1
|
Neuman MD, Feng R, Ellenberg SS, Sieber F, Sessler DI, Magaziner J, Elkassabany N, Schwenk ES, Dillane D, Marcantonio ER, Menio D, Ayad S, Hassan M, Stone T, Papp S, Donegan D, Marshall M, Jaffe JD, Luke C, Sharma B, Azim S, Hymes R, Chin KJ, Sheppard R, Perlman B, Sappenfield J, Hauck E, Hoeft MA, Tierney A, Gaskins LJ, Horan AD, Brown T, Dattilo J, Carson JL, Looke T, Bent S, Franco-Mora A, Hedrick P, Newbern M, Tadros R, Pealer K, Vlassakov K, Buckley C, Gavin L, Gorbatov S, Gosnell J, Steen T, Vafai A, Zeballos J, Hruslinski J, Cardenas L, Berry A, Getchell J, Quercetti N, Bajracharya G, Billow D, Bloomfield M, Cuko E, Elyaderani MK, Hampton R, Honar H, Khoshknabi D, Kim D, Krahe D, Lew MM, Maheshwer CB, Niazi A, Saha P, Salih A, de Swart RJ, Volio A, Bolkus K, DeAngelis M, Dodson G, Gerritsen J, McEniry B, Mitrev L, Kwofie MK, Belliveau A, Bonazza F, Lloyd V, Panek I, Dabiri J, Chavez C, Craig J, Davidson T, Dietrichs C, Fleetwood C, Foley M, Getto C, Hailes S, Hermes S, Hooper A, Koener G, Kohls K, Law L, Lipp A, Losey A, Nelson W, Nieto M, Rogers P, Rutman S, Scales G, Sebastian B, Stanciu T, Lobel G, Giampiccolo M, Herman D, Kaufman M, Murphy B, Pau C, Puzio T, Veselsky M, Apostle K, Boyer D, Fan BC, Lee S, Lemke M, Merchant R, Moola F, Payne K, Perey B, Viskontas D, Poler M, D'Antonio P, O'Neill G, Abdullah A, Fish-Fuhrmann J, Giska M, Fidkowski C, Guthrie ST, Hakeos W, Hayes L, Hoegler J, Nowak K, Beck J, Cuff J, Gaski G, Haaser S, Holzman M, Malekzadeh AS, Ramsey L, Schulman J, Schwartzbach C, Azefor T, Davani A, Jaberi M, Masear C, Haider SB, Chungu C, Ebrahimi A, Fikry K, Marcantonio A, Shelvan A, Sanders D, Clarke C, Lawendy A, Schwartz G, Garg M, Kim J, Caruci J, Commeh E, Cuevas R, Cuff G, Franco L, Furgiuele D, Giuca M, Allman M, Barzideh O, Cossaro J, D'Arduini A, Farhi A, Gould J, Kafel J, Patel A, Peller A, Reshef H, Safur M, Toscano F, Tedore T, Akerman M, Brumberger E, Clark S, Friedlander R, Jegarl A, Lane J, Lyden JP, Mehta N, Murrell MT, Painter N, Ricci W, Sbrollini K, Sharma R, Steel PAD, Steinkamp M, Weinberg R, Wellman DS, Nader A, Fitzgerald P, Ritz M, Bryson G, Craig A, Farhat C, Gammon B, Gofton W, Harris N, Lalonde K, Liew A, Meulenkamp B, Sonnenburg K, Wai E, Wilkin G, Troxell K, Alderfer ME, Brannen J, Cupitt C, Gerhart S, McLin R, Sheidy J, Yurick K, Chen F, Dragert K, Kiss G, Malveaux H, McCloskey D, Mellender S, Mungekar SS, Noveck H, Sagebien C, Biby L, McKelvy G, Richards A, Abola R, Ayala B, Halper D, Mavarez A, Rizwan S, Choi S, Awad I, Flynn B, Henry P, Jenkinson R, Kaustov L, Lappin E, McHardy P, Singh A, Donnelly J, Gonzalez M, Haydel C, Livelsberger J, Pazionis T, Slattery B, Vazquez-Trejo M, Baratta J, Cirullo M, Deiling B, Deschamps L, Glick M, Katz D, Krieg J, Lessin J, Mojica J, Torjman M, Jin R, Salpeter MJ, Powell M, Simmons J, Lawson P, Kukreja P, Graves S, Sturdivant A, Bryant A, Crump SJ, Verrier M, Green J, Menon M, Applegate R, Arias A, Pineiro N, Uppington J, Wolinsky P, Gunnett A, Hagen J, Harris S, Hollen K, Holloway B, Horodyski MB, Pogue T, Ramani R, Smith C, Woods A, Warrick M, Flynn K, Mongan P, Ranganath Y, Fernholz S, Ingersoll-Weng E, Marian A, Seering M, Sibenaller Z, Stout L, Wagner A, Walter A, Wong C, Orwig D, Goud M, Helker C, Mezenghie L, Montgomery B, Preston P, Schwartz JS, Weber R, Fleisher LA, Mehta S, Stephens-Shields AJ, Dinh C, Chelly JE, Goel S, Goncz W, Kawabe T, Khetarpal S, Monroe A, Shick V, Breidenstein M, Dominick T, Friend A, Mathews D, Lennertz R, Sanders R, Akere H, Balweg T, Bo A, Doro C, Goodspeed D, Lang G, Parker M, Rettammel A, Roth M, White M, Whiting P, Allen BFS, Baker T, Craven D, McEvoy M, Turnbo T, Kates S, Morgan M, Willoughby T, Weigel W, Auyong D, Fox E, Welsh T, Cusson B, Dobson S, Edwards C, Harris L, Henshaw D, Johnson K, McKinney G, Miller S, Reynolds J, Segal BS, Turner J, VanEenenaam D, Weller R, Lei J, Treggiari M, Akhtar S, Blessing M, Johnson C, Kampp M, Kunze K, O'Connor M, Looke T, Tadros R, Vlassakov K, Cardenas L, Bolkus K, Mitrev L, Kwofie MK, Dabiri J, Lobel G, Poler M, Giska M, Sanders D, Schwartz G, Giuca M, Tedore T, Nader A, Bryson G, Troxell K, Kiss G, Choi S, Powell M, Applegate R, Warrick M, Ranganath Y, Chelly JE, Lennertz R, Sanders R, Allen BFS, Kates S, Weigel W, Li J, Wijeysundera DN, Kheterpal S, Moore RH, Smith AK, Tosi LL, Looke T, Mehta S, Fleisher L, Hruslinski J, Ramsey L, Langlois C, Mezenghie L, Montgomery B, Oduwole S, Rose T. Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial. Ann Intern Med 2022; 175:952-960. [PMID: 35696684 DOI: 10.7326/m22-0320] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING 46 U.S. and Canadian hospitals. PARTICIPANTS Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION Spinal or general anesthesia. MEASUREMENTS Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION Missing outcome data and multiple outcomes assessed. CONCLUSION Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute.
Collapse
Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Rui Feng
- Department of Biostatistics, Epidemiology, and Informatics, and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (R.F., S.S.E.)
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology, and Informatics, and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (R.F., S.S.E.)
| | - Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland (F.S.)
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland (J.M.)
| | - Nabil Elkassabany
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (E.S.S.)
| | - Derek Dillane
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada (D. Dillane)
| | - Edward R Marcantonio
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.R.M.)
| | - Diane Menio
- Center for Advocacy for the Rights and Interests of the Elderly, Philadelphia, Pennsylvania (D.M.)
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Manal Hassan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio (D.I.S., S. Ayad, M.H.)
| | - Trevor Stone
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada (T.S.)
| | - Steven Papp
- Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa, Ontario, Canada (S.P.)
| | - Derek Donegan
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (D. Donegan)
| | - Mitchell Marshall
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York (M.M.)
| | - J Douglas Jaffe
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina (J.D.J.)
| | - Charles Luke
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (C.L.)
| | - Balram Sharma
- Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington, Massachusetts (B.S.)
| | - Syed Azim
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York (S. Azim)
| | - Robert Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, Virginia (R.H.)
| | - Ki-Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada (K.C.)
| | - Richard Sheppard
- Department of Anesthesiology, Hartford Hospital, Hartford, Connecticut (R.S.)
| | - Barry Perlman
- Oregon Health and Science University, Portland, Oregon (B.P.)
| | - Joshua Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida (J.S.)
| | - Ellen Hauck
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania (E.H.)
| | - Mark A Hoeft
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, Vermont (M.A.H.)
| | - Ann Tierney
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - Lakisha J Gaskins
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.N., N.E., L.J.G.)
| | - Annamarie D Horan
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.D.H.)
| | - Trina Brown
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - James Dattilo
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (A.T., T.B., J.D.)
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.L.C.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Capan M, Schubel LC, Pradhan I, Catchpole K, Shara N, Arnold R, Schwartz JS, Seagull J, Miller K. Display and perception of risk: Analysis of decision support system display and its impact on perceived clinical risk of sepsis-induced health deterioration. Health Informatics J 2022; 28:14604582211073075. [DOI: 10.1177/14604582211073075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite acknowledging the value of clinical decision support systems (CDSS) in identifying risk for sepsis-induced health deterioration in-hospitalized patients, the relationship between display features, decision maker characteristics, and recognition of risk by the clinical decision maker remains an understudied, yet promising, area. The objective of this study is to explore the relationship between CDSS display design and perceived clinical risk of in-hospital mortality associated with sepsis. The study utilized data collected through in-person experimental sessions with 91 physicians from the general medical and surgical floors who were recruited across 12 teaching hospitals within the United States. Results of descriptive and statistical analyses provided evidence supporting the impact of display configuration and clinical case severity on perceived risk associated with in-hospital mortality. Specifically, findings showed that a high level of information (represented by the Predisposition, Infection, Response and Organ dysfunction (PIRO) score) and Figure display (as opposed to Text or baseline) increased awareness to recognizing the risk for in-hospital mortality of hospitalized sepsis patients. A CDSS display that synthesizes the optimal features associated with information level and design elements has the potential to enhance the quantification and communication of clinical risk in complex health conditions beyond sepsis.
Collapse
Affiliation(s)
- Muge Capan
- LeBow College of Business, Drexel University, Philadelphia, PA, USA
| | - Laura C Schubel
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, DC, USA
| | - Ishika Pradhan
- LeBow College of Business, Drexel University, Philadelphia, PA, USA
| | - Ken Catchpole
- Clinical Practice and Human Factors, Medical University of South Carolina, Charleston, SC, USA
| | - Nawar Shara
- Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC, USA
| | - Ryan Arnold
- Emergency Medicine, Santa Ynez Valley Cottage Hospital, Santa Barbara, CA, USA
| | - J Sanford Schwartz
- Department of Health Care Management, University of Pennsylvania, Philadelphia, PA, USA
| | - Jake Seagull
- MedStar Health Research Institute, Hyattsville, MD, USA
| | - Kristen Miller
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, DC, USA
| |
Collapse
|
3
|
Ghogawala Z, Terrin N, Dunbar MR, Breeze JL, Freund KM, Kanter AS, Mummaneni PV, Bisson EF, Barker FG, Schwartz JS, Harrop JS, Magge SN, Heary RF, Fehlings MG, Albert TJ, Arnold PM, Riew KD, Steinmetz MP, Wang MC, Whitmore RG, Heller JG, Benzel EC. Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial. JAMA 2021; 325:942-951. [PMID: 33687463 PMCID: PMC7944378 DOI: 10.1001/jama.2021.1233] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results. OBJECTIVE To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020. INTERVENTIONS Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon's discretion. MAIN OUTCOMES AND MEASURES The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score. RESULTS Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, -2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%). CONCLUSIONS AND RELEVANCE Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02076113.
Collapse
Affiliation(s)
- Zoher Ghogawala
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Norma Terrin
- Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Melissa R. Dunbar
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Janis L. Breeze
- Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Karen M. Freund
- Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Adam S. Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburg, Pennsylvania
| | | | - Erica F. Bisson
- Department of Neurosurgery Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City
| | - Fred G. Barker
- Massachusetts General Hospital Brain Tumor Center, Boston
| | - J. Sanford Schwartz
- University of Pennsylvania Perelman School of Medicine, Philadelphia
- University of Pennsylvania Wharton School, Philadelphia
| | | | - Subu N. Magge
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Robert F. Heary
- Department of Neurological Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada
| | - Todd J. Albert
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York
| | - Paul M. Arnold
- Carle Neuroscience Institute, Carle Foundation Hospital, Urbana, Illinois
| | - K. Daniel Riew
- Columbia University Irving Medical Center, New York, New York
| | | | - Marjorie C. Wang
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Robert G. Whitmore
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - John G. Heller
- Emory Orthopaedics & Spine Center, Emory University School of Medicine, Atlanta, Georgia
| | | |
Collapse
|
4
|
Jayadevappa R, Chhatre S, Gallo JJ, Wittink MN, Morales KH, Lee DI, Guzzo T, Vapiwala N, Wong YN, Newman DK, Van Arsdalen K, Malkowicz SB, Schwartz JS, Wein AJ. Reply to A. Vickers et al. J Clin Oncol 2019; 37:3463-3464. [DOI: 10.1200/jco.19.01450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ravishankar Jayadevappa
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Sumedha Chhatre
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Joseph J. Gallo
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Marsha N. Wittink
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Knashawn H. Morales
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - David I. Lee
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Thomas Guzzo
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Neha Vapiwala
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Yu-Ning Wong
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Diane K. Newman
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Keith Van Arsdalen
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - S. Bruce Malkowicz
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - J. Sanford Schwartz
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| | - Alan J. Wein
- Ravishankar Jayadevappa, PhD, MS, University of Pennsylvania, Philadelphia, PA, and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA; Sumedha Chhatre, PhD, MS, University of Pennsylvania, Philadelphia, PA; Joseph J. Gallo, MD, MPH, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Marsha N. Wittink, MD, MBE, University of Rochester School of Medicine and Dentistry, Rochester, NY; Knashawn H. Morales, ScD, David I. Lee, MD, Thomas Guzzo, MD,
| |
Collapse
|
5
|
Jayadevappa R, Chhatre S, Gallo JJ, Malkowicz SB, Schwartz JS, Wittink MN. Patient-Centered Approach to Develop the Patient's Preferences for Prostate Cancer Care (PreProCare) Tool. MDM Policy Pract 2019; 4:2381468319855375. [PMID: 31259248 PMCID: PMC6589971 DOI: 10.1177/2381468319855375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 04/29/2019] [Indexed: 11/16/2022] Open
Abstract
Objectives. To describe the development of our Patient Preferences for Prostate Cancer Care (PreProCare) tool to aid patient-centered treatment decision among localized prostate cancer patients. Methods. We incorporated patient and provider experiences to develop a patient preference elicitation tool using adaptive conjoint analysis. Our patient-centered approach used systematic literature review, semistructured patient interviews, and provider focus groups to determine the treatment attributes most important for decision making. The resulting computer-based PreProCare tool was pilot tested in a clinical setting. Results. A systematic review of 56 articles published between 1995 and 2015 yielded survival, cancer recurrence, side effects, and complications as attributes of treatment options. We conducted one-on-one interviews with 50 prostate cancer survivors and 5 focus groups of providers. Patients reported anxiety, depression, treatment specifics, and caregiver burden as important for decision making. Providers identified clinical characteristics as important attribute. Input from stakeholders’ advisory group, physicians, and researchers helped finalize 15 attributes for our PreProCare preference assessment tool. Conclusion. The PreProCare tool was developed using a patient-centered approach and may be a feasible and acceptable preference clarification intervention for localized prostate cancer patients. The PreProCare tool may translate into higher participant engagement and self-efficacy, consistent with patients’ personal values.
Collapse
Affiliation(s)
| | | | - Joseph J Gallo
- General Internal Medicine, Johns Hopkins University School of Medicine, and Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - S Bruce Malkowicz
- Division of Urology, Department of Surgery, Perelman School of Medicine
| | | | - Marsha N Wittink
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| |
Collapse
|
6
|
Schubel L, Mosby DL, Blumenthal J, Capan M, Arnold R, Kowalski R, Seagull FJ, Catchpole K, Schwartz JS, Franklin E, Littlejohn R, Miller KE. Informatics and interaction: Applying human factors principles to optimize the design of clinical decision support for sepsis. Health Informatics J 2019; 26:642-651. [PMID: 31081460 DOI: 10.1177/1460458219839623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In caring for patients with sepsis, the current structure of electronic health record systems allows clinical providers access to raw patient data without imputation of its significance. There are a wide range of sepsis alerts in clinical care that act as clinical decision support tools to assist in early recognition of sepsis; however, there are serious shortcomings in existing health information technology for alerting providers in a meaningful way. Little work has been done to evaluate and assess existing alerts using implementation and process outcomes associated with health information technology displays, specifically evaluating clinician preference and performance. We developed graphical model displays of two popular sepsis scoring systems, quick Sepsis Related Organ Failure Assessment and Predisposition, Infection, Response, Organ Failure, using human factors principles grounded in user-centered and interaction design. Models will be evaluated in a larger research effort to optimize alert design to improve the collective awareness of high-risk populations and develop a relevant point-of-care clinical decision support system for sepsis.
Collapse
Affiliation(s)
| | | | | | - Muge Capan
- Drexel University's LeBow College of Business, USA.,MedStar Health, USA
| | - Ryan Arnold
- Drexel University College of Medicine, USA.,MedStar Health, USA
| | | | | | - Ken Catchpole
- Medical University of South Carolina, USA.,MedStar Health, USA
| | | | | | | | | |
Collapse
|
7
|
Jayadevappa R, Chhatre S, Gallo JJ, Wittink M, Morales KH, Lee DI, Guzzo TJ, Vapiwala N, Wong YN, Newman DK, Van Arsdalen K, Malkowicz SB, Schwartz JS, Wein AJ. Patient-Centered Preference Assessment to Improve Satisfaction With Care Among Patients With Localized Prostate Cancer: A Randomized Controlled Trial. J Clin Oncol 2019; 37:964-973. [DOI: 10.1200/jco.18.01091] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To study the effectiveness of the Patient Preferences for Prostate Cancer Care (PreProCare) intervention in improving the primary outcome of satisfaction with care and secondary outcomes of satisfaction with decision, decision regret, and treatment choice among patients with localized prostate cancer. METHODS In this multicenter randomized controlled study, we randomly assigned patients with localized prostate cancer to the PreProCare intervention or usual care. Outcomes were satisfaction with care, satisfaction with decision, decision regret, and treatment choice. Assessments were performed at baseline and at 3, 6, 12, and 24 months, and were analyzed using repeated measures. We compared treatment choice across intervention groups by prostate cancer risk categories. RESULTS Between January 2014 and March 2015, 743 patients with localized prostate cancer were recruited and randomly assigned to receive PreProCare (n = 372) or usual care (n = 371). For the general satisfaction subscale, improvement at 24 months from baseline was significantly different between groups ( P < .001). For the intervention group, mean scores at 24 months improved by 0.44 (SE, 0.06; P < .001) from baseline. This improvement was 0.5 standard deviation, which was clinically significant. The proportion reporting satisfaction with decision and no regret increased over time and was higher for the intervention group, compared with the usual care group at 24 months ( P < .05). Among low-risk patients, a higher proportion of the intervention group was receiving active surveillance, compared with the usual care group ( P < .001). CONCLUSION Our patient-centered PreProCare intervention improved satisfaction with care, satisfaction with decision, reduced regrets, and aligned treatment choice with risk category. The majority of our participants had a high income, with implications for generalizability. Additional studies can evaluate the effectiveness of PreProCare as a mechanism for improving clinical and patient-reported outcomes in different settings.
Collapse
Affiliation(s)
- Ravishankar Jayadevappa
- University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA
| | | | | | - Marsha Wittink
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | | | | | | | | | | | | | - Keith Van Arsdalen
- Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA
| | - S. Bruce Malkowicz
- University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, PA
| | | | | |
Collapse
|
8
|
Goldstein JN, Schwartz JS, McGraw P, Hicks LS. "Implications of cost-sharing for observation care among Medicare beneficiaries: a pilot survey". BMC Health Serv Res 2019; 19:149. [PMID: 30845953 PMCID: PMC6407198 DOI: 10.1186/s12913-019-3982-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 03/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background Medicare beneficiaries hospitalized under observation status have significant cost-sharing responsibilities under Medicare Part B. Prior work has demonstrated an association between increased cost-sharing and health care rationing among low-income Medicare beneficiaries. The objective of this study was to explore the potential impact of observation cost-sharing on future medical decision making of Medicare beneficiaries. Methods Single-center pilot cohort study. A convenience sample of Medicare beneficiaries hospitalized under observation status care was surveyed. Results Out of 144 respondents, low-income beneficiaries were more likely to be concerned about the cost of their observation stay than higher-income respondents (70.7% vs29.3%, p = 0.015). If hospitalized under observation status again, there was a trend among low-income beneficiaries to request completion of their workup outside of the hospital (56.3% vs 43.8%), and to consider leaving against medical advice (AMA) (100% vs 0%), though these trends were not statistically significant (p = 0.30). Conclusion The results of this pilot study suggest that low-income Medicare beneficiaries hospitalized under observation status have greater concerns about their cost-sharing obligations than their higher income peers. Cost-sharing for observation care may have unintended consequences on utilization for low-income beneficiaries. Future studies should examine this potential relationship on a larger scale. Electronic supplementary material The online version of this article (10.1186/s12913-019-3982-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2E70, Newark, DE, 19713, USA.
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, 1203 Blockley Hall, 423 Guardian Drive University, Philadelphia, PA, 19104, USA
| | - Patricia McGraw
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2E70, Newark, DE, 19713, USA
| | - LeRoi S Hicks
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2C50, Newark, DE, 19713, USA
| |
Collapse
|
9
|
Doorey AJ, Weintraub WS, Schwartz JS. Should Procedures or Patients Be Safe? Bias in Recommendations for Periprocedural Discontinuation of Anticoagulation. Mayo Clin Proc 2018; 93:1173-1176. [PMID: 30100193 DOI: 10.1016/j.mayocp.2018.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 04/10/2018] [Accepted: 05/07/2018] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - J Sanford Schwartz
- Perelman School of Medicine at the University of Pennsylvania and Wharton School of Business, Philadelphia, PA
| |
Collapse
|
10
|
Chhatre S, Newman DK, Wein AJ, Jefferson AE, Schwartz JS, Jayadevappa R. Knowledge and attitude for overactive bladder care among women: development and measurement. BMC Urol 2018; 18:56. [PMID: 29866095 PMCID: PMC5987448 DOI: 10.1186/s12894-018-0371-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/21/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Overactive bladder (OAB) affects millions of women. It is important to assess knowledge and attitude in affected patients. The study objective was to develop surveys to assess OAB knowledge and OAB related attitude, and its association with OAB treatment status. METHODS Systematic literature review and qualitative analysis of patient and provider focus groups helped identify OAB knowledge and attitude survey items. We determined psychometric properties of the two surveys in a cross-sectional sample of 104 women, 27% of whom had received OAB treatment. RESULTS The OAB-knowledge survey consisted of 16 items and 3 condition-related concepts: perception of OAB; cause and information; and signs of OAB. The OAB-attitude survey consisted of 16 items and its concepts were treatment seeking; decision-making and effects. Both surveys demonstrated good construct validity and test-retest reliability ((≥ 0.60). In the cross-sectional validation sample, OAB-knowledge and attitude discriminated between those with different levels of ICIQ-UI scores. We observed some difference in the OAB knowledge, OAB attitude, and severity of symptoms between those treated for OAB vs. treatment naive. CONCLUSIONS OAB knowledge and attitude surveys provide a novel tool to assess OAB domains in women. Though we did not find statistical significance in OAB knowledge and attitude scores across treatment status, they may be potentially modifiable factors that affect OAB treatment uptake and treatment compliance. Refinement of these surveys in diverse sub-populations is necessary. Our study provides effect sizes for OAB knowledge and attitude. These effect sizes can help development of fully powered trials to study the association between OAB knowledge and attitude, type and length of treatment, treatment compliance, and quality of life, leading to interventions for enhancing OAB care.
Collapse
Affiliation(s)
- Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market St., Suite 4051, Philadelphia, PA, 19104, USA.
| | - Diane K Newman
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alan J Wein
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ashlie E Jefferson
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - J Sanford Schwartz
- Departments of Medicine and Health Management, Leonard Davis Institute of Health Economics, University of Pennsylvania, Perelman School of Medicine and Wharton School of Business, Philadelphia, PA, 19104, USA
| | - Ravishankar Jayadevappa
- Departments of Medicine and Surgery, Divisions of Geriatrics and Urology, Perelman School of Medicine Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| |
Collapse
|
11
|
|
12
|
Goldstein JN, Zhang Z, Schwartz JS, Hicks LS. The Reply. Am J Med 2018; 131:e69. [PMID: 29362108 DOI: 10.1016/j.amjmed.2017.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine, Christiana Care Health System, Newark, Del; Christiana Care Health System, The Value Institute, Newark, Del
| | - Zugui Zhang
- Christiana Care Health System, The Value Institute, Newark, Del
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pa
| | - LeRoi S Hicks
- Department of Medicine, Christiana Care Health System, Newark, Del; Christiana Care Health System, The Value Institute, Newark, Del
| |
Collapse
|
13
|
Goldstein JN, Zhang Z, Schwartz JS, Hicks LS. Observation Status, Poverty, and High Financial Liability Among Medicare Beneficiaries. Am J Med 2018; 131:101.e9-101.e15. [PMID: 28774801 PMCID: PMC5725232 DOI: 10.1016/j.amjmed.2017.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries. METHODS We performed a retrospective, observational analysis of Medicare Part B claims and US Census Bureau data from 2013. Medicare beneficiaries with Part A and B coverage for the full calendar year, with 1 or more observation stay(s), were included in the study. Beneficiaries were divided into quartiles representing poverty level. The associations between poverty quartile and high use of observation care and between poverty quartile and high financial liability for observation care were evaluated. RESULTS After multivariate adjustment, the risk of high use was higher for beneficiaries in the poor (Quartile 3) and poorest (Quartile 4) quartiles compared with those in the wealthiest quartile (Quartile 1) (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.13-1.31; AOR, 1.24; 95% CI, 1.16-1.33). The risk of high financial liability was higher in every poverty quartile compared with the wealthiest and peaked in Quartile 3, which represented the poor but not the poorest beneficiaries (AOR, 1.17; 95% CI, 1.10-1.24). CONCLUSIONS Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability.
Collapse
Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine, Christiana Care Health System, Newark Del; The Value Institute, Christiana Care Health System, Newark, Del.
| | - Zugui Zhang
- The Value Institute, Christiana Care Health System, Newark, Del
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - LeRoi S Hicks
- Department of Medicine, Christiana Care Health System, Newark Del; The Value Institute, Christiana Care Health System, Newark, Del
| |
Collapse
|
14
|
Abstract
Objective To elicit patient stakeholders’ experience and perspectives about patient-centred care. Design Qualitative. Setting A large urban healthcare system. Participants Four patient stakeholders who are prostate cancer survivors. Main outcome measures Experience and perspectives of patient stakeholders regarding patient-centred care and treatment decisions. Results Our patient stakeholders represented a diverse socio-demographic group. The patient stakeholders identified engagement and dialogue with physicians as crucial elements of patient-centred care model. The degree of patient-centred care was observed to be dependent on the situations. High severity conditions warranted a higher level of patient involvement, compared to mild conditions. They agreed that patient-centred care should not mean that patients can demand inappropriate treatments. Conclusions An important attribute of patient-centred outcomes research model is the involvement of stakeholders. However, we have limited knowledge about the experience of patient stakeholders in patient-centred outcomes research. Our study indicates that patient stakeholders offer a unique perspective as researchers and policy-makers aim to precisely define patient-centred research and care.
Collapse
Affiliation(s)
- Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia 19104, USA
| | - Joseph J Gallo
- Johns Hopkins University School of Medicine, Baltimore 21205, USA.,Johns Hopkins University Bloomberg School of Public Health, Baltimore 21205, USA
| | - Marsha Wittink
- University of Rochester Medical Center, Rochester 14642, USA
| | - J Sanford Schwartz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia 19104, USA.,Abramson Cancer Center, University of Pennsylvania, Philadelphia 19104, USA
| | - Ravishankar Jayadevappa
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia 19104, USA.,Abramson Cancer Center, University of Pennsylvania, Philadelphia 19104, USA.,Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia 19104, USA.,Corporal Michael J. Crescenz VAMC, Philadelphia 19104, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia 19104, USA
| |
Collapse
|
15
|
Schwartz JS, Al-Mot S, Endam MF, Alromaih S, Madrenas J, Desrosiers M. Bacterial immune evasion via an IL-10 mediated host response, a novel pathophysiologic mechanism for chronic rhinosinusitis. Rhinology 2017; 55:227-233. [PMID: 28315920 DOI: 10.4193/rhin16.199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Staphylococcus aureus is a frequently implicated pathogen in chronic rhinosinusitis (CRS). S. aureus may promote commensalism by downregulating pro-inflammatory T cell host responses via an IL-10 mediated pathway. This finding, coupled with the observation that S. aureus and CD8+ T cell numbers are inversely correlated in CRS mucosa, suggests that S. aureus may evade immune destruction via IL-10 induction. To support this hypothesis, we evaluated i) whether IL-10 levels differ in CRS compared to controls (CTL) using microarray and immunohistochemistry and ii) whether IL-10 levels correlate with S. aureus and CD8+ T cell levels. METHODOLOGY Sinus epithelial brush samples from 12 patients undergoing ESS for CRS and 10 CTLs underwent microarray analysis of IL-10 gene expression. Microarray results were verified on simultaneously obtained surgical biopsy samples by immunohistochemistry staining for IL-10. Potential mechanisms were assessed by immunohistochemistry for CD8+ T cells and S. aureus. RESULTS IL-10 gene expression was significantly higher in CRS vs CTL subjects at the time of surgery. Immunohistochemistry confirmed increased levels of intraepithelial IL-10. A strong inverse correlation was observed between intraepithelial IL-10 and CD8+ T cell levels as was intraepithelial IL-10 and S. aureus. CONCLUSION Elevated IL-10 levels in sinus mucosa may be a potential pathophysiologic feature of CRS in association with a significant downregulation of host CD8+ T cell levels. While S. aureus is believed to play a role in IL-10 induction, a comparatively weaker relationship between S. aureus and IL-10 levels suggests other bacterial species may also induce IL-10 production as a common survival strategy in CRS.
Collapse
Affiliation(s)
- J S Schwartz
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Canada
| | - S Al-Mot
- Centre de Recherche du Centre Hospitalier de l Universite de Montreal (CRCHUM), Montreal, Canada
| | - M F Endam
- Centre de Recherche du Centre Hospitalier de l Universite de Montreal (CRCHUM), Montreal, Canada
| | - S Alromaih
- Department of Otolaryngology -Head and Neck Surgery, Faculty of Medicine King Saud University, Riyadh, Saudi Arabia
| | - J Madrenas
- Department of Microbiology and Immunology, McGill University, Montreal, Canada
| | - M Desrosiers
- Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Canada
| |
Collapse
|
16
|
Schwartz AB, Schwartz JS. Physician Certification and Recertification: The Role of Empirical Evidence. JAMA 2017; 317:2288-2289. [PMID: 28609519 DOI: 10.1001/jama.2017.7342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Adam B Schwartz
- Bellevue Hospital Center, Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York, New York
| | - J Sanford Schwartz
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, Department of Health Care Management, Wharton School of Business and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| |
Collapse
|
17
|
Affiliation(s)
- Ravi B Parikh
- From Brigham and Women's Hospital, Boston (R.B.P.); and the Perelman School of Medicine, the Wharton School of Business, and the Leonard Davis Institute of Health Economics, University of Pennsylvania (J.S.S., A.S.N.), and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (A.S.N.) - both in Philadelphia
| | - J Sanford Schwartz
- From Brigham and Women's Hospital, Boston (R.B.P.); and the Perelman School of Medicine, the Wharton School of Business, and the Leonard Davis Institute of Health Economics, University of Pennsylvania (J.S.S., A.S.N.), and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (A.S.N.) - both in Philadelphia
| | - Amol S Navathe
- From Brigham and Women's Hospital, Boston (R.B.P.); and the Perelman School of Medicine, the Wharton School of Business, and the Leonard Davis Institute of Health Economics, University of Pennsylvania (J.S.S., A.S.N.), and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (A.S.N.) - both in Philadelphia
| |
Collapse
|
18
|
Capan M, Khojandi A, Denton BT, Williams KD, Ayer T, Chhatwal J, Kurt M, Lobo JM, Roberts MS, Zaric G, Zhang S, Schwartz JS. From Data to Improved Decisions: Operations Research in Healthcare Delivery. Med Decis Making 2017; 37:849-859. [PMID: 28423982 DOI: 10.1177/0272989x17705636] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The Operations Research Interest Group (ORIG) within the Society of Medical Decision Making (SMDM) is a multidisciplinary interest group of professionals that specializes in taking an analytical approach to medical decision making and healthcare delivery. ORIG is interested in leveraging mathematical methods associated with the field of Operations Research (OR) to obtain data-driven solutions to complex healthcare problems and encourage collaborations across disciplines. This paper introduces OR for the non-expert and draws attention to opportunities where OR can be utilized to facilitate solutions to healthcare problems. METHODS Decision making is the process of choosing between possible solutions to a problem with respect to certain metrics. OR concepts can help systematically improve decision making through efficient modeling techniques while accounting for relevant constraints. Depending on the problem, methods that are part of OR (e.g., linear programming, Markov Decision Processes) or methods that are derived from related fields (e.g., regression from statistics) can be incorporated into the solution approach. This paper highlights the characteristics of different OR methods that have been applied to healthcare decision making and provides examples of emerging research opportunities. EXAMPLES We illustrate OR applications in healthcare using previous studies, including diagnosis and treatment of diseases, organ transplants, and patient flow decisions. Further, we provide a selection of emerging areas for utilizing OR. CONCLUSIONS There is a timely need to inform practitioners and policy makers of the benefits of using OR techniques in solving healthcare problems. OR methods can support the development of sustainable long-term solutions across disease management, service delivery, and health policies by optimizing the performance of system elements and analyzing their interaction while considering relevant constraints.
Collapse
Affiliation(s)
- Muge Capan
- Christiana Care Health System, Value Institute, John H. Ammon Medical Education Center, Newark, DE, USA (MC, KDW)
| | - Anahita Khojandi
- Department of Industrial and Systems Engineering, University of Tennessee, Knoxville, TN, USA (AK)
| | - Brian T Denton
- Industrial and Operations Engineering and Urology, University of Michigan, Ann Arbor, MI, USA (BTD)
| | - Kimberly D Williams
- Christiana Care Health System, Value Institute, John H. Ammon Medical Education Center, Newark, DE, USA (MC, KDW)
| | - Turgay Ayer
- Christiana Care Health System, Value Institute, John H. Ammon Medical Education Center, Newark, DE, USA (MC, KDW).,Georgia Institute of Technology H Milton Stewart School of Industrial and Systems Engineering, Center for Health & Humanitarian Systems, Atlanta, GA, USA (TA)
| | - Jagpreet Chhatwal
- Harvard University, Harvard Medical School, Institute for Technology Assessment; Massachusetts General Hospital, Boston, MA, USA (JC)
| | - Murat Kurt
- Merck Research, Whitehouse Station, NJ, USA (MK)
| | - Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA (JML)
| | - Mark S Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA (MSR)
| | - Greg Zaric
- Richard Ivey School of Business University of Western Ontario, London, ON, Canada (GZ)
| | - Shengfan Zhang
- Department of Industrial Engineering, University of Arkansas, Fayetteville, AR, USA (SZ)
| | - J Sanford Schwartz
- General Internal Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA (JSS)
| |
Collapse
|
19
|
Apter AJ, Morales KH, Han X, Perez L, Huang J, Ndicu G, Localio A, Nardi A, Klusaritz H, Rogers M, Phillips A, Cidav Z, Schwartz JS. A patient advocate to facilitate access and improve communication, care, and outcomes in adults with moderate or severe asthma: Rationale, design, and methods of a randomized controlled trial. Contemp Clin Trials 2017; 56:34-45. [PMID: 28315481 DOI: 10.1016/j.cct.2017.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 11/24/2022]
Abstract
Few interventions to improve asthma outcomes have targeted low-income minority adults. Even fewer have focused on the real-world practice where care is delivered. We adapted a patient navigator, here called a Patient Advocate (PA), a term preferred by patients, to facilitate and maintain access to chronic care for adults with moderate or severe asthma and prevalent co-morbidities recruited from clinics serving low-income urban neighborhoods. We describe the planning, design, methodology (informed by patient and provider focus groups), baseline results, and challenges of an ongoing randomized controlled trial of 312 adults of a PA intervention implemented in a variety of practices. The PA coaches, models, and assists participants with preparations for a visit with the asthma clinician; attends the visit with permission of participant and provider; and confirms participants' understanding of what transpired at the visit. The PA facilitates scheduling, obtaining insurance coverage, overcoming patients' unique social and administrative barriers to carrying out medical advice and transfer of information between providers and patients. PA activities are individualized, take account of comorbidities, and are generalizable to other chronic diseases. PAs are recent college graduates interested in health-related careers, research experience, working with patients, and generally have the same race/ethnicity distribution as potential participants. We test whether the PA intervention, compared to usual care, is associated with improved and sustained asthma control and other asthma outcomes (prednisone bursts, ED visits, hospitalizations, quality of life, FEV1) relative to baseline. Mediators and moderators of the PA-asthma outcome relationship are examined along with the intervention's cost-effectiveness.
Collapse
Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Knashawn H Morales
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Xiaoyan Han
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Luzmercy Perez
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingru Huang
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Ndicu
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna Localio
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alyssa Nardi
- Temple Physicians, Inc., Temple University Health System, Philadelphia, PA 19129, USA
| | - Heather Klusaritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Marisa Rogers
- Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexis Phillips
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Zuleyha Cidav
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - J Sanford Schwartz
- Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Wharton School of Business, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
20
|
Abstract
BACKGROUND Medicare beneficiaries admitted under observation status must pay for postacute inpatient rehabilitation (PAIR) services, out of pocket, at potentially prohibitive costs. OBJECTIVE To determine if there is an unmet need for PAIR among Medicare observation patients and if this care is associated with longer hospital stay and increased rehospitalization. DESIGN/SETTING Observational study using electronic medical record and administrative data from a regional health system. PATIENTS 1323 community-dwelling Medicare patients admitted under observation status. MEASUREMENTS Summary statistics were calculated for demographic and administrative variables. Physical therapy (PT) and case management recommendations for a representative sample of 386 medical records were reviewed regarding need for PAIR services. Linear regression was used to measure the association between PT recommendation and hospital length of stay, adjusting for ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis, age, sex, and provider. Chi-square test was used to determine the association between PT recommendation and 30-day hospital revisit. RESULTS Of the 1323 study patients, 11 (0.83%) were discharged to PAIR facilities. However, 17 (4.4%) of the 386 patients whose charts were reviewed received a recommendation for this care. Adjusted mean hospital stay was longer (P ⟨ 0.001) for patients recommended for rehabilitation (75.9 h) than for patients with no PT needs (46.8 h). In addition, the 30-day hospital revisit rate was higher (P = 0.037) for the patients who had been recommended for rehabilitation (52.9%, 9/17) than for those who had not (25.4%, 30/118). CONCLUSIONS Medicare observation patients' potential need for PAIR services is 5- to 6-fold higher than their use of these services. Observation patients recommended for this care may have worse outcomes. Journal of Hospital Medicine 2017;12:168-172.
Collapse
Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine, Christiana Care Health System, Newark, DE, USA
- Value Institute, Christiana Care Health System, Newark, DE, USA
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Patricia McGraw
- Department of Medicine, Christiana Care Health System, Newark, DE, USA
| | - Tobias L Banks
- Department of Medicine, Christiana Care Health System, Newark, DE, USA
| | - LeRoi S Hicks
- Department of Medicine, Christiana Care Health System, Newark, DE, USA
- Value Institute, Christiana Care Health System, Newark, DE, USA
| |
Collapse
|
21
|
Glick HA, McElligott S, Pauly MV, Willke RJ, Bergquist H, Doshi J, Fleisher LA, Kinosian B, Perfetto E, Polsky DE, Schwartz JS. Comparative effectiveness and cost-effectiveness analyses frequently agree on value. Health Aff (Millwood) 2016; 34:805-11. [PMID: 25941282 DOI: 10.1377/hlthaff.2014.0552] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Patient-Centered Outcomes Research Institute, known as PCORI, was established by Congress as part of the Affordable Care Act (ACA) to promote evidence-based treatment. Provisions of the ACA prohibit the use of a cost-effectiveness analysis threshold and quality-adjusted life-years (QALYs) in PCORI comparative effectiveness studies, which has been understood as a prohibition on support for PCORI's conducting conventional cost-effectiveness analyses. This constraint complicates evidence-based choices where incremental improvements in outcomes are achieved at increased costs of care. How frequently this limitation inhibits efficient cost containment, also a goal of the ACA, depends on how often more effective treatment is not cost-effective relative to less effective treatment. We examined the largest database of studies of comparisons of effectiveness and cost-effectiveness to see how often there is disagreement between the more effective treatment and the cost-effective treatment, for various thresholds that may define good value. We found that under the benchmark assumption, disagreement between the two types of analyses occurs in 19 percent of cases. Disagreement is more likely to occur if a treatment intervention is musculoskeletal and less likely to occur if it is surgical or involves secondary prevention, or if the study was funded by a pharmaceutical company.
Collapse
Affiliation(s)
- Henry A Glick
- Henry A. Glick is a professor of medicine in the Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, in Philadelphia
| | - Sean McElligott
- Sean McElligott is associate director of customer data and analytics at Merck in North Wales, Pennsylvania
| | - Mark V Pauly
- Mark V. Pauly is the Bendheim Professor in the Health Care Management Department at the Wharton School, University of Pennsylvania
| | - Richard J Willke
- Richard J. Willke is vice president of Cardiovascular/Metabolic, Pain, Gender Health, and Respiratory Outcomes and Evidence, Global Health and Value at Pfizer Inc. in New York City
| | - Henry Bergquist
- Henry Bergquist is a PhD candidate in the Health Care Management Department at the Wharton School, University of Pennsylvania
| | - Jalpa Doshi
- Jalpa Doshi is an associate professor of medicine in the Health Services Research Unit of the Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Lee A Fleisher
- Lee A. Fleisher is chair and Robert Dunning Dripps Professor of Anesthesiology and Critical Care in the Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania
| | - Bruce Kinosian
- Bruce Kinosian is an associate professor of medicine in the Perelman School of Medicine, University of Pennsylvania
| | - Eleanor Perfetto
- Eleanor Perfetto is a professor at the School of Pharmacy-Pharmaceutical Health Services Research, University of Maryland, Baltimore
| | - Daniel E Polsky
- Daniel E. Polsky is executive director and the Robert D. Eilers Professor in Health Care Management and Economics at the Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - J Sanford Schwartz
- J. Sanford Schwartz is the Leon Hess Professor in Internal Medicine in the Division of General Internal Medicine, Perelman School of Medicine, at the University of Pennsylvania
| |
Collapse
|
22
|
Abstract
Background Cost sharing is widely used to encourage therapeutic substitution. This study aimed to examine the impact of increases in patient cost‐sharing differentials for brand name and generic drugs on statin utilization on entry into the Medicare Part D coverage gap. Method and Results Using 5% Medicare Chronic Condition Warehouse files from 2006, this quasi‐experimental study examined patients with hyperlipidemia who filled prescriptions for atorvastatin or rosuvastatin between January and March 2006. Propensity score matching and difference‐in‐difference regressions were used to compare changes in statin utilization for the study group (patients who were not eligible for low‐income subsidies [non–LIS] and had generic‐only gap coverage) to those of a control group (LIS patients who faced the same cost sharing before and during the Part D coverage gap). In the final sample, 801 patients in the study group were matched to 801 patients in the control group. We found that, compared to the control group, the study group had a larger decline in any monthly brand‐name statin use (−0.24 30‐day fills, P<0.001). This was only partially offset by increased monthly generic statin use (+0.06 30‐day fill, P<0.001), with an overall drop in any monthly statin use (−0.18 30‐day fills, P<0.001). Overall adherence with statins declined (OR 0.81, P<0.001), and statin discontinuation increased (OR 1.62, P<0.001) in the study group as compared to the control group. Conclusions Increases in cost‐sharing differentials for brand name and generic drugs on coverage gap entry were associated with discontinuation of statins in Medicare Part D patients with hyperlipidemia.
Collapse
Affiliation(s)
- Pengxiang Li
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA .,Leonard Davis Institute of Health Economics, Philadelphia, PA
| | - J Sanford Schwartz
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Health Care Management Department, The Wharton School of Business, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, Philadelphia, PA
| | - Jalpa A Doshi
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, Philadelphia, PA
| |
Collapse
|
23
|
Sanford Schwartz J, Cohen AB. SMDM's Ninth Annual Meeting. Med Decis Making 2016. [DOI: 10.1177/0272989x8700700303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Alan B. Cohen
- 1987 Scientific Program Committee Society for Medical Decision Making
| |
Collapse
|
24
|
Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, Coumans JVCE, Harrington JF, Amin-Hanjani S, Schwartz JS, Sonntag VKH, Barker FG, Benzel EC. Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. N Engl J Med 2016; 374:1424-34. [PMID: 27074067 DOI: 10.1056/nejmoa1508788] [Citation(s) in RCA: 497] [Impact Index Per Article: 62.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown. METHODS In this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression-alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores indicating more disability related to back pain). Patients were followed for 4 years. RESULTS A total of 66 patients (mean age, 67 years; 80% women) underwent randomization. The rate of follow-up was 89% at 1 year, 86% at 2 years, and 68% at 4 years. The fusion group had a greater increase in SF-36 physical-component summary scores at 2 years after surgery than did the decompression-alone group (15.2 vs. 9.5, for a difference of 5.7; 95% confidence interval, 0.1 to 11.3; P=0.046). The increases in the SF-36 physical-component summary scores in the fusion group remained greater than those in the decompression-alone group at 3 years and at 4 years (P=0.02 for both years). With respect to reductions in disability related to back pain, the changes in the Oswestry Disability Index scores at 2 years after surgery did not differ significantly between the study groups (-17.9 in the decompression-alone group and -26.3 in the fusion group, P=0.06). More blood loss and longer hospital stays occurred in the fusion group than in the decompression-alone group (P<0.001 for both comparisons). The cumulative rate of reoperation was 14% in the fusion group and 34% in the decompression-alone group (P=0.05). CONCLUSIONS Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health-related quality of life than laminectomy alone. (Funded by the Jean and David Wallace Foundation and others; SLIP ClinicalTrials.gov number, NCT00109213.).
Collapse
Affiliation(s)
- Zoher Ghogawala
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - James Dziura
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - William E Butler
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Feng Dai
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Norma Terrin
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Subu N Magge
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Jean-Valery C E Coumans
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - J Fred Harrington
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Sepideh Amin-Hanjani
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - J Sanford Schwartz
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Volker K H Sonntag
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Fred G Barker
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| | - Edward C Benzel
- From the Alan L. and Jacqueline B. Stuart Spine Research Center, the Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington (Z.G., S.N.M.), and the Department of Neurosurgery, Massachusetts General Hospital (W.E.B., J.-V.C.E.C., F.G.B.), and Tufts Clinical and Translational Science Institute, Tufts University School of Medicine (N.T.), Boston - all in Massachusetts; Wallace Trials Center, Greenwich Hospital, Greenwich (Z.G.), and Yale Center for Analytical Sciences, Yale School of Public Health, New Haven (J.D., F.D.) - both in Connecticut; the Department of Neurosurgery, University of New Mexico, Albuquerque (J.F.H.); the Department of Neurosurgery, University of Illinois at Chicago, Chicago (S.A.-H.); Perelman School of Medicine (J.S.S.), Wharton School of Business (J.S.S), and the Leonard Davis Institute (J.S.S.), University of Pennsylvania, Philadelphia; Barrow Neurosurgical Associates, Barrow Neurological Institute, Phoenix, AZ (V.K.H.S.); and the Center for Spine Health and the Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland (E.C.B.)
| |
Collapse
|
25
|
Dean LT, Kumar A, Kim T, Herling M, Brown JC, Zhang Z, Evangelisti M, Hackley R, Kim J, Cheville A, Troxel AB, Schwartz JS, Schmitz KH. Race or Resource? BMI, Race, and Other Social Factors as Risk Factors for Interlimb Differences among Overweight Breast Cancer Survivors with Lymphedema. J Obes 2016; 2016:8241710. [PMID: 27433356 PMCID: PMC4940553 DOI: 10.1155/2016/8241710] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/16/2016] [Accepted: 06/06/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction. High BMI is a risk factor for upper body breast cancer-related lymphedema (BCRL) onset. Black cancer survivors are more likely to have high BMI than White cancer survivors. While observational analyses suggest up to 2.2 times increased risk of BCRL onset for Black breast cancer survivors, no studies have explored race or other social factors that may affect BCRL severity, operationalized by interlimb volume difference (ILD). Materials and Methods. ILD was measured by perometry for 296 overweight (25 > BMI < 50) Black (n = 102) or White (n = 194) breast cancer survivors (>6 months from treatment) in the WISER Survivor trial. Multivariable linear regression examined associations between social and physical factors and ILD. Results. Neither Black race (-0.26, p = 0.89) nor BMI (0.22, p = 0.10) was associated with ILD. Attending college (-4.89, p = 0.03) was the strongest factor associated with ILD, followed by having more lymph nodes removed (4.75, p = 0.01), >25% BCRL care adherence (4.10, p = 0.01), and years since treatment (0.55, p < 0.001). Discussion. Neither race nor BMI was associated with ILD among overweight cancer survivors. Education, a proxy for resource level, was the strongest factor associated with greater ILD. Tailoring physical activity and weight loss interventions designed to address BCRL severity by resource rather than race should be considered.
Collapse
Affiliation(s)
- Lorraine T. Dean
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Anagha Kumar
- MedStar Health Research Institute and MedStar Georgetown University Hospital, Division of Biostatistics, Washington, DC 20007, USA
| | - Taehoon Kim
- School of Arts & Sciences, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Matthew Herling
- The Wharton School of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Justin C. Brown
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Zi Zhang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Margaret Evangelisti
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Renata Hackley
- Recruitment, Outcomes, and Assessment Resource Core, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jiyoung Kim
- School of Arts & Sciences, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Andrea Cheville
- The Mayo Clinic, Department of Physical Medicine and Rehabilitation, Rochester, MN 55905, USA
| | - Andrea B. Troxel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - J. Sanford Schwartz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kathryn H. Schmitz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- *Kathryn H. Schmitz:
| |
Collapse
|
26
|
Jayadevappa R, Chhatre S, Gallo JJ, Wittink M, Morales KH, Bruce Malkowicz S, Lee D, Guzzo T, Caruso A, Van Arsdalen K, Wein AJ, Sanford Schwartz J. Treatment preference and patient centered prostate cancer care: Design and rationale. Contemp Clin Trials 2015; 45:296-301. [PMID: 26435200 DOI: 10.1016/j.cct.2015.09.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/27/2015] [Accepted: 09/30/2015] [Indexed: 11/28/2022]
Abstract
Prostate cancer is a slow progressing cancer that affects millions of men in the US. Due to uncertainties in outcomes and treatment complications, it is important that patients engage in informed decision making to choose the "optimal treatment". Patient centered care that encompasses informed decision-making can improve treatment choice and quality of care. Thus, assessing patient treatment preferences is critical for developing an effective decision support system. The objective of this patient-centered randomized clinical trial was to study the comparative effectiveness of a conjoint analysis intervention compared to usual care in improving subjective and objective outcomes in prostate cancer patients. We identified preferred attributes of alternative prostate cancer treatments that will aid in evaluating attributes of treatment options. In this two-phase study, in Phase 1 we used mixed methods to develop an adaptive conjoint task instrument. The conjoint task required the patients to trade-off attributes associated with treatments by assessing their relative importance. Phase 2 consisted of a randomized controlled trial of men with localized prostate cancer. We analyzed the effect of conjoint task intervention on the association between preferences, treatment and objective and subjective outcomes. Our conjoint task instrument can lead to a values-based patient-centered decision aid tool and help tailor treatment decision making to the values of prostate cancer patients. This will ultimately improve clinical decision making, clinical policy process, enhance patient centered care and improve prostate cancer outcomes.
Collapse
Affiliation(s)
- Ravishankar Jayadevappa
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States; Division of Urology, Perelman School of Medicine, University of Pennsylvania, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, United States.
| | - Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, United States
| | - Joseph J Gallo
- Bloomberg School of Public Health, Johns Hopkins University, United States
| | - Marsha Wittink
- Department of Psychiatry, University of Rochester Medical Center, United States
| | - Knashawn H Morales
- Department of Biostatistics and Epidemiology, University of Pennsylvania, United States
| | - S Bruce Malkowicz
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, United States; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, United States
| | - David Lee
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, United States
| | - Thomas Guzzo
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, United States
| | - Adele Caruso
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, United States
| | - Keith Van Arsdalen
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, United States; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, United States
| | - Alan J Wein
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, United States
| | - J Sanford Schwartz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States
| |
Collapse
|
27
|
Chhatre S, Bruce Malkowicz S, Sanford Schwartz J, Jayadevappa R. Understanding the Racial and Ethnic Differences in Cost and Mortality Among Advanced Stage Prostate Cancer Patients (STROBE). Medicine (Baltimore) 2015; 94:e1353. [PMID: 26266389 PMCID: PMC4616711 DOI: 10.1097/md.0000000000001353] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/15/2015] [Accepted: 07/18/2015] [Indexed: 11/26/2022] Open
Abstract
The aims of the study were to understand the racial/ethnic differences in cost of care and mortality in Medicare elderly with advanced stage prostate cancer.This retrospective, observational study used SEER-Medicare data. Cohort consisted of 10,509 men aged 66 or older and diagnosed with advanced-stage prostate cancer between 2001and 2004. The cohort was followed retrospectively up to 2009. Racial/ethnic variation in cost was analyzed using 2 part-models and quantile regression. Step-wise GLM log-link and Cox regression was used to study the association between race/ethnicity and cost and mortality. Propensity score approach was used to minimize selection bias.Pattern of cost and mortality varies between racial/ethnic groups. Compared with other racial/ethnic groups, non-Hispanic white patients had higher unadjusted costs in treatment and follow-up phases. Quintile regression results indicated that in treatment phase, Hispanics had higher costs in the 95th quantile and non-Hispanic blacks had lower cost in the 95th quantile, compared with non-Hispanic white men. In terminal phase non-Hispanic blacks and Hispanics had higher cost. After controlling for treatment, all-cause and prostate cancer-specific mortality was not significant for non-Hispanic black men, compared with non-Hispanic white men. However, for Asians, mortality remained significantly lower compared with non-Hispanic white men.In conclusion, relationship between race/ethnicity, cost of care, and mortality is intricate. For non-Hispanic black men, disparity in mortality can be attributed to treatment differences. To reduce racial/ethnic disparities in prostate cancer care and outcomes, tailored policies to address underuse, overuse, and misuse of treatment and health services are necessary.
Collapse
Affiliation(s)
- Sumedha Chhatre
- From the Department of Psychiatry (SC); Division of Urology, Department of Surgery (SBM, RJ); Department of Medicine (JSS, RJ); and Leonard Davis Institute of Health Economics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania (JSS, RJ)
| | | | | | | |
Collapse
|
28
|
Ghogawala Z, Benzel EC, Heary RF, Riew KD, Albert TJ, Butler WE, Barker FG, Heller JG, McCormick PC, Whitmore RG, Freund KM, Schwartz JS. Cervical spondylotic myelopathy surgical trial: randomized, controlled trial design and rationale. Neurosurgery 2015; 75:334-46. [PMID: 24991714 DOI: 10.1227/neu.0000000000000479] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the world. There are significant practice variation and uncertainty as to the optimal surgical approach for treating CSM. OBJECTIVE To determine whether ventral surgery is associated with superior Short Form-36 Physical Component Summary outcome at the 1-year follow-up compared with dorsal (laminectomy/fusion or laminoplasty) surgery for the treatment of CSM, to investigate whether postoperative sagittal balance is an independent predictor of overall outcome, and to compare health resource use for ventral and dorsal procedures. METHODS The study is a randomized, controlled trial with a nonrandomized arm for patients who are eligible but decline randomization. Two hundred fifty patients (159 randomized) with CSM from 11 sites will be recruited over 18 months. The primary outcome is the Short Form-36 Physical Component Summary score. Secondary outcomes include disease-specific outcomes, overall health-related quality of life (EuroQOL 5-dimension questionnaire), and health resource use. EXPECTED OUTCOMES This will be the first randomized, controlled trial to compare directly the health-related quality-of-life outcomes for ventral vs dorsal surgery for treating CSM. DISCUSSION A National Institutes of Health-funded (1R13AR065834-01) investigator meeting was held before the initiation of the trial to bring multiple stakeholders together to finalize the study protocol. Study investigators, coordinators, and major stakeholders were able to attend and discuss strengths of, limitations of, and concerns about the study. The final protocol was approved for funding by the Patient-Centered Outcomes Research Institute (CE-1304-6173). The trial began enrollment on April 1, 2014.
Collapse
Affiliation(s)
- Zoher Ghogawala
- *Alan and Jacqueline Stuart Spine Center, Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts; ‡Tufts University School of Medicine, Boston, Massachusetts; §Wallace Trials Center, Greenwich Hospital, Greenwich, Connecticut; ¶Center for Spine Health and Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio; ‖Department of Neurosurgery, Rutgers, State University of New Jersey--New Jersey Medical School, Newark, New Jersey; #Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri; **Department of Orthopedic Surgery, Thomas Jefferson University and Rothman Institute, Philadelphia, Pennsylvania; ‡‡Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts; §§Department of Orthopedic Surgery, Emory Spine Center, Atlanta, Georgia; ¶¶Department of Neurological Surgery, Neurological Institute of New York, Columbia University Medical Center, New York, New York; ‖‖Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tuft University School of Medicine, Boston, Massachusetts; and ##Perelman School of Medicine, Wharton School of Business and Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Lester-Coll NH, Lee JM, Gogineni K, Hwang WT, Schwartz JS, Prosnitz RG. Benefits and risks of contralateral prophylactic mastectomy in women undergoing treatment for sporadic unilateral breast cancer: a decision analysis. Breast Cancer Res Treat 2015; 152:217-226. [DOI: 10.1007/s10549-015-3462-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/05/2015] [Indexed: 11/28/2022]
|
30
|
Ramsey SD, Malin JL, Goulart B, Ambrose LF, Kanne JP, McKee AB, Reed SD, Schwartz JS, Sullivan SD. Implementing Lung Cancer Screening Using Low-Dose Computed Tomography: Recommendations From an Expert Panel. J Oncol Pract 2015; 11:e44-9. [DOI: 10.1200/jop.2014.001528] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Implementation of effective and efficient population-based CT lung cancer screening will require involvement and coordination of stakeholders across the health care system.
Collapse
Affiliation(s)
- Scott D. Ramsey
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Jennifer L. Malin
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Bernardo Goulart
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Laurie F. Ambrose
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey P. Kanne
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Andrea B. McKee
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Shelby D. Reed
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - J. Sanford Schwartz
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Sean D. Sullivan
- University of Washington; Fred Hutchinson Cancer Research Center, Seattle, WA; Wellpoint, Santa Monica, CA; Lung Cancer Alliance, Washington, DC; University of Wisconsin School of Medicine and Public Health, Madison, WI; Lahey Hospital and Medical Center, Burlington, MA; Duke Clinical Research Institute, Durham, NC; and School of Medicine, Wharton School, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
31
|
Dean LT, Kim T, Herling M, Brown J, Schwartz JS, Schmitz K. Abstract C31: Racial/ethnic differences in cancer survivorship: The example of breast cancer-related lymphedema severity. Cancer Epidemiol Biomarkers Prev 2014. [DOI: 10.1158/1538-7755.disp13-c31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Introduction: Breast-cancer related lymphedema (BCRL) is a persistent adverse outcome of cancer treatment that affects the physical health and quality of life of up to 1 in 3 of the 2.9 million breast cancer survivors in the US. For those with BCRL, known predictors of progression include BMI, type of surgery and radiation treatment, each of which is independently associated with race/ethnicity. Observational studies have found that Black/African-American women are more likely than Whites to develop BCRL, but no studies have explored the association of race/ethnicity with BCRL severity.
Method: The WISER Survivor Trial has collected baseline data from 149 overweight (BMI≥25) women with upper body BCRL (61% White; 39% African-American). Ordinal logistic regression modeling was used to explore the associations of known predictors of lymphedema progression and race/ethnicity with lymphedema grade (0-3).
Results: In univariate analysis, higher age at breast cancer surgery, being African-American, and having had chemotherapy or radiation therapy were significantly associated with higher lymphedema grade. Multivariate analysis revealed that race mediates the relationship between BMI and lymphedema grade such that being African-American AND having an elevated BMI is associated with higher lymphedema grade while elevated BMI is not associated with higher lymphedema grade among White women, such that at equivalent BMI, African-American women were 20% more likely to have a higher lymphedema severity (OR=1.20 [1.00, 1.44]; p=0.043).
Discussion: These findings point to a need for clinicians to be aware of increased risk of lymphedema for overweight African-American female breast cancer survivors. The cause of the observed interaction of African-American race/ethnicity and BMI on lymphedema severity remains to be elucidated. Previous studies have observed a relationship of higher lymphedema grade with higher costs to care for the condition, as well as worse functional ability of the upper body. Therefore, increased odds of higher lymphedema grade among African-American women with elevated BMI could contribute to a meaningful difference in the burden of breast cancer survivorship for this underserved minority population. To further elucidate this relationship, prospective collection on health-care costs for breast cancer survivors with lymphedema is warranted. This work has implications to affect care for and quality of life of up to 1 in 3 of the 2.9 million breast cancer survivors in the US who have BCRL.
Citation Format: Lorraine T. Dean, Taehoon Kim, Matthew Herling, Justin Brown, J Sanford Schwartz, Kathryn Schmitz. Racial/ethnic differences in cancer survivorship: The example of breast cancer-related lymphedema severity. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C31. doi:10.1158/1538-7755.DISP13-C31
Collapse
Affiliation(s)
| | - Taehoon Kim
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | | |
Collapse
|
32
|
Goff DC, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R, Greenland P, Lackland DT, Levy D, O’Donnell CJ, Robinson JG, Schwartz JS, Shero ST, Smith SC, Sorlie P, Stone NJ, Wilson PWF, Jordan HS, Nevo L, Wnek J, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, DeMets D, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Smith SC, Tomaselli GF. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. Circulation 2014; 129:S49-73. [DOI: 10.1161/01.cir.0000437741.48606.98] [Citation(s) in RCA: 2266] [Impact Index Per Article: 226.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
33
|
Neuman MD, Goldstein JN, Cirullo MA, Schwartz JS. Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations. JAMA 2014; 311:2092-100. [PMID: 24867012 PMCID: PMC4346183 DOI: 10.1001/jama.2014.4949] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Little is known regarding the durability of clinical practice guideline recommendations over time. OBJECTIVE To characterize variations in the durability of class I ("procedure/treatment should be performed/administered") American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations. DESIGN, SETTING, AND PARTICIPANTS Textual analysis by 4 independent reviewers of 11 guidelines published between 1998 and 2007 and revised between 2006 and 2013. MAIN OUTCOMES AND MEASURES We abstracted all class I recommendations from the first of the 2 most recent versions of each guideline and identified corresponding recommendations in the subsequent version. We classified recommendations replaced by less determinate or contrary recommendations as having been downgraded or reversed; we classified recommendations for which no corresponding item could be identified as having been omitted. We tested for differences in the durability of recommendations according to guideline topic and underlying level of evidence using bivariable hypothesis tests and conditional logistic regression. RESULTS Of 619 index recommendations, 495 (80.0%; 95% CI, 76.6%-83.1%) were retained in the subsequent guideline version, 57 (9.2%; 95% CI, 7.0%-11.8%) were downgraded or reversed, and 67 (10.8%; 95% CI, 8.4%-13.3%) were omitted. The percentage of recommendations retained varied across guidelines from 15.4% (95% CI, 1.9%-45.4%) to 94.1% (95% CI, 80.3%-99.3%; P < .001). Among recommendations with available information on level of evidence, 90.5% (95% CI, 83.2%-95.3%) of recommendations supported by multiple randomized studies were retained, vs 81.0% (95% CI, 74.8%-86.3%) of recommendations supported by 1 randomized trial or observational data and 73.7% (95% CI, 65.8%-80.5%) of recommendations supported by opinion (P = .001). After accounting for guideline-level factors, the probability of being downgraded, reversed, or omitted was greater for recommendations based on opinion (odds ratio, 3.14; 95% CI, 1.69-5.85; P < .001) or on 1 trial or observational data (odds ratio, 3.49; 95% CI, 1.45-8.41; P = .005) vs recommendations based on multiple trials. CONCLUSIONS AND RELEVANCE The durability of class I cardiology guideline recommendations for procedures and treatments promulgated by the ACC/AHA varied across individual guidelines and levels of evidence. Downgrades, reversals, and omissions were most common among recommendations not supported by multiple randomized studies.
Collapse
Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Jennifer N Goldstein
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Michael A Cirullo
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - J Sanford Schwartz
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia3Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Department of Health Care Management
| |
Collapse
|
34
|
Goldsack JC, Reilly C, Bush C, McElligott S, Bristol MN, Motanya UN, Field R, Vozniak JM, Wong YN, Schwartz JS, Domchek S. Impact of shortages of injectable oncology drugs on patient care. Am J Health Syst Pharm 2014; 71:571-8. [DOI: 10.2146/ajhp130569] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jennifer C. Goldsack
- The Value Institute, Christiana Care Health System, John H. Ammon Medical Education Center, Newark, DE
| | | | - Colleen Bush
- American Society of Health-System Pharmacists, Bethesda, MD
| | | | - Mirar N. Bristol
- General Internal Medicine, University of Pennsylvania, Philadelphia
| | - U. Nkiru Motanya
- General Internal Medicine, University of Pennsylvania, Philadelphia
| | - Robert Field
- Department of Health Management and Policy, Drexel School of Public Health, Drexel University, Philadelphia, PA
| | - J. Michael Vozniak
- Professional Practice, Hospital of the University of Pennsylvania, Philadelphia
| | - Yu-Ning Wong
- Medical Oncology, and Assistant Professor, Fox Chase Cancer Center, Philadelphia
| | - J. Sanford Schwartz
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Susan Domchek
- Department of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
35
|
Stone NJ, Robinson JG, Lichtenstein AH, Goff DC, Lloyd-Jones DM, Smith SC, Blum C, Schwartz JS. Treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: synopsis of the 2013 American College of Cardiology/American Heart Association cholesterol guideline. Ann Intern Med 2014; 160:339-43. [PMID: 24474185 DOI: 10.7326/m14-0126] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
DESCRIPTION In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical practice guideline on the treatment of blood cholesterol to reduce cardiovascular risk in adults. This synopsis summarizes the major recommendations. METHODS In 2008, the National Heart, Lung, and Blood Institute convened the Adult Treatment Panel (ATP) IV to update the 2001 ATP-III cholesterol guidelines using a rigorous process to systematically review randomized, controlled trials (RCTs) and meta-analyses of RCTs that examined cardiovascular outcomes. The panel commissioned independent systematic evidence reviews on low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol goals in secondary and primary prevention and the effect of lipid drugs on atherosclerotic cardiovascular disease events and adverse effects. In September 2013, the panel's draft recommendations were transitioned to the ACC/AHA. RECOMMENDATIONS This synopsis summarizes key features of the guidelines in 8 areas: lifestyle, groups shown to benefit from statins, statin safety, decision making, estimation of cardiovascular disease risk, intensity of statin therapy, treatment targets, and monitoring of statin therapy.
Collapse
|
36
|
Harvie HS, Shea JA, Andy UU, Propert K, Schwartz JS, Arya LA. Validity of utility measures for women with urge, stress, and mixed urinary incontinence. Am J Obstet Gynecol 2014; 210:85.e1-6. [PMID: 24055585 DOI: 10.1016/j.ajog.2013.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/28/2013] [Accepted: 09/16/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to evaluate the construct validity of 3 health status classification system instruments-Health Utilities Index Mark 3 (HUI-3), EuroQol (EQ-5D), and Short Form 6D (SF-6D)-and a visual analog scale (VAS) for measuring utility scores in women with urge, stress, and mixed urinary incontinence. STUDY DESIGN Utility scores were measured in 202 women with urinary incontinence. Pelvic floor symptom severity and quality of life were measured using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire, respectively. Construct, discriminant, and concurrent validity were evaluated. RESULTS Significant correlations were noted between utility scores and the Pelvic Floor Distress Inventory (r = -0.22 to -0.42, P < .05) and the Pelvic Floor Impact Questionnaire (r = -0.32 to -0.50, P < .05). Mean utility scores were significantly lower for women with urge or mixed incontinence compared to stress incontinence for the EQ-5D (0.71 ± 0.23, 0.73 ± 0.26, and 0.81 ± 0.16, respectively, P = .02) and the SF-6D (0.76 ± 0.12, 0.74 ± 0.12, and 0.81 ± 0.11, respectively, P = .02) but not the HUI-3 or the VAS. There was a clinically important difference in utility scores (>0.03) between women with urge or mixed incontinence as compared to stress incontinence for the HUI-3, EQ-5D, and SF-6D but not the VAS. Utility preference scores were significantly lower for women with combined urinary and fecal incontinence (0.69-0.73) than urinary incontinence alone (0.77-0.84, P < .01). CONCLUSION The HUI-3, EQ-5D, and SF-6D, but not the VAS, provide valid measurements for utility scores in women with stress, urge, and mixed urinary incontinence.
Collapse
|
37
|
Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC, Watson K, Wilson PWF. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 63:2889-934. [PMID: 24239923 DOI: 10.1016/j.jacc.2013.11.002] [Citation(s) in RCA: 2924] [Impact Index Per Article: 265.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
38
|
Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC, Watson K, Wilson PWF, Eddleman KM, Jarrett NM, LaBresh K, Nevo L, Wnek J, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, DeMets D, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Smith SC, Tomaselli GF. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation 2013; 129:S1-45. [DOI: 10.1161/01.cir.0000437738.63853.7a] [Citation(s) in RCA: 3010] [Impact Index Per Article: 273.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
39
|
Hornik R, Parvanta S, Mello S, Freres D, Kelly B, Schwartz JS. Effects of scanning (routine health information exposure) on cancer screening and prevention behaviors in the general population. J Health Commun 2013; 18:1422-35. [PMID: 24083417 PMCID: PMC4235954 DOI: 10.1080/10810730.2013.798381] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Research on health information exposure focuses primarily on deliberate information-seeking behavior and its effects on health. By contrast, this study explores the complementary and perhaps more influential role of health information acquired through exposure to routinely used sources, called scanning. The authors hypothesized that scanning from nonmedical sources, both mediated and interpersonal, affects cancer screening and prevention decisions. The authors used a nationally representative longitudinal survey of 2,489 adults 40 to 70 years of age to analyze the effects of scanning on 3 cancer screening behaviors (mammography, prostate-specific antigen [PSA], and colonoscopy) and 3 prevention behaviors (exercising, eating fruits and vegetables, and dieting to lose weight). After adjustment for baseline behaviors and covariates, scanning at baseline predicted weekly exercise days 1 year later as well as daily fruit and vegetable servings 1 year later for those whose consumption of fruits and vegetables was already higher at baseline. Also, among those reporting timely screening mammogram behavior at baseline, scanning predicted repeat mammography. Scanning was marginally predictive of PSA uptake among those not reporting a PSA at baseline. Although there were strong cross-sectional associations, scanning did not predict dieting or colonoscopy uptake in longitudinal analyses. These analyses provide substantial support for a claim that routine exposure to health content from nonmedical sources affects specific health behaviors.
Collapse
Affiliation(s)
- Robert Hornik
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Parvanta
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan Mello
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | - Derek Freres
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | | | - J. Sanford Schwartz
- Department of Medicine and The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
40
|
Wong YN, Egleston BL, Sachdeva K, Eghan N, Pirollo M, Stump TK, Beck JR, Armstrong K, Schwartz JS, Meropol NJ. Cancer patients' trade-offs among efficacy, toxicity, and out-of-pocket cost in the curative and noncurative setting. Med Care 2013; 51:838-45. [PMID: 23872905 PMCID: PMC3857689 DOI: 10.1097/mlr.0b013e31829faffd] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND When making treatment decisions, cancer patients must make trade-offs among efficacy, toxicity, and cost. However, little is known about what patient characteristics may influence these trade-offs. METHODS A total of 400 cancer patients reviewed 2 of 3 stylized curative and noncurative scenarios that asked them to choose between 2 treatments of varying levels of efficacy, toxicity, and cost. Each scenario included 9 choice sets. Demographics, cost concerns, numeracy, and optimism were assessed. Within each scenario, we used latent class methods to distinguish groups with discrete preferences. We then used regressions with group membership probabilities as covariates to identify associations. RESULTS The median age of the patients was 61 years (range, 27-90 y). Of the total number of patients included, 25% were enrolled at a community hospital, and 99% were insured. Three latent classes were identified that demonstrated (1) preference for survival, (2) aversion to high cost, and (3) aversion to toxicity. Across all scenarios, patients with higher income were more likely to be in the class that favored survival. Lower income patients were more likely to be in the class that was averse to high cost (P<0.05). Similar associations were found between education, employment status, numeracy, cost concerns, and latent class. CONCLUSIONS Even in these stylized scenarios, socioeconomic status predicted the treatment choice. Higher income patients may be more likely to focus on survival, whereas those of lower socioeconomic status may be more likely to avoid expensive treatment, regardless of survival or toxicity. This raises the possibility that insurance plans with greater cost-sharing may have the unintended consequence of increasing disparities in cancer care.
Collapse
Affiliation(s)
- Yu-Ning Wong
- Fox Chase Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University
| | - Brian L Egleston
- Fox Chase Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University
| | - Kush Sachdeva
- South Jersey Healthcare, Case Comprehensive Cancer Center, Case Western Reserve University
| | - Naa Eghan
- Premier Research, Case Comprehensive Cancer Center, Case Western Reserve University
| | - Melanie Pirollo
- South Jersey Healthcare, Case Comprehensive Cancer Center, Case Western Reserve University
| | - Tammy K Stump
- University of Utah, Case Comprehensive Cancer Center, Case Western Reserve University
| | - J Robert Beck
- Fox Chase Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University
| | - Katrina Armstrong
- University of Pennsylvania, Case Comprehensive Cancer Center, Case Western Reserve University
| | - J Sanford Schwartz
- University of Pennsylvania, Case Comprehensive Cancer Center, Case Western Reserve University
| | - Neal J Meropol
- University Hospitals Case Medical Center Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University
| |
Collapse
|
41
|
Whitmore RG, Ghogawala Z, Petrov D, Schwartz JS, Stein SC. Functional outcome instruments used for cervical spondylotic myelopathy: interscale correlation and prediction of preference-based quality of life. Spine J 2013; 13:902-7. [PMID: 23523443 DOI: 10.1016/j.spinee.2012.11.058] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Accepted: 11/17/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There is limited literature comparing different functional outcome measures used for cervical spondylotic myelopathy (CSM). PURPOSE To determine the correlation among five functional outcome measures used in CSM patient assessment and their ability to predict preference-based quality of life (QOL). STUDY DESIGN/SETTING Prospective observational study. PATIENT SAMPLE Patients, aged 40 to 85 years, with CSM and cervical spinal cord compression at two or more levels from degenerative spondylosis were enrolled from seven sites over a 2-year period. OUTCOME MEASURES The modified Japanese Orthopedic Association scale, Oswestry neck disability index (Oswestry NDI or Oswestry), Nurick scale, norm-based short-form 36 physical component summary, and EuroQol-5D (EQ-5D) were collected. METHODS The Jean and David Wallace foundation provided funding for this study. Cervical spondylotic myelopathy patients undergoing either anterior or posterior surgery were prospectively followed with five different functional outcome measures over 1 year. Correlations among scales were tested using the Spearman rank correlation test. The sensitivity and specificity of each scale for predicting the global index of the EQ-5D were determined, and receiver-operating characteristic analysis was used to compare each scale's ability to discriminate QOL. RESULTS A total of 106 patients were initially enrolled; 103 were operated on for CSM and followed for 1 year. Their ages ranged from 40 to 82 years (mean 61.9), and 61.3% were men. Correlations among the various functional outcome instruments were all highly significant (p<.001), but the degree of correlation varied greatly. Correlation between the EQ-5D scale and the Nurick scale was the least (Spearman rho 0.5539); correlation was the highest with the Oswestry NDI (Spearman rho 0.8306). The Oswestry NDI also had the greatest ability to discriminate favorable from adverse QOL compared with the other outcome instruments (p=.023). CONCLUSIONS Preference-based quality-of-life instruments, such as the EQ-5D, are important measures for studying spinal disorders. Among the various commonly used outcome instruments for CSM, the Oswestry NDI is the most predictive of preference-based QOL.
Collapse
Affiliation(s)
- Robert G Whitmore
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3rd Floor Silverstein, 3400 Spruce St, Philadelphia, PA 19104, USA.
| | | | | | | | | |
Collapse
|
42
|
Stump TK, Eghan N, Egleston BL, Hamilton O, Pirollo M, Schwartz JS, Armstrong K, Beck JR, Meropol NJ, Wong YN. Cost concerns of patients with cancer. J Oncol Pract 2013; 9:251-7. [PMID: 23943901 DOI: 10.1200/jop.2013.000929] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Health care providers are accustomed to identifying populations for whom cost-related concerns may be a significant barrier, such as the poor, but few empiric data have been collected to substantiate such assumptions, particularly among insured patients. METHODS Patients with cancer from academic and community hospitals completed a questionnaire that included closed-ended items concerning demographic variables, optimism, numeracy, and concerns about present and future medical costs. In addition, they answered open-ended questions regarding cost concerns and medical expenses. RESULTS Nearly all (99%) participants were insured. In response to the closed-ended questions, 30.3% of patients reported concern about paying for their cancer treatment, 22.3% reported that their family had made sacrifices to pay for their care, and 8.3% stated that their insurance adequately covered their current health care costs, and 17.3% reported concerns about coverage for their costs in the future. On open-ended questions, 35.3% reported additional expenses, and 47.5% reported concerns about health care costs. None of the assessed patient characteristics proved to be a robust predictor across all cost-related concerns. There was a strong association between the identification of concerns or expenses on the open-ended questions and concerns on closed-ended questions. CONCLUSION Cost concerns are common among patients with cancer who have health insurance. Health care providers may alleviate concerns by discussing cost-related concerns with all patients, not only those of lower socioeconomic status or those without insurance. A closed-ended screening question may help to initiate these conversations. This may identify potential resources, lower distress, and enable patients to make optimal treatment decisions.
Collapse
Affiliation(s)
- Tammy K Stump
- University of Utah, Salt Lake City, UT; Premier Research Group Limited; Fox Chase Cancer Center; University of Pennsylvania, Philadelphia, PA; South Jersey Healthcare, Vineland, NJ; and University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Ramírez AS, Freres D, Martinez LS, Lewis N, Bourgoin A, Kelly BJ, Lee CJ, Nagler R, Schwartz JS, Hornik RC. Information seeking from media and family/friends increases the likelihood of engaging in healthy lifestyle behaviors. J Health Commun 2013; 18:527-42. [PMID: 23472825 PMCID: PMC4254799 DOI: 10.1080/10810730.2012.743632] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The amount of cancer-related information available to the general population continues to grow; yet, its effects are unclear. This study extends previous cross-sectional research establishing that cancer information seeking across a variety of sources is extensive and positively associated with engaging in health-related behaviors. The authors studied how active information seeking about cancer prevention influenced three healthy lifestyle behaviors using a 2-round nationally representative sample of adults ages 40-70 years (n = 1,795), using propensity scoring to control for potential confounders including baseline behavior. The adjusted odds of dieting at follow-up were 1.51 (95% CI: 1.05, 2.19) times higher for those who reported baseline seeking from media and interpersonal sources relative to nonseekers. Baseline seekers ate 0.59 (95% CI: 0.28, 0.91) more fruits and vegetable servings per day and exercised 0.36 (95% CI: 0.12, 0.60) more days per week at 1-year follow-up compared with nonseekers. The effects of seeking from media and friends/family on eating fruits and vegetables and exercising were independent of seeking from physicians. The authors offer several explanations for why information seeking predicts healthy lifestyle behaviors: information obtained motivates these behaviors; information sought teaches specific techniques; and the act of information seeking may reinforce a psychological commitment to dieting, eating fruits and vegetables, and exercising.
Collapse
Affiliation(s)
- A Susana Ramírez
- Cancer Prevention Fellowship Program, National Cancer Institute, 6130 Executive Boulevard, Room 4051A, Bethesda, MD 20892, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Luce BR, Drummond MF, Dubois RW, Neumann PJ, Jönsson B, Siebert U, Schwartz JS. Principles for planning and conducting comparative effectiveness research. J Comp Eff Res 2012; 1:431-40. [DOI: 10.2217/cer.12.41] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aims: To develop principles for planning and conducting comparative effectiveness research (CER). Methods: Beginning with a modified existing list of health technology assessment principles, we developed a set of CER principles using literature review, engagement of multiple experts and broad stakeholder feedback. Results & conclusion: Thirteen principles and actions to fulfill their intent are proposed. Principles include clarity of objectives, transparency, engagement of stakeholders, consideration of relevant perspectives, use of relevant comparators, and evaluation of relevant outcomes and treatment heterogeneity. Should these principles be found appropriate and useful, CER studies should be audited for adherence to them and monitored for their impact on care management, patient relevant outcomes and clinical guidelines.
Collapse
Affiliation(s)
- Bryan R Luce
- United BioSource Corporation, Science Policy, Bethesda, MD, USA
- University of Washington, Seattle, WA, USA
| | | | | | - Peter J Neumann
- Institute for Clinical Research & Health Policy Studies, Tufts Medical Center & Tufts University School of Medicine, Boston, MA, USA
| | - Bengt Jönsson
- Stockholm School of Economics, Department of Economics, Stockholm, Sweden
| | - Uwe Siebert
- University for Health Sciences, Medical Informatics & Technology, Hall i.T., Austria
- Oncotyrol – Center for Personalized Cancer Medicine, Innsbruck, Austria
- Harvard University, Boston, MA, USA
| | - J Sanford Schwartz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Wharton School of Business, Medicine & Health Management & Economics, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
45
|
Mello S, Tan ASL, Armstrong K, Sanford Schwartz J, Hornik RC. Anxiety and depression among cancer survivors: the role of engagement with sources of emotional support information. Health Commun 2012; 28:389-396. [PMID: 22809393 PMCID: PMC4195239 DOI: 10.1080/10410236.2012.690329] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This study explores cancer survivors' engagement with information about emotional support from doctors, interpersonal sources, and the media and examines to what extent such engagement affects subsequent self-reported anxiety and depression. Patients with colorectal, breast, or prostate cancer (n = 1,128) were surveyed over 3 years following diagnosis. Using lagged logistic regression, we predicted the odds of experiencing anxiety or depression based on earlier engagement with sources of emotional support, adjusting for prior symptoms and confounders. Among those reporting anxiety or depression (n = 476), we also asked whether information engagement affected the severity of those symptoms. Participants obtained information about emotional support from multiple sources, but most often from physicians. Discussions with physicians about emotional support increased the odds of cancer survivors subsequently reporting anxiety or depression by 1.58 times (95% CI: 1.06 to 2.35; p = 0.025), adjusted for prior symptoms and confounders. Scanning from media sources was also significantly associated with increased odds of reporting emotional symptoms (OR=1.72; 95% CI: 1.03 to 2.87; p = 0.039). However, among those who reported symptoms, doctor-patient engagement predicted slightly reduced interference of these symptoms with daily activities (B = -0.198; 95% CI: -0.393 to -0.003; p = 0.047). Important implications for health communication research and practice are discussed.
Collapse
Affiliation(s)
- Susan Mello
- Center of Excellence in Cancer Communication Research, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | | | |
Collapse
|
46
|
Li P, McElligott S, Bergquist H, Schwartz JS, Doshi JA. Effect of the Medicare Part D coverage gap on medication use among patients with hypertension and hyperlipidemia. Ann Intern Med 2012; 156:776-84, W-263, W-264, W-265, W-266, W-267, W-268, W-269. [PMID: 22665815 DOI: 10.7326/0003-4819-156-11-201206050-00004] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Prior studies of the Medicare Part D coverage gap are limited in generalizability and scope. OBJECTIVE To determine the effect of the coverage gap on drugs used for asymptomatic (antihypertensive and lipid-lowering drugs) and symptomatic (pain relievers, acid suppressants, and antidepressants) conditions in elderly patients with hypertension and hyperlipidemia. DESIGN Quasi-experimental study using pre-post design and contemporaneous control group. SETTING Medicare claims files from 2005 and 2006 for 5% random sample of Medicare beneficiaries. PATIENTS Part D plan enrollees with hypertension or hyperlipidemia aged 65 years or older who had no coverage, generic-only coverage, or both brand-name and generic coverage during the gap in 2006. Patients who were fully eligible for the low-income subsidy served as the control group. MEASUREMENTS Monthly 30-day supply prescriptions available, medication adherence, and continuous medication gaps of 30 days or more for antihypertensive or lipid-lowering drugs; monthly 30-day supply prescriptions available for pain relievers, acid suppressants, or antidepressants before and after coverage gap entry. RESULTS Patients with no gap coverage had a decrease in monthly antihypertensive and lipid-lowering drug prescriptions during the coverage gap. Nonadherence also increased in this group (antihypertensives: odds ratio [OR], 1.60 [95% CI, 1.50 to 1.71]; lipid-lowering drugs: OR, 1.59 [CI, 1.50 to 1.68]). The proportion of patients with no gap coverage who had continuous medication gaps in lipid-lowering medication use and antihypertensive use increased by an absolute 7.3% (OR, 1.38 [CI, 1.29 to 1.46]) and 3.2% (OR, 1.35 [CI, 1.25 to 1.45]), respectively, because of the coverage gap. Decreases in use were smaller for pain relievers and antidepressants and larger for acid suppressants in patients with no gap coverage. Patients with generic-only coverage had decreased use of cardiovascular medications but no change in use of drugs for symptomatic conditions. No measures changed in the brand-name and generic coverage groups. Results of sensitivity analyses were consistent with the main findings. LIMITATION Because this study was nonrandomized, unobserved differences may still exist between study groups. CONCLUSION The Part D coverage gap was associated with decreased use of medications for hypertension and hyperlipidemia in patients with no gap coverage and generic-only gap coverage. The proposed phasing out of the gap by 2020 will benefit such patients; however, use of low-value medications may also increase. PRIMARY FUNDING SOURCE Penn-Pfizer Alliance and American Heart Association.
Collapse
Affiliation(s)
- Pengxiang Li
- University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | | | |
Collapse
|
47
|
Abstract
Despite an increase in direct-to-consumer (DTC) genetic testing, little is known about how variations in website content might alter consumer behavior. We evaluated the impact of risk information provision on women's attitudes about DTC BRCA testing. We conducted a randomized experiment; women viewed a 'mock' BRCA testing website without [control group (CG)] or with information on the potential risks of DTC testing [RG; framed two ways: unattributed risk (UR) information and risk information presented by experts (ER)]. Seven hundred and sixty-seven women participated; mean age was 37 years, mean education was 15 years, and 79% of subjects were white. Women in the RG had less positive beliefs about DTC testing (mean RG = 23.8, CG = 25.2; p = 0.001), lower intentions to get tested (RG = 2.8, CG = 3.1; p = 0.03), were more likely to prefer clinic-based testing (RG = 5.1, CG = 4.8; p = 0.03) and to report that they had seen enough risk information (RG = 5.3, CG = 4.7; p < 0.001). UR and ER exposure produced similar effects. Effects did not differ for women with or without a personal/family history of breast/ovarian cancer. Exposing women to the potential risks of DTC BRCA testing altered their beliefs, preferences, and intentions. Risk messages appear to be salient to women irrespective of their chance of having a BRCA mutation.
Collapse
Affiliation(s)
- S W Gray
- Population Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA.
| | | | | | | |
Collapse
|
48
|
Lester-Coll NH, Lee JM, Gogineni K, Hwang WT, Schwartz JS, Prosnitz RG. PD02-02: A Decision Analysis of Contralateral Prophylactic Mastectomy in Women Undergoing Treatment for Sporadic Unilateral Breast Cancer. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-pd02-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background:
The intent of contralateral prophylactic mastectomy (CPM) is to improve survival after a diagnosis of unilateral breast cancer by reducing the risk of contralateral breast cancer (CBC). CPM rates are rising among women with sporadic breast cancer, despite limited evidence that its benefits outweigh its harms. Although CPM is highly effective in reducing a woman's risk of CBC, the competing mortality risk from a patient's index breast cancer may offset its benefits. Furthermore, any examination of CPM needs to consider quality of life effects.
Methods:
We developed a Markov decision analytic model to estimate the effect of CPM in women with newly diagnosed unilateral breast cancer. The primary outcomes examined were gains in life expectancy (LE) and quality-adjusted life expectancy (QALE) for CPM compared with no CPM in 18 hypothetical cohorts of 45-year old women. Data from the British Columbia Cancer Agency (BCCA) was used to generate AJCC stage and molecular subtype-specific estimates of the risk of developing distant metastases from an index breast cancer. A correction factor was applied to account for the omission of relevant systemic therapy (including trastuzamab) in some women in the BCCA cohort. Additional model parameters, including utilities (quality of life weights) for breast cancer and CPM health states, were identified from the published medical literature. LE and QALE estimates were not discounted in the base case. Univariate sensitivity analysis was used to examine the impact of plausible variation in the key model parameters on model results.
Results:
CPM improved LE in all cohorts (range: 0.06 - 0.54 years, Table 1). AJCC stage had more effect on LE than molecular subtype (stage I mean, 0.43 years, stage III mean, 0.11 years). However, after adjusting for quality of life, a strategy of no CPM was favored in all cohorts. Univariate sensitivity analysis demonstrated that the only model parameter that influenced the outcome of QALE was the utility for health after CPM. In the base case the utility after CPM was 0.81 (compared to 0.85 for No CPM). The preferred strategy did not change from No CPM to CPM unless the utility after CPM exceeded 0.83. Model results were otherwise stable across the ranges of the key parameters examined, including the risk of distant metastases resulting from a patient's index breast cancer by stage and subtype, duration of survival with metastatic breast cancer, and the risk of CBC.
Conclusions:
The primary drivers of survival after unilateral breast cancer are stage at diagnosis and molecular subtype. Our model demonstrates that CPM confers modest additional LE gains, even in women with early-stage, favorable-subtype breast cancer. Furthermore, this modest benefit is negated if one assumes a small reduction in quality of life due to CPM. The decision to pursue CPM as part of treatment of unilateral breast cancer should include consideration of both patient specific breast cancer characteristics and individual preferences.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD02-02.
Collapse
Affiliation(s)
- NH Lester-Coll
- 1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Massachusetts General Hospital, Boston, MA; Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - JM Lee
- 1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Massachusetts General Hospital, Boston, MA; Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - K Gogineni
- 1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Massachusetts General Hospital, Boston, MA; Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - W-T Hwang
- 1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Massachusetts General Hospital, Boston, MA; Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - JS Schwartz
- 1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Massachusetts General Hospital, Boston, MA; Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - RG Prosnitz
- 1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Massachusetts General Hospital, Boston, MA; Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
49
|
Abstract
Abstract
BACKGROUND:
Medical cost analysis is increasingly important, but the methodology is complex and varied.
OBJECTIVE:
To illustrate how different cost analysis methodologies influence conclusions generated from data from a prospective nonrandomized trial for treatment of cervical spondylotic myelopathy.
METHODS:
Patients 40 to 85 years of age with degenerative cervical spondylotic myelopathy were enrolled from 7 sites over 2 years (2007–2009). Patients were treated with ventral or dorsal fusion surgery, and outcomes were measured to 1 year postoperatively. A hospital-based cost analysis was performed using Medicare cost-to-charge ratios (CCRs) multiplied by hospital charges from the index hospitalization (CCR method). A society-based cost analysis was performed by estimating costs from the index hospitalization using Medicare coding reimbursement (the Medicare reimbursement method). A separate outpatient cost analysis was performed on a subset of 20 patients.
RESULTS:
Of the 85 patients analyzed, 72 had 1-year follow-up. The CCR method showed a difference in upfront direct costs between the dorsal and ventral approaches ($27 942 ± 14 220 vs $21 563 ± 8721; P = .02). Overall upfront direct costs with the Medicare reimbursement method were not different. With the CCR method, the ventral approach dominates an incremental cost-effectiveness ratio analysis. With the Medicare reimbursement method, the incremental cost-effectiveness ratio for ventral surgery is $34 533, the cost of 1 additional quality-adjusted life-year gained by using ventral instead of dorsal surgery. In the subanalysis, outpatient costs were less after ventral surgery than dorsal surgery ($1997 ± 1211 vs $4734 ± $2874; P = .006).
CONCLUSION:
The choice of cost methodology may substantially influence the final results of an economic study.
Collapse
Affiliation(s)
- Robert G. Whitmore
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Wallace Clinical Trials Center, Greenwich Hospital, Greenwich, Connecticut
| | - J. Sanford Schwartz
- School of Medicine and Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sydney Simmons
- Wallace Clinical Trials Center, Greenwich Hospital, Greenwich, Connecticut
| | - Sherman C. Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zoher Ghogawala
- Wallace Clinical Trials Center, Greenwich Hospital, Greenwich, Connecticut
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, Massachusetts
| |
Collapse
|
50
|
Lewis N, Martinez LS, Freres DR, Schwartz JS, Armstrong K, Gray SW, Fraze T, Nagler RH, Bourgoin A, Hornik RC. Seeking cancer-related information from media and family/friends increases fruit and vegetable consumption among cancer patients. Health Commun 2011; 27:380-8. [PMID: 21932985 PMCID: PMC4197929 DOI: 10.1080/10410236.2011.586990] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Previous research suggests positive effects of health information seeking on prevention behaviors such as diet, exercise, and fruit and vegetable consumption among the general population. The current study builds upon this research by examining the effect of cancer patients' active information seeking from media and (nonmedical) interpersonal sources on fruit and vegetable consumption. The results of this longitudinal study are based on data collected from a randomly drawn sample from the Pennsylvania Cancer Registry, comprising breast, prostate, and colorectal cancer patients who completed mail surveys in the fall of 2006 and 2007. There was a 65% response rate for baseline subjects (resulting n = 2013); of those, 1,293 were interviewed one year later and 845 were available for final analyses. We used multiple imputation to replace missing data and propensity scoring to adjust for effects of possible confounders. There is a positive effect of information seeking at baseline on fruit and vegetable servings at follow-up; seekers consumed 0.43 (95% CI: 0.28 to 0.58) daily servings more than nonseekers adjusting for baseline consumption and other confounders. Active information seeking from media and interpersonal sources may lead to improved nutrition among the cancer patient population.
Collapse
Affiliation(s)
- Nehama Lewis
- Department of Psychology Florida International University Miami, FL, USA
| | - Lourdes S. Martinez
- Annenberg School for Communication University of Pennsylvania Philadelphia, PA, USA
| | - Derek R. Freres
- Annenberg School for Communication University of Pennsylvania Philadelphia, PA, USA
| | - J. Sanford Schwartz
- Department of Medicine and The Wharton School Philadelphia, PA, USA University of Pennsylvania
| | - Katrina Armstrong
- Department of Medicine University of Pennsylvania Philadelphia, PA, USA
| | - Stacy W. Gray
- Dana-Farber Cancer Institute Harvard University Boston, MA, USA
| | | | | | - Angel Bourgoin
- Annenberg School for Communication University of Pennsylvania Philadelphia, PA, USA
| | - Robert C. Hornik
- Annenberg School For Communication University of Pennsylvania Philadelphia, PA, USA
| |
Collapse
|