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Influenza Vaccination in Patients with Diabetes: Exploration of the Healthy User in Pharmacoepidemiology Studies Open Access


Other title
Influenza Vaccination
Healthy User Bias
Type of item
Degree grantor
University of Alberta
Author or creator
Achtymichuk, Karly A
Supervisor and department
Eurich, Dean (School of Public Health)
Examining committee member and department
Johnson, Jeff (School of Public Health)
Simpson, Scot (Pharmacy and Pharmaceutical Sciences)
School of Public Health
Clinical Epidemiology
Date accepted
Graduation date
Master of Science
Degree level
Pharmacoepidemiologic studies of preventive medications or therapies are prone to the healthy user bias, as patients who are prescribed and adhere to preventive medications/therapies are likely different than patients not receiving these medications in multiple aspects of their lives. These differences can be a source of bias in estimating the isolated effect of the medication/therapy under study. The objectives of this research were to explore characteristics and behaviors of patients who receive influenza vaccination, which has previously been shown to be a strong marker of healthy users. Two studies were conducted; the first study was done in a prospective cohort of adults with type 2 diabetes, and involved statistical modeling to identify predictors of influenza vaccine receipt, which included: taking preventive medications (e.g., aspirin, blood pressure medications and cholesterol-lowering medications) and having foot checks done by a healthcare professional. These associated behaviors reinforce the need for observational studies of influenza vaccine effectiveness to control for healthy user attributes in order to reduce associated biases. The second study involved building a healthy user index to be used for adjustment of bias in large administrative databases. The score was developed based on characteristics believed to be associated with the healthy user (identified using influenza vaccination as a prototypical surrogate) from the literature. The index was internally validated and significantly predicted influenza vaccination. Future research should be aimed at evaluating the ability of the index to control for healthy user bias in real-world observational studies of preventive medications/ therapies.
Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.
Citation for previous publication
K.A. Achtymichuk, J.A. Johnson, F. Al Sayah, and D.T. Eurich, “Characteristics and Health Behaviors of Diabetic Patients Receiving Influenza Vaccination”, Vaccine [serial online]. July 9, 2015;33:3549-3555. Available from: ScienceDirect, Ipswich, MA.

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