How do observational studies expand the evidence base for therapy?

Clinical heterogeneity between two subgroups of patients with idiopathic orbital inflammation

Objective

Idiopathic orbital inflammation (IOI) is a group of orbital inflammatory diseases of unknown etiopathogenesis. We investigated whether patients with IOI have clinical heterogeneity based on the presence (typical group) or absence (atypical group) of a unique onset that periocular inflammatory symptoms emerge suddenly but progress slowly.

Methods and analysis

This retrospective cohort study included 195 patients diagnosed with IOI. We analysed the clinical data of patients, including the outcomes of corticosteroid treatment, in two subgroups stratified on the basis of the presence (130 patients) or absence (65 patients) of the unique onset.

Results

Patients in the typical group were significantly younger at disease onset than those in the atypical group (median age; 52 vs 65 years, p=0.002); had more ocular adnexa-specific lesions, namely, dacryoadenitis, myositis, scleritis and optic perineuritis (78% vs 45%, p=0.00001); and had significantly fewer associations with immune-mediated inflammatory diseases (4% vs 15%, p=0.004). Among 30/119 patients (25%) who were steroid refractory in the typical group, a long period of time from symptom onset to initiation of treatment was a significant steroid-refractory risk factor (OR: 16.7), whereas, among the 18/40 patients (45%) who were steroid refractory in the atypical group, intraconal diffuse lesions were a significant steroid-refractory risk factor (OR: 8.8).

Conclusion

This cohort study suggests clinical heterogeneity between the two subgroups of patients with IOI.

Methodological evaluation of bias in observational coronavirus disease 2019 studies on drug effectiveness

Background and objective

Observational studies may provide valuable evidence on real-world causal effects of drug effectiveness in patients with coronavirus disease 2019 (COVID-19). As patients are usually observed from hospital admission to discharge and drug initiation starts during hospitalization, advanced statistical methods are needed to account for time-dependent drug exposure, confounding and competing events. Our objective is to evaluate the observational studies on the three common methodological pitfalls in time-to-event analyses: immortal time bias, confounding bias and competing risk bias.

Methods

We performed a systematic literature search on 23 October 2020, in the PubMed database to identify observational cohort studies that evaluated drug effectiveness in hospitalized patients with COVID-19. We included articles published in four journals: British Medical Journal, New England Journal of Medicine, Journal of the American Medical Association and The Lancet as well as their sub-journals.

Results

Overall, out of 255 articles screened, 11 observational cohort studies on treatment effectiveness with drug exposure–outcome associations were evaluated. All studies were susceptible to one or more types of bias in the primary study analysis. Eight studies had a time-dependent treatment. However, the hazard ratios were not adjusted for immortal time in the primary analysis. Even though confounders presented at baseline have been addressed in nine studies, time-varying confounding caused by time-varying treatment exposure and clinical variables was less recognized. Only one out of 11 studies addressed competing event bias by extending follow-up beyond patient discharge.

Conclusions

In the observational cohort studies on drug effectiveness for treatment of COVID-19 published in four high-impact journals, the methodological biases were concerningly common. Appropriate statistical tools are essential to avoid misleading conclusions and to obtain a better understanding of potential treatment effects.

Association of Receiving Multiple, Concurrent Fracture-Associated Drugs With Hip Fracture Risk

IMPORTANCE

Many prescription drugs increase fracture risk, which raises concern for patients receiving 2 or more such drugs concurrently. Logic suggests that risk will increase with each additional drug, but the risk of taking multiple fracture-associated drugs (FADs) is unknown.

OBJECTIVE

To estimate hip fracture risk associated with concurrent exposure to multiple FADs.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a 20% random sample of Medicare fee-for-service administrative data for age-eligible Medicare beneficiaries from 2004 to 2014. Sex-stratified Cox regression models estimated hip fracture risk associated with current receipt of 1, 2, or 3 or more of 21 FADs and, separately, risk associated with each FAD and 2-way FAD combination vs no FADs. Models included sociodemographic characteristics, comorbidities, and use of non-FAD medications. Analyses began in November 2018 and were completed April 2019.

EXPOSURE

Receipt of prescription FADs.

MAIN OUTCOMES AND MEASURES

Hip fracture hospitalization.

RESULTS

A total of 11.3 million person-years were observed, reflecting 2 646 255 individuals (mean [SD] age, 77.2 [7.3] years, 1 615 613 [61.1%] women, 2 136 585 [80.7%] white, and 219 579 [8.3%] black). Overall, 2 827 284 person-years (25.1%) involved receipt of 1 FAD; 1 322 296 (11.7%), 2 FADs; and 954 506 (8.5%), 3 or more FADs. In fully adjusted, sex-stratified models, an increase in hip fracture risk among women was associated with the receipt of 1, 2, or 3 or more FADs (1 FAD: hazard ratio [HR], 2.04; 95% CI, 1.99-2.11; P < .001; 2 FADs: HR, 2.86; 95% CI, 2.77-2.95; P < .001; ≥3 FADs: HR, 4.50; 95% CI, 4.36-4.65; P < .001). Relative risks for men were slightly higher (1 FAD: HR, 2.23; 95% CI, 2.11-2.36; P < .001; 2 FADs: HR, 3.40; 95% CI, 3.20-3.61; P < .001; ≥3 FADs: HR, 5.18; 95% CI, 4.87-5.52; P < .001). Among women, 2 individual FADs were associated with HRs greater than 3.00; 80 pairs of FADs exceeded this threshold. Common, risky pairs among women included sedative hypnotics plus opioids (HR, 4.90; 95% CI, 3.98-6.02; P < .001), serotonin reuptake inhibitors plus benzodiazepines (HR, 4.50; 95% CI, 3.76-5.38; P < .001), and proton pump inhibitors plus opioids (HR, 4.00; 95% CI, 3.56-4.49; P < .001). Receipt of 1, 2, or 3 or more non-FADs was associated with a small, significant reduction in fracture risk compared with receipt of no non-FADs among women (1 non-FAD: HR, 0.93; 95% CI, 0.90-0.96; P < .001; 2 non-FADs: HR, 0.84; 95% CI, 0.81-0.87; P < .001; ≥3 non-FADs: HR, 0.74; 95% CI, 0.72-0.77; P < .001).

CONCLUSIONS AND RELEVANCE

Among older adults, FADs are commonly used and commonly combined. In this cohort study, the addition of a second and third FAD was associated with a steep increase in fracture risk. Many risky pairs of FADs included potentially avoidable drugs (eg, sedatives and opioids). If confirmed, these findings suggest that fracture risk could be reduced through tighter adherence to long-established prescribing guidelines and recommendations.

Are Cure Rates for Breast Cancer Improved by Local and Regional Anesthesia?

BACKGROUND AND OBJECTIVES

Recent preclinical basic science studies suggest that patient tumor immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective review concluded that breast cancer patients receiving paravertebral block and GA had better cancer outcomes compared with patients receiving GA alone. This study has not been validated. We hypothesized that local or regional anesthesia (LRA) would be associated with better cancer outcomes compared with GA.

METHODS

We retrospectively reviewed a prospectively collected database to identify all stage 0-III breast cancer patients undergoing surgery in a single center during a 9-year period ending January 1, 2010. Patients were divided into 2 groups: those who received only LRA and those who received GA. Overall survival (OS), disease-free survival (DFS), and local regional recurrence (LRR) were calculated using the Kaplan-Meier method with log-rank comparison before and after propensity score matching.

RESULTS

Median age of the 1107 patients who met study criteria was 64 years (range, 24-97 years). Median and longest follow-up were 5.5 and 12.5 years, respectively. General anesthesia was used for 461 patients (42%), and 646 (58%) received LRA. The point estimates of cumulative OS, DFS, and LRR "free" rates at 5 years for the GA and LRA groups were 85.5% and 87.1%, 94.2% and 96.1%, and 96.3% and 95.8%, respectively. Cox regression showed no significant differences between the 2 groups (GA and LRA) for the 3 outcomes: OS (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.59-1.10; P = 0.17), DFS (HR, 0.91; 95% CI, 0.55-1.76; P = 0.87), and LRR (HR, 1.73; 95% CI, 0.83-3.63; P = 0.15).

CONCLUSIONS

Breast cancer OS, DFS, and LRR were not affected by type of anesthesia in our institution. This result differs from that of the only prior published clinical report on this topic and does not provide clinical corroboration of the basic science studies that suggest oncologic benefits to LRA.

Evidence Summaries and Synthesis: Necessary but Insufficient Approach for Determining Clinical Practice of Integrated Medicine?

The heart of evidence-based practice is in fact to be found in the use of evidence gained from systematic reviews or more correctly in the synthesis of evidence from systematic reviews. But just as studies vary in the quality of the design so do systematic reviews, and it is therefore necessary for those wishing to make clinical decisions based on this evidence to evaluate the evidence summaries and synthesis themselves. This article examines the criteria available for evaluating the quality of the evidence summary and synthesis. It provides a set of questions for doing this: who did the review; w hat was the objective of the review; how was the review done? Together these questions allow us to determine the trustworthiness of the review. However, that by itself is insufficient for making clinical decisions. The article suggests that this occurs because the very studies that improve the quality of reviews, that is, the randomized controlled trials, deal with efficacy and not effectiveness. Because they tend to be conducted under ideal conditions, they seldom provide the type of information needed to make a decision vis-à-vis an individual patient. The article suggests that observation studies provide much better information in this regard. The challenge here, however, is to develop standards for judging quality observation studies. In conclusion, systematic reviews and syntheses of evidence are a necessary but an insufficient method for making clinical decisions.

Evidence for risk stratification when monitoring for toxicities following initiation of combination antiretroviral therapy

OBJECTIVE

Laboratory monitoring is recommended during combination antiretroviral therapy (cART), but the pattern of detected abnormalities and optimal monitoring are unknown. We assessed laboratory abnormalities during initial cART in 2000-2010 across the United States.

DESIGN

Observational study in the Centers for AIDS Research Network of Integrated Clinical Systems Cohort.

METHODS

Among patients with normal results within a year prior to cART initiation, time to first significant abnormality was assessed by Kaplan-Meier curves stratified by event type, with censoring at first of regimen change, loss to follow-up, or 104 weeks. Incidence rates of first events were estimated using Poisson regression; multivariable analyses identified associated factors. Results were stratified by time (16 weeks) from therapy initiation.

RESULTS

A total of 3470 individuals contributed 3639 person-years. Median age, pre-cART CD4, and follow-up duration were 40 years, 206 cells/μl, and 51 weeks, respectively. Incidence rates for significant abnormalities (per 100 person-years) in the first 16 weeks post-cART initiation were as follows: lipid=49 [95% confidence interval (CI) 41-58]; hematologic=44 (40-49); hepatic=24 (20-27); and renal=9 (7-11), dropping substantially during weeks 17-104 of cART to lipid=23 (18-29); hematologic=5 (4-6); hepatic=6 (5-8); and renal=2 (1-3) (all P<0.05). Among patients receiving initial cART with no prior abnormality (N=1889), strongest associations for hepatic abnormalities after 16 weeks were hepatitis B and C [hazard ratio=2.3 (95% CI 1.2-4.5) and hazard ratio=3.0 (1.9-4.5), respectively]. The strongest association for renal abnormalities was hypertension [hazard ratio=2.8 (1.4-5.6)].

CONCLUSION

New abnormalities decreased after week 16 of cART. For abnormalities not present by week 16, subsequent monitoring should be guided by comorbidities.

Reassessing the evidence hierarchy in asthma: evaluating comparative effectiveness

Classical randomized controlled trials are the gold standard in medical evidence because of their high internal validity. However, their necessarily strict design can limit their external validity and the ability to extrapolate these data to real world patients. Therefore, alternatively designed studies may play a complementary role in evaluating the comparative effectiveness of therapies in nonidealized patients in more naturalistic, real world settings. Observational studies have high external validity and can evaluate real world outcomes. Their strength lies in hypothesis generation and testing and in identifying areas in which further clinical trials may be required. Pragmatic trials are designed to maximize applicability of trial results to usual care settings by relying on clinically important outcomes and enrolling a wide range of participants. A combination of these approaches is preferable and necessary.

Use of restaging bladder tumor resection for bladder cancer among Medicare beneficiaries

OBJECTIVE

To evaluate the use and effectiveness of restaging bladder tumor resection using population-based data. Restaging bladder tumor resection improves staging accuracy and the response to intravesical therapy. However, its use outside of a tertiary care setting, and its subsequent clinical implications, are unknown.

METHODS

We identified 62 016 patients diagnosed with bladder cancer between 1992 and 2005 using SEER-Medicare data. Restaging bladder tumor resection was defined as 2 or more resections occurring within 60 days of diagnosis. Using multivariable models, we assessed the relationship between the use of restaging resection and cancer-specific survival.

RESULTS

Restaging resection was performed in only 3064 (4.9%) of newly diagnosed bladder cancer patients, but was most common among those with high grade (7.7% vs 2.0% in low grade, P < .001) and stage (8.8% in T2 vs 2.8% in Ta/Tis, P < .001) disease. Compared to patients with muscle-invasive cancers who did not undergo restaging at diagnosis, restaging resection was associated with improved 5-year cancer-specific mortality among pathologically staged patients (20.4% vs 28.0%, P = .02), while clinically staged patients trended toward improved mortality (28.2% vs 31.9%, P = .07).

CONCLUSION

Restaging transurethral resection for bladder cancer is relatively uncommon and associated with improved survival among patients with muscle invasive bladder cancer. Greater use of restaging warrants further investigation as a simple means of improving outcomes among patients suspected of having muscle invasive disease.

Delays in diagnosis and bladder cancer mortality

BACKGROUND

Mortality from invasive bladder cancer is common, even with high-quality care. Thus, the best opportunities to improve outcomes may precede the diagnosis. Although screening currently is not recommended, better medical care of patients who are at risk (ie, those with hematuria) has the potential to improve outcomes.

METHODS

The authors used the Surveillance, Epidemiology, and End Results-Medicare linked database for the years 1992 through 2002 to identify 29,740 patients who had hematuria in the year before a bladder cancer diagnosis and grouped them according to the interval between their first claim for hematuria and their bladder cancer diagnosis. Cox proportional hazards models were fitted to assess relations between these intervals and bladder cancer mortality, adjusting first for patient demographics and then for disease severity. Adjusted logistic models were used to estimate the patient's probability of receiving a major intervention.

RESULTS

Patients (n = 2084) who had a delay of 9 months were more likely to die from bladder cancer compared with patients who were diagnosed within 3 months (adjusted hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.20-1.50). This risk was not markedly attenuated after adjusting for disease stage and tumor grade (adjusted HR, 1.29; 95% CI, 1.14-1.45). In fact, the effect was strongest among patients who had low-grade tumors (adjusted HR, 2.11; 95% CI, 1.69-2.64) and low-stage disease (ie, a tumor [T] classification of Ta or tumor in situ; adjusted HR, 2.02; 95% CI, 1.54-2.64).

CONCLUSIONS

A delay in the diagnosis of bladder cancer increased the risk of death from disease independent of tumor grade and or disease stage. Understanding the mechanisms that underlie these delays may improve outcomes among patients with bladder cancer.

Understanding the variation in treatment intensity among patients with early stage bladder cancer

BACKGROUND

Given the uncertainty surrounding the optimal management for early stage bladder cancer, physicians vary in how they approach the disease. The authors of this report linked cancer registry data with medical claims to identify the sources of variation and opportunities for improving the value of cancer care.

METHODS

By using data from the Surveillance, Epidemiology, and End Results-Medicare database (1992-2005), patients with early stage bladder cancer were abstracted (n=18,276). The primary outcome was the intensity of initial treatment that patients received, as measured by all Medicare payments for bladder cancer incurred in the 2 years after diagnosis. Multilevel models were fitted to partition the variation in treatment intensity attributable to patient versus provider factors, and the potential savings to Medicare from reducing the physician contribution were estimated.

RESULTS

Provider factors accounted for 9.2% of the variation in treatment intensity. Increasing provider treatment intensity did not correlate with improved cancer-specific survival (P=.07), but it was associated with the subsequent receipt of major interventions, including radical cystectomy (P<.001). If provider-level variation was reduced and clinical practice was aligned with that of physicians who performed in the 25th percentile of treatment intensity, then total payments made for the average patient could be lowered by 18.6%, saving Medicare $18.7 million annually.

CONCLUSIONS

The current results indicated that a substantial amount of the variation in initial treatment intensity for early stage bladder cancer is driven by the physician. Furthermore, a more intensive practice style was not associated with improved cancer-specific survival or the avoidance of major interventions. Therefore, interventions aimed at reducing between-provider differences may improve the value of cancer care.

Racial differences in treatment and outcomes among patients with early stage bladder cancer

BACKGROUND

Black patients are at greater of risk of death from bladder cancer than white patients. Potential explanations for this disparity include a more aggressive phenotype and delays in diagnosis resulting in higher stage disease. Alternatively, black patients may receive a lower quality of care, which may explain this difference.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the years from 1992 through 2002, the authors identified patients with early stage bladder cancer. Multivariate models were fitted to measure relations between race and mortality, adjusting for differences in patients and treatment intensity. Next, shared-frailty proportional hazards models were fitted to evaluate whether the disparity was explained by differences in the quality of care provided.

RESULTS

Compared with white patients (n = 14,271), black patients (n = 342) were more likely to undergo restaging resection (12% vs 6.5%; P < .01) and urine cytologic evaluation (36.8% vs 29.7%; P < .01), yet they received fewer endoscopic evaluations (4 vs 5; P < .01). The use of aggressive therapies (cystectomy, systemic chemotherapy, radiation) was found to be similar among black patients and white patients (12% vs 10.2%, respectively; P = .31). Although black patients had a greater risk of death compared with white patients (hazards ratio [HR], 1.23; 95% confidence interval [95% CI], 1.07-1.42), this risk was attenuated only modestly after adjusting for differences in treatment intensity and provider effects (HR, 1.22; 95% CI, 1.06-1.42).

CONCLUSIONS

Although differences in initial treatment were evident, they did not appear to be systematic and had unclear clinical significance. Whereas black patients are at greater risk of death, this disparity did not appear to be caused by differences in the intensity or quality of care provided.

Provider treatment intensity and outcomes for patients with early-stage bladder cancer

BACKGROUND

Bladder cancer is among the most prevalent and expensive to treat cancers in the United States. In the absence of high-level evidence to guide the optimal management of bladder cancer, urologists may vary widely in how aggressively they treat early-stage disease. We examined associations between initial treatment intensity and subsequent outcomes.

METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients who were diagnosed with early-stage bladder cancer from January 1, 1992, through December 31, 2002 (n = 20 713), and the physician primarily responsible for providing care to each patient (n = 940). We ranked the providers according to the intensity of treatment they delivered to their patients (as measured by their average bladder cancer expenditures reported to Medicare in the first 2 years after a diagnosis) and then grouped them into quartiles that contained approximately equal numbers of patients. We assessed associations between treatment intensity and outcomes, including survival through December 31, 2005, and the need for subsequent major interventions by using Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

The average Medicare expenditure per patient for providers in the highest quartile of treatment intensity was more than twice that for providers in the lowest quartile of treatment intensity ($7131 vs $2830, respectively). High-treatment intensity providers more commonly performed endoscopic surveillance and used more intravesical therapy and imaging studies than low-treatment intensity providers. However, the intensity of initial treatment was not associated with a lower risk of mortality (adjusted hazard ratio of death from any cause for patients of low- vs high-treatment intensity providers = 1.03, 95% confidence interval 0.97 to 1.09). Initial intensive management did not obviate the need for later interventions. In fact, a higher proportion of patients treated by high-treatment intensity providers than by low-treatment intensity providers subsequently underwent a major medical intervention (11.0% vs 6.4%, P = .02).

CONCLUSIONS

Providers vary widely in how aggressively they manage early-stage bladder cancer. Patients treated by high-treatment intensity providers do not appear to benefit in terms of survival or in avoidance of subsequent major medical interventions.

Aspirin use, dose, and clinical outcomes in postmenopausal women with stable cardiovascular disease: the Women's Health Initiative Observational Study

BACKGROUND

Despite compelling evidence that aspirin reduces fatal and nonfatal vascular events among the overall population in various settings, women have frequently been underrepresented and their data underreported. We sought to evaluate the relationship between aspirin use, dose (81 or 325 mg), and clinical outcomes among postmenopausal women with stable cardiovascular disease (CVD).

METHODS AND RESULTS

Women with CVD (n=8928) enrolled in the Women's Health Initiative Observational Study were used for this analysis. The primary outcome was the incidence of all-cause mortality and cardiovascular events (myocardial infarction, stroke, and cardiovascular death). Among 8928 women with stable CVD, 4101 (46%) reported taking aspirin, of whom 30% were on 81 mg and 70% were on 325 mg. At 6.5 years of follow-up, no significant association was noted for aspirin use and all-cause mortality or cardiovascular events. However, after multivariate adjustment, aspirin use was associated with a significantly lower all-cause (adjusted hazard ratio, 0.86 [0.75 to 0.99]; P=0.04) and cardiovascular-related mortality (adjusted hazard ratio, 0.75 [0.60 to 0.95]; P=0.01) compared with no aspirin. Aspirin use was associated with a lower risk of cardiovascular events (adjusted hazard ratio, 0.90 [0.78 to 1.04]; P=0.14), which did not meet statistical significance. Compared with 325 mg, use of 81 mg was not significantly different for all-cause mortality, cardiovascular events, or any individual end point.

CONCLUSIONS

After multivariate adjustment, aspirin use was associated with significantly lower risk of all-cause mortality, specifically, cardiovascular mortality, among postmenopausal women with stable CVD. No significant difference was noted between 81 mg and 325 mg of aspirin. Overall, aspirin use was low in this cohort of women with stable CVD.

Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis

OBJECTIVES

The purpose of our multicenter study was to examine the impact of pre-operative administration of clopidogrel on reoperation rates, incidence of life-threatening bleeding, inpatient length of stay, and other bleeding-related outcomes in acute coronary syndrome (ACS) patients requiring cardiopulmonary bypass (coronary artery bypass graft surgery [CABG]) in a broad cross section of U.S. hospitals.

BACKGROUND

There is relative uncertainty about the relationship between clopidogrel and CABG-associated outcomes in the setting of ACS.

METHODS

A retrospective cohort analysis was performed of randomly selected ACS patients requiring CABG in 14 hospitals across the U.S. Patients exposed to clopidogrel were compared with those not exposed to clopidogrel within 5 days prior to surgery.

RESULTS

Of the 596 patients enrolled in the study, 298 had been exposed to clopidogrel within 5 days (Group A). Patients in Group A were more than 3-fold more likely to require reoperation for assessment of bleeding than patients not exposed to clopidogrel (6.4% vs. 1.7% Group B, p = 0.004). Major bleeding occurred in 35% of Group A patients versus 26% of Group B patients (p = 0.049). Length of stay was greater in Group A compared with Group B (9.7 +/- 6.0 days vs. 8.6 +/- 4.7 days, unadjusted p = 0.016). After logistic regression analysis, clopidogrel exposure within 5 days of CABG was the strongest predictor of reoperation (odds ratio [OR]: 4.60, 95% confidence interval [CI]: 1.45 to 14.55) and major bleeding (OR: 1.824, 95% CI: 1.106 to 3.008).

CONCLUSIONS

After ACS, patients who undergo CABG within 5 days of receiving clopidogrel are at increased risk for reoperation, major bleeding, and increased length of stay. These risks must be balanced by the clinical benefits of clopidogrel use demonstrated in randomized clinical trials.

Impact of aspirin treatment on long-term outcome (over 10 years) after percutaneous coronary intervention

Aspirin has been shown to reduce cardiovascular morbidity and mortality following percutaneous coronary intervention (PCI). However, its effects on long-term (over 10 years) mortality have not been fully elucidated. This retrospective study recorded the patient characteristics and admission medication for all patients undergoing PCI over an 8-year period from 1984 to 1992. Follow-up information was available for 748 patients (100%) for a mean of 143.6 +/- 43.4 months. A propensity analysis was performed to adjust for presumed selection biases in the administration of aspirin. The baseline clinical characteristics were similar between the group that received aspirin and the group that did not, except for the administration of statins and PCI procedural success rate. Of the 748 patients, 535 (71.5%) received aspirin treatment at the time of PCI. During the 12-year follow-up, 54 patients died from any cause and 20 patients from cardiac death. Kaplan-Meier analysis showed that aspirin treatment led to a significant reduction in all cause mortality (10% versus 16.4%; P = 0.01) and cardiac death (3.7% versus 8.0%; P = 0.02) compared to other antiplatelet drugs. The hazard ratio (HR) for the total mortality and cardiac mortality rates was adjusted using the Cox-proportional hazard model for confounding variables and propensity score. The all cause (HR, 0.49; 95%CI [0.29-0.80], P = 0.005) and cardiac mortality rates (HR, 0.32; 95%CI [0.14-0.72], P = 0.006) for patients receiving aspirin remained lower than for those not receiving aspirin. Aspirin treatment at the time of PCI significantly reduced the risk of death from any cause and cardiac death. The administration of aspirin had a positive impact on the over 10-year long-term outcomes of patients who underwent PCI.

The contribution of observational studies to the knowledge of drug effectiveness in heart failure

AIMS

Randomized controlled trials (RCTs) are the golden standard for the assessment of drug efficacy. Little is known about the add-on value of observational studies in heart failure (HF). We aimed to assess the contribution of observational studies to actual knowledge regarding the effectiveness of angiotensin-converting enzyme inhibitors (ACEI), and beta-blockers (BB) in HF.

METHODS

Observational studies that assessed the effectiveness of ACEI and BB in HF were identified by searching Medline, Embase, Cochrane Database (1990-2005) and the bibliographies of published articles. Cohort, case-control and time-series analysis studies were considered for inclusion. Studies with <100 patients and those who did not perform a multivariate analysis were excluded.

RESULTS

A total of 23 cohort studies met the inclusion criteria. Studies of ACEI and BB showed a decrease in mortality with drug use in elderly patients with a broad range of ejection fraction (EF), and in those with depressed EF. Additionally, they showed a decrease in mortality in patients with renal insufficiency. The effect of ACEI and BB in HF with preserved EF was not clear, although last evidence suggests a potential benefit. Low-dose ACEI and BB may have beneficial effects. Target doses of ACEI seemed superior to low doses, but there was no clear dose-response relationship.

CONCLUSIONS

Observational studies in HF validate the effectiveness of ACEI and BB in populations underrepresented or excluded from RCTs. Observational studies of drug effectiveness provide relevant additional information for clinical practice.

The role of a homoeopathic preparation compared with conventional therapy in the treatment of injuries: an observational cohort study

OBJECTIVES

To assess the use, effectiveness and safety of a homoeopathic preparation (Traumeel) compared with conventional therapies in the treatment of trauma and injuries.

METHODS

Multi-centre, prospective, comparative observational cohort study of patients with various musculoskeletal injuries. German physicians who were using homoeopathy in addition to conventional medicine included patients. Patients treated with Traumeel were compared with patients managed conventionally. The primary outcome measure was the rate of resolution of the principal symptoms (i.e. pain and inflammatory symptoms) at the end of therapy.

RESULTS

Sixty-nine Traumeel treated and 64 conventionally treated patients fitted the selection criteria. The most common diagnoses were acute injuries (sprains, strains, contusions, etc.) of the ankles, knees and hands. There were no significant differences between demographic and anamnestic baseline characteristics of both groups. Complete resolution of the principal symptom at the end of therapy occurred in 41 (59.4%) patients in the homoeopathy group versus 37 (57.8%) patients in the conventional group. No adverse events were reported in the Traumeel group compared to six adverse events (6.3%) in the conventional group. Physician-assessed tolerability was significantly better in the Traumeel group (P=0.001).

CONCLUSION

Traumeel is as effective as conventional medicines in the management of mild to moderate injuries in this population. Traumeel was safe in use and judged by physicians to be better tolerated than conventional medicines. This study contributes to the case for a broad clinical effectiveness of Traumeel in the treatment of acute injuries and trauma.

Evidence Based Complementary and Alternative Medicine: Promises and Problems

OBJECTIVE

The present paper examines the experience of establishing a center for evidence-based complementary and alternative medicine (EBCAM) practice. It examines both the difficulties and the challenges of doing research to establish EBCAM. The paper also examines the political context of the demand for evidence- based practice (EBP) for CAM.

IMPLEMENTATION

A center for EBCAM was funded for 3 years within the Southern California Evidence-Based Practice Center by the National Center for CAM and administered by the Agency for Health Research Quality. This experience provides the basis for this paper.

RESULTS

While the experience of creating an EBM Center for CAM has shown that much work can be accomplished by applying standard methods of EBP medicine, it also highlights the weaknesses of such an agenda. Many standard research methods are simply not applicable to CAM, and even where they are, effectiveness is a much more important means of assessing CAM than simply efficacy. Researchers however, must be conscious of the political motivations behind much of the demand for EBCAM. Where such demands are coming from allopathic medicine, they clearly form a continuing part of medical opposition to CAM and may be intended to perpetuate the dominance of the biomedical paradigm in healthcare. The challenge for CAM is to recognize the limitations of EBP but not to throw the 'baby out with the bathwater'. There is much in EBP that clearly should be emulated by the CAM community but only where it is appropriate.

An Invasive Strategy Is Associated With Decreased Mortality in Patients 80 Years and Older With Acute Myocardial Infarction

The value of invasive therapy in elderly patients with acute myocardial infarction is controversial. The authors performed a retrospective chart review of 140 consecutive patients 80 years and older who were hospitalized with acute myocardial infarction. Hospital outcomes and long-term survival were compared in 79 patients referred for cardiac catheterization during hospitalization with outcomes in 61 patients managed conservatively. Vital status as of December 2003 was determined from the Social Security Death Index. Propensity analysis was used to limit confounding from 13 variables. After a mean follow-up of 333 days, unadjusted mortality was lower in the invasive group (16.5% vs 50.8%; P<.001). The multivariable propensity-adjusted hazard ratio for death was 0.30 (95% confidence interval, 0.11-0.76; P=.01), favoring the invasive group. These data suggest that in patients 80 years and older who are hospitalized with acute myocardial infarction, an invasive strategy confers a significant survival advantage during the first year after hospital discharge.

Does multidisciplinary rehabilitation benefit whiplash recovery?: results of a population-based incidence cohort study

STUDY DESIGN

Population-based, incidence cohort.

OBJECTIVES

To evaluate a government policy of funding community and hospital-based fitness training and multidisciplinary rehabilitation for whiplash.

SUMMARY OF BACKGROUND DATA

Although insurance benefits commonly include rehabilitation for whiplash, its effectiveness is unknown.

METHODS

All Saskatchewan adults treated for whiplash (n = 6,021) over a 2-year period were followed up at 6 weeks, 3, 6, 9, and 12 months. Recovery was defined by self-report of improvement. Recovery times were compared between those attending fitness training at health clubs (n = 833), multidisciplinary outpatient rehabilitation (n = 468), and multidisciplinary inpatient rehabilitation (n = 135) to those receiving usual insured individual care.

RESULTS

Recovery was 32% slower in those receiving fitness training within 69 days of injury (P = 0.001) and 19% slower when received within 119 days of injury (P = 0.041). Recovery was 50% slower in those receiving outpatient rehabilitation within 119 days of injury (P = 0.001). Attending inpatient rehabilitation did not influence recovery rates during the follow up (P = 0.131). Multivariable adjustment for important prognostic factors did not change these results.

CONCLUSIONS

We found no evidence to support the effectiveness of a population-based program of fitness training and multidisciplinary rehabilitation for whiplash. Rehabilitation programs should be tested in randomized trials before being recommended to injured populations.

Prognosis research: why is Dr. Lydgate still waiting?

BACKGROUND

Understanding prognosis--the future risk of adverse outcomes among people with existing disease--plays third fiddle behind clinical research into therapeutic interventions and novel diagnostic technologies.

METHODS AND RESULTS

Diseases show marked variations in a wide range of prognostic outcomes, yet these variations have seldom been the subject of systematic and sustained epidemiologic and multidisciplinary research. This is important to prioritize hypotheses for testing in intervention studies in groups, and to refine tools for prognostication in individuals. Methodologic standards for the design, conduct, analysis and reporting of prognosis research are required. Training is needed for the clinicians, policymakers, and payers who use prognostic information.

CONCLUSION

Here, arguments detracting from the potential scope of prognosis research are rebutted and misconceptions addressed with the aim of stimulating debate on the evolving role of prognosis research.

Hydroxymethylglutaryl-CoA reductase inhibitors in older persons with acute myocardial infarction: evidence for an age-statin interaction

OBJECTIVES

To characterize the relationship between hydroxymethylglutaryl-CoA reductase inhibitors (statins) and outcomes in older persons with acute myocardial infarction (AMI).

DESIGN

Observational study.

SETTING

Acute care hospitals in the United States from April 1998 to June 2001.

PARTICIPANTS

Medicare patients aged 65 and older with a principal discharge diagnosis of AMI (N=65,020) who did and did not receive a discharge prescription for statins.

MEASUREMENTS

The primary outcome of interest was all-cause mortality at 3 years after discharge.

RESULTS

Of 23,013 patients with AMI assessed, 5,513 (24.0%) were receiving a statin at discharge. Nearly 40% of eligible patients (n=8,452) were aged 80 and older, of whom 1,310 (15.5%) were receiving a statin at discharge. In a multivariable model taking into account demographic, clinical, physician and hospital characteristics, and propensity score, discharge statin therapy was associated with significantly lower 3-year mortality (hazard ratio (HR)=0.89 (95% confidence interval (CI)=0.83-0.96)). In an analysis stratified by age, discharge statins were associated with lower mortality in patients younger than 80 (HR=0.84, 95% CI=0.76-0.92) but not in those aged 80 and older (HR=0.97, 95% CI=0.87-1.09).

CONCLUSION

Statin therapy is associated with lower mortality in older patients with AMI younger than 80 but not in those aged 80 and older, as a group. This finding questions whether statin efficacy data in younger patients can be broadly applied to the very old and indicates the need for further study of this group.

Weaknesses of goodness-of-fit tests for evaluating propensity score models: the case of the omitted confounder

PURPOSE

Propensity scores are used in observational studies to adjust for confounding, although they do not provide control for confounders omitted from the propensity score model. We sought to determine if tests used to evaluate logistic model fit and discrimination would be helpful in detecting the omission of an important confounder in the propensity score.

METHODS

Using simulated data, we estimated propensity scores under two scenarios: (1) including all confounders and (2) omitting the binary confounder. We compared the propensity score model fit and discrimination under each scenario, using the Hosmer-Lemeshow goodness-of-fit (GOF) test and the c-statistic. We measured residual confounding in treatment effect estimates adjusted by the propensity score omitting the confounder.

RESULTS

The GOF statistic and discrimination of propensity score models were the same for models excluding an important predictor of treatment compared to the full propensity score model. The GOF test failed to detect poor model fit for the propensity score model omitting the confounder. C-statistics under both scenarios were similar. Residual confounding was observed from using the propensity score excluding the confounder (range: 1-30%).

CONCLUSIONS

Omission of important confounders from the propensity score leads to residual confounding in estimates of treatment effect. However, tests of GOF and discrimination do not provide information to detect missing confounders in propensity score models. Our findings suggest that it may not be necessary to compute GOF statistics or model discrimination when developing propensity score models.

Long-Term Effects of Integrated Rehabilitation in Patients with Advanced Angina Pectoris: A Nonrandomized Comparative Study

OBJECTIVES

An evaluation of Integrative Rehabilitation (IR) of patients with angina pectoris with respect to death rate, the need for invasive treatment, and cost effectiveness.

DESIGN

A report from a clinical database. Death rates were compared to those of the general Danish population matched for age, gender, and observation period, as well as with data from the literature concerning medical and invasive treatments.

SETTING

The treatment was carried out as an ambulatory treatment in a private clinic.

SUBJECTS

One hundred and sixty-eight (168) patients with angina pectoris, of whom 103 were candidates for invasive treatment and 65 for whom this had been rejected.

INTERVENTIONS

Integrated rehabilitation consists of acupuncture, a self-care program including acupressure, Chinese health philosophy, stress management techniques, and lifestyle adjustments.

OUTCOME MEASURES

Death rate from any cause, the need for invasive treatment, and health care expenses.

RESULTS

The 3-year accumulated risk of death was 2.0% (95% confidence limits: 0.0%-4.7%) for the 103 candidates for invasive treatment, 6.4% for the general Danish population, 5.4% (4.7%-6.1%), and 8.4% (7.7%-9.1%) for patients who underwent percutaneous transluminal balloon angioplasty and coronary artery bypass grafting, respectively, in New York. For the 65 inoperable patients the risk of death due to heart disease was 7.7% (3.9%-11.5%), compared to 16% (10%-34%) and 25% (18%-36%) for American patients, who were treated with laser revascularization or medication, respectively. Of the 103 candidates for invasive treatment, only 19 (18%) still required surgery. Cost savings over 3 years were US 36,000 dollars and US 22,000 dollars for surgical and nonsurgical patients, respectively. These were mainly achieved by the reduction in the use of invasive treatment and a 95% reduction in in-hospital days.

CONCLUSIONS

Integrated rehabilitation was found to be cost effective, and added years to the lives of patients with severe angina pectoris. The results invite further testing in a randomized trial.

Prognostic importance of presenting symptoms in patients undergoing exercise testing for evaluation of known or suspected coronary disease

PURPOSE

Chest symptoms, along with standard cardiovascular risk factors, are commonly factored into pretest risk stratification of patients who are referred for stress testing. We sought to determine the independent prognostic value of chest symptoms.

METHODS

We studied the outcomes of 10,870 patients referred for symptom-limited exercise testing who had no history of myocardial revascularization, heart failure, or arrhythmias. Chest symptoms were prospectively characterized according to prespecified definitions. Propensity analysis was used to account for differences in baseline and exercise characteristics.

RESULTS

Typical angina was present in 635 patients (6%), atypical angina in 3408 (33%), nonanginal chest pain in 1805 (17%), and dyspnea in 841 (8%). The remaining 4181 patients (38%) were asymptomatic. During a mean follow-up of 4.3 years, there were 381 deaths. After propensity matching patients who had typical angina with asymptomatic patients, symptoms were not predictive of mortality (adjusted hazard ratio [HR] = 0.8; 95% confidence interval [CI]: 0.6 to 1.3; P = 0.4). Among patients who had chest pain, typical angina was associated with a highly significant risk of mortality as compared with nonanginal chest pain (HR = 2.7; 95% CI: 1.4 to 5.1; P = 0.002), but not compared with atypical angina (HR = 1.3; 95% CI: 0.9 to 2.1; P = 0.21).

CONCLUSION

After accounting for baseline and exercise characteristics, the presence of symptoms was not independently associated with increased mortality among patients undergoing testing for known or suspected coronary disease. Among patients who actually had chest pain, typical angina carried a higher mortality risk.

A restrictive use of both autologous donation and recombinant human erythropoietin is an efficient policy for primary total hip or knee arthroplasty

A limitation of preoperative autologous blood donation (PABD) in nonanemics and the use of recombinant human erythropoietin (EPO) in anemics (baseline hematocrit [Hct] < or = 39%) could be an efficient approach of the cost-benefit ratio of transfusion during primary total hip (THA) or knee (TKA) arthroplasties. We evaluated the consequences on transfusion rates and costs of two different applications of a transfusion policy based on personal requirements during primary THA or TKA. This quality assurance observational study compared two prospective successive time periods; each included successive patients treated by the same medical team and standardized care. In Study 1 (n = 182), PABD was indicated if there were insufficient estimated red blood cell reserve and a life expectancy > or = 10 yr, no use of EPO, and identical criteria for any transfusion. Because this policy led to a 50% allogeneic transfusion rate when baseline Hct < or = 37% and autologous blood wastage in the nonanemics (baseline Hct > 39%), 2 refinements were introduced in Study 2 (n = 708): EPO without PABD when baseline Hct < or = 37%, and life expectancy > or = 10 yr, and avoidance of PABD in nonanemics. This novel care induced a marked decrease in transfusion rates (respectively, from 41% to 7%, P < 0.0002, in nonanemics; from 58% to 27%, P < 0.003, in anemics; and from 43% to 12%, P < 0.0001, overall), with no change in allogeneic transfusion (10%) and discharge Hct, and a 39% financial savings. This saving effect is a result of the suppression of PABD in nonanemics, who represent 75% of this surgical population. Although erythropoietin is expensive, it can be used with cost savings in selected patients because the overall cost of transfusion is reduced.

Propensity Analysis of Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease and High-Risk Features

Background— Although most randomized clinical trials have suggested that long-term survival rates after percutaneous coronary intervention (PCI) or surgical multivessel coronary revascularization (CABG) are equivalent, some post hoc analyses in high-risk groups and adjustment for severity of coronary disease have suggested higher mortality after PCI.

Methods and Results— We studied 6033 consecutive patients who underwent revascularization in the late 1990s. PCI was performed in 872 patients; 5161 underwent CABG. Half the patients had significant left ventricular dysfunction or diabetes. Propensity analysis to predict the probability of undergoing PCI according to 22 variables and their interactions was used. The C-statistic for this model was 0.90, indicating excellent discrimination between treatments. There were 931 deaths during 5 years of follow-up. The 1- and 5-year unadjusted mortality rates were 5% and 16% for PCI and 4% and 14% for CABG (unadjusted hazard ratio, 1.13; 95% CI, 1.0 to 1.4; P =0.07). PCI was associated with an increased risk of death (propensity-adjusted hazard ratio, 2.3; 95% CI, 1.9 to 2.9; P <0.0001). This difference was observed across all categories of propensity for PCI and in patients with diabetes or left ventricular dysfunction. Other independent predictors of mortality ( P ≤0.01 for all) were renal dysfunction, age, diabetes mellitus, chronic lung disease, peripheral vascular disease, left main trunk stenosis, and extent of coronary disease (Duke angiographic score).

Conclusions— In patients with multivessel coronary artery disease and many high-risk characteristics, CABG was associated with better survival than PCI after adjustment for risk profile.

Managing chronic disease: evidence-based medicine or patient centred medicine?

Chronic diseases are recognized as a leading cause of mortality, morbidity, health care utilization and cost. A constant tailoring of care to the actual needs of individual patients, complexity and long duration are the distinguishing features of chronic disease management. Given the rapid development and high use of services providing complex management, the number of controlled clinical trials in this field is limited. The information from the few available controlled clinical trials may be difficult to interpret, mainly due to a large variety in the interventions being studied, differences in 'control treatments' and a confined set of outcome measures that are used. The ethical issue with this observation is, that in the absence of randomised clinical trial information on clinical effectiveness and in consequence of the lack of additional data that are crucial for therapeutic decisions in the process of caring, specific patient groups, such as patients with chronic diseases, may become disadvantaged. The scarcity and incompleteness of controlled trial information can partly be explained by difficulties in conducting this type of research in the field of chronic disease management. To avoid that patients with chronic diseases become disadvantaged, the use of alternative designs such as observational studies to evaluate chronic disease management must be accepted and supported. Moreover, in chronic disease management the process of caring needs to emphasized and appraised appropriately. For that purpose, new measurement methods, focussing on concepts of caring that are not included in the majority of current clinical trials, need to be developed.

Outcomes of rehabilitation services for nursing home residents

OBJECTIVE

To examine survival and community discharge outcomes related to rehabilitation services among patients admitted to nursing homes before the implementation of the Balanced Budget Amendment of 1997.

DESIGN

Retrospective cohort.

SETTING

A total of 945 Medicaid-certified nursing homes in Ohio.

PARTICIPANTS

A total of 11,150 patients admitted for the first time to a nursing home from 1994 to 1996.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Community discharge and survival rates among patients who did or did not receive rehabilitation services, using multivariable techniques to adjust for patients' propensity to receive rehabilitation and for other potential confounders. In secondary analyses, we also examined dose-response effects and analyzed the effects of rehabilitation when patients were divided into 5 diagnostic groups (stroke, hip fracture, congestive heart failure, chronic lung disease, other).

RESULTS

Rehabilitation was provided to 58% of the patients and was associated with higher community discharge rates (relative risk=1.48; 95% confidence interval [CI], 1.40-1.57) and a lower hazard of death (hazard ratio=.81; 95% CI,.75-.88). Dose-response effects were observed for both outcomes (P<.001) among patients receiving rehabilitation. Rehabilitation was associated with improved community discharge rates in each of the 5 diagnostic groups.

CONCLUSIONS

New reimbursement policies that discourage the provision of rehabilitation services may have adverse effects on patients, their families, and societal costs of care.

Database studies in asthma pharmacoeconomics: uses, limitations and quality markers

Asthma is a common chronic disease resulting in significant morbidity and health resource utilisation, and multiple therapeutic options exist. Clinicians and healthcare providers need accurate information on the clinical and cost- effectiveness of asthma treatments to make informed decisions on management strategies. Randomised, controlled trials demonstrate cause and effect relationships between treatments and outcomes, but their tight entry criteria and strict study protocols mean that their results cannot automatically be generalised or used for economic modelling. There is a need for observational data to examine the effectiveness of alternative interventions in routine practice. Clinical and administrative databases are a possible information source for observational studies, and are increasingly used in asthma clinical, epidemiological and economic research. This paper examines the types of database used, the advantages and limitations of such studies and considers quality markers. High quality database studies can provide important epidemiological and economic information that can be of value in understanding the causes and effective management of asthma.

The effect of pneumonia on mortality among patients hospitalized for acute stroke

OBJECTIVE

To determine the effect of pneumonia on 30-day mortality in patients hospitalized for acute stroke.

METHODS

Subjects in the initial cohort were 14,293 Medicare patients admitted for stroke to 29 greater Cleveland hospitals between 1991 and 1997. The relative risk (RR) of pneumonia for 30-day mortality was determined in a final cohort (n = 11,286) that excluded patients dying or having a do not resuscitate order within 3 days of admission. Clinical data were obtained from chart abstraction and were merged with Medicare Provider Analysis and Review files to obtain deaths within 30 days. A predicted-mortality model (c-statistic = 0.78) and propensity score for pneumonia (c-statistic = 0.83) were used for risk adjustment in logistic regression analyses.

RESULTS

Pneumonia was identified in 6.9% (n = 985) of all patients and in 5.6% (n = 635) of the final cohort. The rates of pneumonia were higher in patients with greater stroke severity and features indicating general frailty. Unadjusted 30-day mortality rates were six times higher for patients with pneumonia than for those without (26.9% vs 4.4%, p < 0.001). After adjusting for admission severity and propensity for pneumonia, RR of pneumonia for 30-day death was 2.99 (95% CI 2.44 to 3.66), and population attributable risk was 10.0%.

CONCLUSION

In this large community-wide study of stroke outcomes, pneumonia conferred a threefold increased risk of 30-day death, adding impetus to efforts to identify and reduce the risk of pneumonia in patients with stroke.

Meta-analysis of relaparotomy for secondary peritonitis

BACKGROUND

Planned relaparotomy and relaparotomy on demand are two frequently employed surgical treatment strategies for patients with abdominal sepsis.

METHODS

The available literature was evaluated to compare the efficacy of both surgical treatment strategies. A systematic search for studies comparing planned and on-demand relaparotomy strategies in adult patients with secondary peritonitis was employed. Studies were reviewed independently for design features, inclusion and exclusion criteria, and outcomes. The primary outcome measure was in-hospital mortality.

RESULTS

No randomized studies were found; eight observational studies with a total of 1266 patients (planned relaparotomy, 286; relaparotomy on demand, 980) met the inclusion criteria and were included in the meta-analysis. These eight studies were heterogeneous on clinical and statistical grounds (chi2= 40.7, d.f. = 7, P < 0.001). Using a random-effects approach, the combined odds ratio for in-hospital mortality was 0.70 (95 per cent confidence interval 0.27 to 1.80) in favour of the on-demand strategy.

CONCLUSION

The combined results of observational studies show a statistically non-significant reduction in mortality for the on-demand relaparotomy strategy compared with the planned relaparotomy strategy when corrected for heterogeneity in a random-effects model. Owing to the non-randomized nature of the studies, the limited number of patients per study, and the heterogeneity between studies, the overall evidence generated by the eight studies was inconclusive.

The impact of a cardioprotective protocol on the incidence of cardiac complications after aortic abdominal surgery

We analyzed a local database including 468 consecutive patients who underwent elective aortic abdominal surgery over an 8-yr period in a single institution. A new cardioprotective perioperative protocol was introduced in January 1997, and we questioned whether perioperative cardiac outcome could be favorably influenced by the application of a stepwise cardiovascular evaluation based on the American College of Cardiology/American Heart Association guidelines and by the use of antiadrenergic drugs. Clonidine was administered during surgery, and beta-blockers were titrated after surgery to achieve heart rates less than 80 bpm. We compared data of two consecutive 4-yr periods (1993-1996 [control period] versus 1997-2000 [intervention period]). Implementation of American College of Cardiology/American Heart Association guidelines was associated with increased preoperative myocardial scanning (44.3% vs 20.6%; P < 0.05) and coronary revascularization (7.7% vs 0.8%; P < 0.05). During the intervention period, there was a significant decrease in the incidence of cardiac complications (from 11.3% to 4.5%) and an increase in event-free survival at 1 yr after surgery (from 91.3% to 98.2%). Multivariate regression analysis showed that the combined administration of clonidine and beta-blockers was associated with a decreased risk of cardiovascular events (odds ratio, 0.3; 95% confidence interval, 0.1-0.8), whereas major bleeding, renal insufficiency, and chronic obstructive pulmonary disease were predictive of cardiac complications. In conclusion, cardiac testing was helpful to identify a small subset of high-risk patients who might benefit from coronary revascularization. Sequential and selective antiadrenergic treatments were associated with improved postoperative cardiac outcome.

IMPLICATIONS

Implementation of American College of Cardiology/American Heart Association guidelines and use of antiadrenergic drugs were associated with better cardiac outcomes after major vascular surgery.

The need for a national infrastructure to improve the rational use of therapeutics

The current medical care environment has created expectations that exceed its capabilities, one effect of which has been an increasing awareness of lapses in the quality of healthcare, including medical errors. As more new therapies reach clinical application, the expectations on the part of the public are unlikely to lessen, and yet the ability to assure patients that the benefits of these therapies are known, and that they are without serious side-effects or untoward consequences, eludes the healthcare system. Based on initial experience with a new federal program, the Centers for Education and Research on Therapeutics (CERTs), we propose a national approach to therapeutics education and research, through a public-private partnership that involves academic medical centers, the federal government, industry, and the public. Through a concerted approach, we believe that significant gaps in our understanding of key issues in therapeutics and our ability to educate practitioners, policy makers, and consumers can be significantly enhanced in a manner that could not be achieved without a coordinated approach.

Inhaled corticosteroids plus salmeterol or montelukast: effects on resource utilization and costs

BACKGROUND

Experimental clinical studies have demonstrated that the addition of salmeterol to inhaled corticosteroids (ICSs) is superior to the addition of montelukast to ICSs. Observational research from real-world clinical practice is needed to confirm these results.

OBJECTIVE

The present study was designed to assess, in clinical practice, the comparative impact on health care utilization and cost of 2 dual-controller therapies, ICS + salmeterol and ICS + montelukast.

METHODS

This study involved the use of a 24-month pre/post retrospective design in patients continuously enrolled in any of 14 United HealthCare plans. Outcomes assessed were post-index pharmacy costs, rates of emergency department visits and hospitalizations, numbers of filled prescriptions for short-acting beta-agonists (SABAs), total asthma costs, and total health care costs.

RESULTS

Subjects in the ICS + salmeterol group had 35% fewer post-index SABA claims than subjects in the montelukast add-on group (P <or=.05). Subjects using ICS + montelukast were 2.5 times more likely to have an asthma-related hospitalization than subjects using ICS + salmeterol (P <or=.065). Total adjusted asthma costs were 63% higher for the patients receiving ICS + montelukast than for the patients receiving ICS + salmeterol (P <or=.0001). In addition, total health care costs were 25% lower in the ICS + salmeterol group. (P <or=.0004). Additional reductions in hospitalization and emergency department visits were observed when the patients on FP + salmeterol were studied separately.

CONCLUSION

In comparison with the use of montelukast and ICS, the use of salmeterol and ICS was associated with a significant reduction in SABA use, decreased hospital event rates, and significantly lower total asthma care costs.