0.68 (0.57 to 0.81) for those with heart failure.The adjusted hazard ratios for cardiovascular drugs were similar to those with common combinations of four coexisting conditions, with trends toward variable effects for β blockers.The study drugs consisted of all oral prescription drugs (non-prescription ones such as aspirin were not available in the dataset), used by at least 10% of the study population and recommended in US national disease guidelines for any study condition.6 7 8 9 10 11 21 22 We accepted any evidence level in identifying the study drugs.23 The nine drugs included β blockers (cardioselective or αβ blockers); calcium channel blockers; clopidogrel; metformin; renin-angiotensin system (RAS) blockers, including angiotensin converting enzyme inhibitors and angiotensin II receptor blockers; selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazide diuretics; and warfarin.

The drugs recommended in the national guidelines that were not included in the current study because they are not used orally, are not prescription drugs in the United States, or were used by less than 10% of the population is listed in the footnote in table 1.

We estimated the association between nine guideline recommended and commonly prescribed drugs and death in a nationally representative sample of older adults with multiple chronic conditions, including common combinations of coexisting conditions.

The study sample included Medicare Current Beneficiary Survey participants enrolled from 2005-09, with follow-up through 2011.19 The Medicare Current Beneficiary Survey is a representative sample of Medicare—the federal health insurance for older adults and people with disabilities—beneficiaries in the United States obtained using stratified multistage sampling from the Centers for Medicare and Medicaid Services enrollment file.19 We included all participants aged 65 years or more with at least two of nine chronic conditions, identified by at least one inpatient or two other kinds of claims (outpatient, physician, skilled nursing, home health) during the first two years of participation.

A recent Cochrane review showed that observational study results often are similar to those found in randomized controlled trials, suggesting this design may be suitable for studying drug effects.18 Average effect in either randomized controlled trials or observational studies, however, is not a sufficient measure of drug effects among older adults with multiple chronic conditions.

Results in people with key combinations of chronic conditions are also needed to guide clinical decision making.

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