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Eckman MH, Wise R, Knochelmann C, Mardis R, Leonard AC, Wright S, Gummadi A, Dixon E, Becker RC, Schauer DP, Flaherty ML, Costea A, Kleindorfer D, Ireton R, Baker P, Harnett BM, Adejare A, Sucharew H, Arduser L, Kues J. Can a best practice advisory improve anticoagulation prescribing to reduce stroke risk in patients with atrial fibrillation? J Cardiol 2024; 83:285-290. [PMID: 37579873 DOI: 10.1016/j.jjcc.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common cardiac rhythm disorder and a risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce strokes in AF patients. Yet, widespread underutilization of this therapy continues. To address this practice gap, we designed a study to implement and evaluate the effectiveness of a best practice advisory (BPA) for an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record. METHODS Our intervention is provider-facing, focused on decision support. Clinical setting is ambulatory patients being seen by primary care physicians. We prospectively enrolled 608 patients in our health system who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST and randomized them to one of two arms - 1) usual care, in which the AFDST is available for use; or 2) addition of a BPA to the AFDST notifying clinicians that their patient stands to gain significant benefit from a change in current therapy. Primary outcome was effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post-enrollment. Secondary endpoints included Reach and Adoption from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, & Maintenance) framework for implementation studies. RESULTS Among 562 patients with a minimum follow-up of 3 months, addition of a BPA to the AFDST resulted in significant improvement in anticoagulation therapy, 5 % (12/248) versus 11 % (33/314) p = 0.02, odds ratio 2.31 (95 % CI, 1.17-4.87). CONCLUSIONS A BPA added to an AF decision support tool improved anticoagulation therapy among AF patients in a primary care academic health system setting.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Ruth Wise
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carol Knochelmann
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rachael Mardis
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anthony C Leonard
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sharon Wright
- Department of Pharmacy, University Hospital, Cincinnati, OH, USA
| | - Ashish Gummadi
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Estrelita Dixon
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel P Schauer
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matthew L Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Dawn Kleindorfer
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Rob Ireton
- Center for Health Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Pete Baker
- Center for Health Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brett M Harnett
- Center for Health Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Heidi Sucharew
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lora Arduser
- Department of English, University of Cincinnati, Cincinnati, OH, USA
| | - John Kues
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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León-García M, Humphries B, Morales PR, Gravholt D, Eckman MH, Bates SM, Suárez NRE, Xie F, Perestelo-Pérez L, Alonso-Coello P. Assessment of a venous thromboembolism prophylaxis shared decision-making intervention (DASH-TOP) using the decisional conflict scale: a mixed-method study. BMC Med Inform Decis Mak 2023; 23:250. [PMID: 37932759 PMCID: PMC10629184 DOI: 10.1186/s12911-023-02349-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 10/21/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and death. The use of low-molecular-weight heparin (LMWH), despite being the standard of care to prevent VTE, comes with some challenges. Shared decision-making (SDM) interventions are recommended to support patients and clinicians in making preference-sensitive decisions. The quality of the SDM process has been widely assessed with the decisional conflict scale (DCS). Our aim is to report participants' perspectives of each of the components of an SDM intervention (DASH-TOP) in relation to the different subscales of the DCS. METHODS Design: A convergent, parallel, mixed-methods design. PARTICIPANTS The sample consisted of 22 health care professionals, students of an Applied Clinical Research in Health Sciences (ICACS) master program. INTERVENTION We randomly divided the participants in three groups: Group 1 received one component (evidence -based information), Group 2 received two components (first component and value elicitation exercises), and Group 3 received all three components (the first two and a decision analysis recommendation) of the SDM intervention. ANALYSIS For the quantitative strand, we used a non-parametric test to analyze the differences in the DCS subscales between the three groups. For the qualitative strand, we conducted a content analysis using the decisional conflict domains to deductively categorize the responses. RESULTS Groups that received more intervention components experienced less conflict and better decision-making quality, although the differences between groups were not statistically significant. The decision analysis recommendation improved the efficacy with the decision-making process, however there are some challenges when implementing it in clinical practice. The uncertainty subscale showed a high decisional conflict for all three groups; contributing factors included low certainty of the evidence-based information provided and a perceived small effect of the drug to reduce the risk of a VTE event. CONCLUSIONS The DASH-TOP intervention reduced decisional conflict in the decision -making process, with decision analysis being the most effective component to improve the quality of the decision. There is a need for more implementation research to improve the delivery of SDM interventions in the clinical encounter.
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Affiliation(s)
- Montserrat León-García
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain.
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Brittany Humphries
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Pablo Roca Morales
- Faculty of Health Sciences, Universidad Villanueva, Madrid, Spain
- School of Health Sciences, Valencian International University, Valencia, Spain
| | - Derek Gravholt
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nataly R Espinoza Suárez
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- VITAM Research Center for Sustainable Health, Quebec City, Canada
- Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Lilisbeth Perestelo-Pérez
- Evaluation Unit (SESCS), Canary Islands Health Service (SCS), Tenerife, Spain
- Network for Research On Chronicity, Primary Care, and Health Promotion (RICAPPS), Tenerife, Spain
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
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Whitham T, Wima K, Harnett B, Kues JR, Eckman MH, Starnes SL, Schmidt KA, Kapur S, Salfity H, Van Haren RM. Lung cancer screening utilization rate varies based on patient, provider, and hospital factors. J Thorac Cardiovasc Surg 2023; 166:1331-1339. [PMID: 36934071 DOI: 10.1016/j.jtcvs.2023.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 09/13/2022] [Revised: 12/26/2022] [Accepted: 01/20/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVE Low-dose computed tomography has been proven to reduce mortality, yet utilization remains low. The purpose of this study is to identify factors that impact the utilization of lung cancer screening. METHODS We performed a retrospective review of our institution's primary care network from November 2012 to June 2022 to identify patients who were eligible for lung cancer screening. Eligible patients were 55 to 80 years of age and current or former smokers with at least a 30 pack-year history. Analyses were performed on the screened populations and patients who met eligibility criteria but were not screened. RESULTS A total of 35,279 patients in our primary care network were current/former smokers aged 55 to 80 years. A total of 6731 patients (19%) had a 30 pack-year or more cigarette history, and 11,602 patients (33%) had an unknown pack-year history. A total of 1218 patients received low-dose computed tomography. The utilization rate of low-dose computed tomography was 18%. The utilization rate was significantly lower (9%) if patients with unknown pack-year history were included (P < .001). The utilization rates between primary care clinic locations were significantly different (range, 18% vs 41%, P < .05). Utilization of low-dose computed tomography on multivariate analysis was associated with Black race, former smoker, chronic obstructive pulmonary disease, bronchitis, family history of lung cancer, and number of primary care visits (all P < .05). CONCLUSIONS Lung cancer screening utilization rates are low and vary significantly on the basis of patient comorbidities, family history of lung cancer, primary care clinic location, and accurate documentation of pack-year cigarette history. The development of programs to address patient, provider, and hospital-level factors is needed to ensure appropriate lung cancer screening.
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Affiliation(s)
- Tarik Whitham
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Koffi Wima
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Brett Harnett
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio
| | - John R Kues
- Center for Improvement Science, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mark H Eckman
- Division of General Internal Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sandra L Starnes
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Katherine A Schmidt
- Division of General Internal Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sangita Kapur
- Division of Cardiopulmonary Imaging, Department of Radiology, University of Cincinnati, Ohio
| | - Hai Salfity
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Robert M Van Haren
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
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Humphries B, León-García M, Bates SM, Guyatt G, Eckman MH, D'Souza R, Shehata N, Jack SM, Alonso-Coello P, Xie F. Decision Analysis in SHared decision making for Thromboprophylaxis during Pregnancy (DASH-TOP): a sequential explanatory mixed-methods pilot study. BMJ Evid Based Med 2023; 28:309-319. [PMID: 36858800 DOI: 10.1136/bmjebm-2022-112098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2023] [Indexed: 03/03/2023]
Abstract
OBJECTIVES To gain insight into formal methods of integrating patient preferences and clinical evidence to inform treatment decisions, we explored patients' experience with a personalised decision analysis intervention, for prophylactic low-molecular-weight heparin (LMWH) in the antenatal period. DESIGN Mixed-methods explanatory sequential pilot study. SETTING Hospitals in Canada (n=1) and Spain (n=4 sites). Due to the COVID-19 pandemic, we conducted part of the study virtually. PARTICIPANTS 15 individuals with a prior venous thromboembolism who were pregnant or planning pregnancy and had been referred for counselling regarding LMWH. INTERVENTION A shared decision-making intervention that included three components: (1) direct choice exercise; (2) preference elicitation exercises and (3) personalised decision analysis. MAIN OUTCOME MEASURES Participants completed a self-administered questionnaire to evaluate decision quality (decisional conflict, self-efficacy and satisfaction). Semistructured interviews were then conducted to explore their experience and perceptions of the decision-making process. RESULTS Participants in the study appreciated the opportunity to use an evidence-based decision support tool that considered their personal values and preferences and reported feeling more prepared for their consultation. However, there were mixed reactions to the standard gamble and personalised treatment recommendation. Some participants could not understand how to complete the standard gamble exercises, and others highlighted the need for more informative ways of presenting results of the decision analysis. CONCLUSION Our results highlight the challenges and opportunities for those who wish to incorporate decision analysis to support shared decision-making for clinical decisions.
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Affiliation(s)
- Brittany Humphries
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Montserrat León-García
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - M H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rohan D'Souza
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Susan M Jack
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
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Yang W, Gao Y, Li P, Eckman MH. Should asymptomatic patients with congenital lung malformations undergo surgery? A decision analysis. Pediatr Pulmonol 2023; 58:449-456. [PMID: 36251577 PMCID: PMC10092826 DOI: 10.1002/ppul.26206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/28/2022] [Revised: 09/22/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Congenital lung malformations (CLMs) are being detected more frequently during pregnancy. There is controversy regarding the optimal treatment for an asymptomatic child with prenatally diagnosed CLMs. Due to the paucity of information from clinical trials, we developed decision analytic models to compare two treatment strategies for such patients-elective surgical resection versus expectant management. METHODS We built decision analytic models stratified by lesion size. We used data from English language literature identified through PubMed searches along with estimates from expert opinions of surgical colleagues. We analyzed results for two hypothetical asymptomatic 6-month-old children with CLMs; one has a large lesion occupying more than 50% of the involved lobe, while the other has a small lesion occupying less than 50% of the involved lobe. We used quality-adjusted life years (QALYs) to measure effectiveness. RESULTS For an asymptomatic child with a small or large lesion, expectant management resulted in a small gain of 0.09 or 0.15 QALYs, respectively. Sensitivity analyses showed that surgical resection would be preferred if the probability of remaining asymptomatic was low. CONCLUSIONS In contrast to current practice, expectant management may be a better alternative for asymptomatic children born with CLMs. More longitudinal studies are required to improve the accuracy of the model.
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Affiliation(s)
- Weili Yang
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Pediatric Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ya Gao
- Department of Pediatric Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Peng Li
- Department of Pediatric Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Mark H Eckman
- Division of General Internal Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Abstract
BACKGROUND Direct oral anticoagulants (DOACs) offer an alternative to low-molecular-weight heparin (LMWH) and warfarin for treating cancer-associated thrombosis (CAT). OBJECTIVE To determine the cost and effectiveness of DOACs versus LMWH. DESIGN Cohort-state transition decision analytic model. DATA SOURCES Network meta-analysis comparing DOACs versus LMWH. TARGET POPULATION Adult patients with cancer at the time they develop thrombosis. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Strategies of 1) enoxaparin, 2) apixaban, 3) edoxaban, and 4) rivaroxaban for treatment of CAT. OUTCOME MEASURES Incremental cost-effectiveness ratio (ICER) in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS In the base-case scenario, using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule, apixaban dominated enoxaparin and edoxaban by being less costly and more effective. Rivaroxaban was slightly more effective than apixaban, with an ICER of $493 246. In a scenario analysis using "real-world" drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50 053 per QALY. RESULTS OF SENSITIVITY ANALYSIS Results were highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50 000 per QALY, apixaban was preferred in 80% of simulations. However, sensitivity analyses also demonstrated that apixaban only remained cost-effective if monthly medication costs were below $530. Above this, rivaroxaban became cost-effective. LIMITATIONS An assumption was made that patients would continue anticoagulation indefinitely unless they suffered a major bleed. Nonmedical costs such as patient and caregiver loss of productivity were not accounted for, and long-term thrombotic complications were not explicitly modeled. CONCLUSION The 3 DOACs are more effective and more cost-effective than LMWH. The most cost-effective DOAC depends on the relative cost of each of these agents. These are important considerations for treating physicians and health policymakers. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Shuchi Gulati
- Division of Hematology and Oncology, Department of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, California (S.G.)
| | - Mark H Eckman
- University of Cincinnati Medical Center, Cincinnati, and Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio (M.H.E.)
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Martinez KA, Eckman MH, Pappas MA, Rothberg MB. Prescribing of anticoagulation for atrial fibrillation in primary care. J Thromb Thrombolysis 2022; 54:616-624. [PMID: 35449383 PMCID: PMC10481404 DOI: 10.1007/s11239-022-02655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.
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Affiliation(s)
- Kathryn A Martinez
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA.
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew A Pappas
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
| | - Michael B Rothberg
- Cleveland Clinic Center for Value-Based Care Research, 9500 Euclid Ave, G10, Cleveland, OH, 44195, USA
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Varnell CD, Rich KL, Modi AC, Hooper DK, Eckman MH. A Cost-effectiveness Analysis of Adherence Promotion Strategies to Improve Rejection Rates in Adolescent Kidney Transplant Recipients. Am J Kidney Dis 2022; 80:330-340. [PMID: 35227823 PMCID: PMC9398956 DOI: 10.1053/j.ajkd.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/16/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Nonadherence to medical regimens increases the risk of graft loss among adolescent and young adult recipients of kidney transplants. Interventions that improve adherence may decrease rejection rates, but their perceived costs are a barrier to clinical implementation. We developed a model to assess the cost-effectiveness of an adherence promotion strategy, the Medication Adherence Promotion System (MAPS). STUDY DESIGN Simulation-based. Data sources included published articles indexed in Medline or referenced in bibliographies of relevant English-language articles. Data on costs and outcomes were taken from a single clinical center. SETTING & POPULATION US adolescent patients after their first kidney transplant. INTERVENTION Usual posttransplant care versus usual care plus MAPS. OUTCOME Effectiveness measured in quality-adjusted life years (QALYs) and costs measured in 2020 US dollars. MODEL, PERSPECTIVE, & TIMEFRAME Markov state transition decision model. We used a health care system perspective with a lifelong time horizon. RESULTS In the base-case analysis, MAPS was more effective and less costly than usual care. MAPS cost $9,106 per patient less than usual care and resulted in a gain of 0.32 QALYs. In probabilistic sensitivity analyses, MAPS was cost saving 100% of the time. Extending results to a program level with 100 patients, any adherence promotion intervention similar in effectiveness to MAPS would cost less than $50,000/QALY if the start-up costs were <$2.5 million and annual costs <$188,000. Strategies with costs similar to MAPS that reduce the risk of rejection by as little as 3% would also have similar cost-effectiveness. LIMITATIONS Estimates of components and costs for MAPS were based on a single center. CONCLUSIONS Adherence promotion strategies with costs similar to MAPS can be cost-effective as long as they reduce rejection rates by at least 3%. This model can be applied to study the cost-effectiveness of adherence promotion strategies with varying costs and outcomes.
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Affiliation(s)
- Charles D Varnell
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
| | - Kristin L Rich
- Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Avani C Modi
- Division of Behavioral and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - David K Hooper
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mark H Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio.
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Adejare AA, Duncan HJ, Motz RG, Shah S, Thakar CV, Eckman MH. Implementing a Health Utility Assessment Platform to Acquire Health Utilities in a Hemodialysis Outpatient Setting: Feasibility Study. JMIR Form Res 2022; 6:e33562. [PMID: 35900828 PMCID: PMC9377480 DOI: 10.2196/33562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is using hepatitis C virus (HCV)-viremic kidneys. OBJECTIVE As preparation for developing a shared decision-making tool to assist patients with ESKD with the decision to accept an HCV-viremic kidney transplant, our initial goal was to assess the feasibility of using The Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Our secondary goals were to collect health utilities for patients with ESKD and to explore whether the use of race-matched versus race-mismatched exemplars impacted the knowledge gained during the assessment process. METHODS We used The Gambler II to elicit utilities for the following ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and postintervention knowledge assessments. RESULTS A total of 63 patients with hemodialysis from 4 outpatient Dialysis Center Inc sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5, respectively. General group knowledge assessment scores improved by 10 points (P<.05) following utility assessment process. The use of race-matched exemplars had little effect on the results of the knowledge assessment of patients. CONCLUSIONS Using The Gambler II to collect utilities for patients with ESKD in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients' knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. A wide variation in patient health state utilities reinforces the importance of incorporating patients' preferences into decisions regarding use of HCV-viremic kidneys for transplantation.
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Affiliation(s)
- Adeboye A Adejare
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, OH, United States
| | - Heather J Duncan
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - R Geoffrey Motz
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Silvi Shah
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Charuhas V Thakar
- Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, OH, United States
| | - Mark H Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, United States
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Eckman MH, Wise R, Leonard AC, Baker P, Ireton R, Harnett BM, Dixon E, Awosika B, Ezigbo C, Flaherty ML, Adejare A, Knochelmann C, Mardis R, Wright S, Gummadi A, Becker R, Schauer DP, Costea A, Kleindorfer D, Sucharew H, Costanzo A, Anderson L, Kues J. Racial and sex differences in optimizing anticoagulation therapy for patients with atrial fibrillation. Am Heart J Plus 2022; 18:100170. [PMID: 38559416 PMCID: PMC10978356 DOI: 10.1016/j.ahjo.2022.100170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/28/2022] [Accepted: 06/28/2022] [Indexed: 04/04/2024]
Abstract
Study objective Atrial fibrillation (AF) is the most common cardiac rhythm disorder, responsible for 15 % of strokes in the United States. Studies continue to document underuse of anticoagulation therapy in minority populations and women. Our objective was to compare the proportion of AF patients by race and sex who were receiving non-optimal anticoagulation as determined by an Atrial Fibrillation Decision Support Tool (AFDST). Design setting and participants Retrospective cohort study including 14,942 patients within University of Cincinnati Health Care system. Data were analyzed between November 18, 2020, and November 20, 2021. Main outcomes and measures Discordance between current therapy and that recommended by the AFDST. Results In our two-category analysis 6107 (41 %) received non-optimal anticoagulation therapy, defined as current treatment category ≠ AFDST-recommended treatment category. Non-optimal therapy was highest in Black (42 % [n = 712]) and women (42 % [n = 2668]) and lower in White (39 % [n = 4748]) and male (40 % [n = 3439]) patients. Compared with White patients, unadjusted and adjusted odds ratios of receiving non-optimal anticoagulant therapy for Black patients were 1.13; 95 % CI, 1.02-1.30, p = 0.02; and 1.17; 95%CI, 1.04-1.31, p = 0.01; respectively, and 1.10; 95 % CI 1.03-1.18, p = 0.005; and 1.36; 95 % CI, 1.25-1.47, p < 0.001; for females compared with males. Conclusions and relevance In patients with atrial fibrillation in the University of Cincinnati Health system, Black race and female sex were independently associated with an increased odds of receiving non-optimal anticoagulant therapy.
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Affiliation(s)
- Mark H. Eckman
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Ruth Wise
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Anthony C. Leonard
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, United States of America
| | - Pete Baker
- Center for Health Informatics, University of Cincinnati College of Medicine, United States of America
| | - Rob Ireton
- Center for Health Informatics, University of Cincinnati College of Medicine, United States of America
| | - Brett M. Harnett
- Center for Health Informatics, University of Cincinnati College of Medicine, United States of America
| | - Estrelita Dixon
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Bi Awosika
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Chika Ezigbo
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Matthew L. Flaherty
- Department of Neurology, University of Cincinnati College of Medicine, United States of America
| | - Adeboye Adejare
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, United States of America
| | - Carol Knochelmann
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, United States of America
| | - Rachael Mardis
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, United States of America
| | - Sharon Wright
- University of Cincinnati Health System, United States of America
| | - Ashish Gummadi
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Richard Becker
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, United States of America
| | - Daniel P. Schauer
- Division of General Internal Medicine, University of Cincinnati College of Medicine, United States of America
| | - Alexandru Costea
- Division of Cardiovascular Diseases, University of Cincinnati College of Medicine, United States of America
| | - Dawn Kleindorfer
- Department of Neurology, University of Michigan College of Medicine, United States of America
| | - Heidi Sucharew
- Cincinnati Children's Hospital Medical Center, United States of America
| | - Amy Costanzo
- University of Cincinnati College of Nursing, United States of America
| | | | - John Kues
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, United States of America
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11
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Couch SC, Helsley RN, Siegel FU, Saelens BE, Magazine M, Eckman MH, Summer S, Fenchel M, King EC, Bhatt DL, Steen DL. Design and rationale for the supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial. Am Heart J 2022; 248:21-34. [PMID: 35218725 DOI: 10.1016/j.ahj.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/16/2022] [Accepted: 02/19/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The prevalence of chronic diseases is increasing largely due to suboptimal dietary habits. It is not known whether individualized, supermarket-based, nutrition education delivered by registered dietitians, utilizing the advantages of the in-store and online environments, and electronically collected purchasing data, can increase dietary quality. METHODS AND RESULTS The supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial is a randomized, controlled dietary intervention study. Adults identified from a primary care network with 1 or more risk factors were randomized at their preferred store to: (1) standard of care plus individualized, point- of-purchase nutrition education; (2) standard of care plus individualized, point- of-purchase nutrition education enhanced with online shopping technologies and training; or (3) standard of care alone. Educational sessions within each store's clinic and aisles, emphasized the dietary approaches to stop hypertension (DASH) diet. The primary assessment was an intention-to-treat comparison on the effects of the dietary interventions on mean change in DASH score (90-point range) from baseline to 3 months (post-intervention). Additional outcomes included blood pressure, lipids, weight, purchasing behavior, food literacy, and intervention feedback. Between April 2019 to February 2021, 267 participants were randomized (20 excluded due to coronavirus disease pandemic). Median age was 58 years, 69% were female, 64% had a college degree, 53% worked full-time, 64% were obese, 73% were treated with blood pressure and 42% with cholesterol medications, and most had low-to-moderate diet quality. CONCLUSION The SuperWIN trial was designed to provide a rigorous evaluation of the efficacy of 2 novel, comprehensive, supermarket-based dietary intervention programs.
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Eckman MH, Wise R, Knochelmann C, Mardis R, Wright S, Gummadi A, Dixon E, Becker R, Schauer DP, Flaherty ML, Costea A, Kleindorfer D, Ireton R, Baker P, Harnett BM, Adejare A, Leonard AC, Sucharew H, Costanzo A, Arduser L, Kues J. Electronic health record-embedded decision support to reduce stroke risk in patients with atrial fibrillation - Study protocol. Am Heart J 2022; 247:42-54. [PMID: 35081360 DOI: 10.1016/j.ahj.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful common risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce the risk of stroke in patients with AF. Yet, there continues to be widespread underutilization of this therapy. To address this practice gap locally and improve efforts to reduce the risk of stroke for patients with AF in our health system, we have designed a study to implement and evaluate the effectiveness of an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record. METHODS Our intervention is provider-facing and focused on decision support. The clinical setting is ambulatory patients being seen by primary care physicians. Patients include those with both incident and prevalent AF. This randomized, prospective trial will enroll 800 patients in our University of Cincinnati Health System who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST. Patients will be randomized to one of two arms - 1) usual care, in which the AFDST is available for use; 2) addition of a best practice advisory (BPA) to the AFDST notifying the clinician that their patient stands to gain a significant benefit from a change in their current thromboprophylactic therapy. RESULTS The primary outcome is effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post randomization. Secondary endpoints include Reach and Adoption, from the RE-AIM framework for implementation studies. Sample size is based upon an improvement from inappropriate to appropriate anticoagulation therapy estimated at 4% in the usual care arm and ≥10% in the experimental arm. CONCLUSION Our goal is to examine whether addition of a BPA to an AFDST focused on primary care physicians in an ambulatory care setting will improve "appropriate thromboprophylaxis" compared with usual care. Results will be examined at 3 months post randomization and at the end of the study to evaluate durability of changes. We expect to complete patient enrollment by the end of June 2022. TRIAL REGISTRATION Clinicaltrials.gov NCT04099485.
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E Doers M, Zafar MA, Stolz U, Eckman MH, Panos RJ, Loftus TM. Predicting Adverse Events Among Patients With COPD Exacerbations in the Emergency Department. Respir Care 2021; 67:56-65. [PMID: 34702769 DOI: 10.4187/respcare.09013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
BACKGROUND COPD exacerbations lead to excessive health care utilization, morbidity, and mortality. The Ottawa COPD Risk Scale (OCRS) was developed to predict short-term serious adverse events (SAEs) among patients in the emergency department (ED) with COPD exacerbations. We assessed the utility of the OCRS, its component elements, and other clinical variables for ED disposition decisions in a United States population. METHODS We compared the OCRS and other factors in predicting SAEs among a retrospective cohort of ED patients with COPD exacerbations. We followed subjects for 30 d, and the primary outcome, SAE, was defined as any death, admission to monitored unit, intubation, noninvasive ventilation, major procedure, myocardial infarction, or revisit with hospital admission. RESULTS A total of 246 subjects (median 61-y old, 46% male, total admission rate to ward 52%) were included, with 46 (18.7%) experiencing SAEs. Median OCRS scores did not differ significantly between those with and without an SAE (difference: 0 [interquartile range 0-1)]. The OCRS predicted SAEs poorly (Hosmer-Lemeshow goodness of fit [H-L GOF] P ≤ .001, area under the receiver operating characteristic [ROC] curve 0.519). Three variables were significantly related to SAEs in our final model (H-L GOF P = .14, area under the ROC curve 0.808): Charlson comorbidity index (odds ratio [OR] 1.3 [1.1-1.5] per 1-point increase); triage venous PCO2 (OR 1.7 [1.2-2.4] per 10 mm Hg increase); and hospitalization within previous year (OR 9.1 [3.3-24.8]). CONCLUSIONS The OCRS did not reliably predict SAEs in our population. We found 3 risk factors that were significantly associated with 30-d SAE in our United States ED population: triage PCO2 level, Charlson comorbidity index, and hospitalization within the previous year. Further studies are needed to develop generalizable decision tools to improve safety and resource utilization for this patient population.
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Affiliation(s)
- Matthew E Doers
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Muhammad A Zafar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Uwe Stolz
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mark H Eckman
- Division of General Internal Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph J Panos
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio and also affiliated with the Department of Medicine, Veterans Affairs Medical Center, Cincinnati, Ohio
| | - Timothy M Loftus
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Humphries B, León-García M, Quispe ENDG, Canelo-Aybar C, Valli C, Pacheco-Barrios K, Agarwal A, Mirabi S, Eckman MH, Guyatt G, Bates SM, Xie F, Alonso-Coello P. More work needed on decision analysis for shared decision-making: A scoping review. J Clin Epidemiol 2021; 141:106-120. [PMID: 34628018 DOI: 10.1016/j.jclinepi.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 05/14/2021] [Revised: 09/21/2021] [Accepted: 10/03/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To explore and characterize published evidence on the ways decision analysis has been used to inform shared decision-making. STUDY DESIGN AND SETTING For this scoping review, we searched five bibliographic databases (from inception until February 2021), reference lists of included studies, trial registries, a thesis database and websites of relevant interest groups. Studies were eligible if they evaluated the application of decision analysis in a shared decision-making encounter. Pairs of reviewers independently screened and selected studies for inclusion, extracted study information using a data extraction form developed by the research team and assessed risk of bias for all studies with an experimental or quasi-experimental design. Data were narratively synthesized. RESULTS We identified 27 studies that varied greatly with regard to their patient population, design, content and delivery. A range of outcomes were evaluated to explore the effectiveness and acceptability of decision analytic interventions, with little information about the implementation process. Most studies found that decision analysis was broadly beneficial. CONCLUSION Despite the compelling rationale on the potential for decision analysis to support shared decision-making, rigorous randomized controlled trials are needed to confirm these interventions' effectiveness, while qualitative studies should seek to understand their potential implementation.
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Affiliation(s)
- Brittany Humphries
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Montserrat León-García
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ena Niño de Guzman Quispe
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Carlos Canelo-Aybar
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Claudia Valli
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, USA; Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud. Lima, Peru
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan Mirabi
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Center for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada.
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
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Eckman MH, Adejare AA, Duncan H, Woodle ES, Thakar CV, Alloway RR, Sherman KE. Incorporating Patients' Values and Preferences Into Decision Making About Transplantation of HCV-Naïve Recipients With Kidneys From HCV-Viremic Donors: A Feasibility Study. MDM Policy Pract 2021; 6:23814683211056537. [PMID: 34734119 PMCID: PMC8558609 DOI: 10.1177/23814683211056537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction. While use of (hepatitis C virus) HCV-viremic kidneys may result in net benefit for the average end-stage kidney disease (ESKD) patient awaiting transplantation, patients may have different values for ESKD-related health states. Thus, the best decision for any individual may be different depending on the balance of these factors. Our objective was to explore the feasibility of sampling health utilities from hemodialysis patients in order to perform patient-specific decision analyses considering various transplantation strategies. Study Design. We assessed utilities on a convenience sample of hemodialysis patients for health states including hemodialysis, and transplantation with either an HCV-uninfected kidney or an HCV-viremic kidney. We performed patient-specific decision analyses using each patient's age, race, gender, dialysis vintage, and utilities. We used a Markov state transition model considering strategies of continuing hemodialysis, transplantation with an HCV-unexposed kidney, and transplantation with an HCV-viremic kidney and HCV treatment. We interviewed 63 ESKD patients from four dialysis centers (Dialysis Clinic Inc., DCI) in the Cincinnati metropolitan area. Results. Utilities for ESKD-related health states varied widely from patient to patient. Mean values were highest for -transplantation with an HCV-uninfected kidney (0.89, SD: 0.18), and were 0.825 (SD: 0.231) and 0.755 (SD: 0.282), respectively, for hemodialysis and transplantation with an HCV-viremic kidney. Patient-specific decision analyses indicated 37 (59%) of the 63 ESKD patients in the cohort would have a net gain in quality-adjusted life years from transplantation of an HCV-viremic kidney, while 26 would have a net loss. Conclusions. It is feasible to gather dialysis patients' health state utilities and perform personalized decision analyses. This approach could be used in the future to guide shared decision-making discussions about transplantation strategies for ESKD patients.
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Affiliation(s)
- Mark H. Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio
| | - Adeboye A. Adejare
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Heather Duncan
- Division of Nephrology, University of Cincinnati, Cincinnati, Ohio
| | - E. Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Rita R. Alloway
- Division of Nephrology, University of Cincinnati, Cincinnati, Ohio
| | - Kenneth E. Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, Ohio
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Eckman MH, Powers-Fletcher MV, Forrester JW, Fichtenbaum CJ, Lofgren R, Smulian AG. Take Your Best Shot: Which SARS-CoV-2 Vaccine Should I Get? MDM Policy Pract 2021; 6:23814683211031226. [PMID: 34621992 PMCID: PMC8492082 DOI: 10.1177/23814683211031226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/13/2021] [Accepted: 06/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background. Three vaccines against SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) have now received emergency use authorization by the US Food and Drug Administration. Patients may have the opportunity to make a choice about which vaccine they prefer to receive. Vaccine hesitancy is a hurdle to the development of widespread immunity, with many patients struggling to decide whether to get vaccinated at all. Objective. Develop a decision model exploring the question, "Should I get vaccinated with mRNA or adenovirus vector vaccine (AVV) if either is available now?"Design. Markov state transition model with lifetime time horizon. Data Sources. MEDLINE searches, bibliographies from relevant English-language articles. Setting. United States, ambulatory clinical setting. Participants. Previously uninfected, nonimmunized adults in the United States. Interventions. 1) Do Not Vaccinate, 2) Vaccination with mRNA Vaccine, 3) Vaccination with Adenovirus Vector Vaccine. Main Measures. Quality-adjusted life years (QALYs). Key Results. Base case-for a healthy 65-year-old patient, both vaccines yield virtually equivalent results (difference of 0.0028 QALYs). In sensitivity analyses, receiving the AVV is preferred if the short-term morbidity associated with each vaccine dose exceeds 1.8 days. Both vaccines afford an even greater benefit compared with Do Not Vaccinate if the pandemic is in a surge phase with a rising incidence of infection or if the current 7-day incidence is greater than the base case estimate of 105 cases per 100,000. Conclusions. Preferred vaccination strategies change under differing assumptions, but differences in outcomes are negligible. The best advice for patients is to get vaccinated against COVID-19 disease with whatever vaccine is available first. Providing mRNA vaccine to the remaining eligible US population would result in an aggregate gain of 3.92 million QALYs.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, Ohio
| | | | - Jennifer W Forrester
- Division of Infectious Diseases, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Carl J Fichtenbaum
- Division of Infectious Diseases, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Richard Lofgren
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Alan George Smulian
- Division of Infectious Diseases, University of Cincinnati Medical Center, Cincinnati, Ohio
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Wu DTY, Xu C, Kim A, Bindhu S, Mah KE, Eckman MH. A Scoping Review of Health Information Technology in Clinician Burnout. Appl Clin Inform 2021; 12:597-620. [PMID: 34233369 PMCID: PMC8263130 DOI: 10.1055/s-0041-1731399] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Clinician burnout is a prevalent issue in healthcare, with detrimental implications in healthcare quality and medical costs due to errors. The inefficient use of health information technologies (HIT) is attributed to having a role in burnout. OBJECTIVE This paper seeks to review the literature with the following two goals: (1) characterize and extract HIT trends in burnout studies over time, and (2) examine the evidence and synthesize themes of HIT's roles in burnout studies. METHODS A scoping literature review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with two rounds of searches in PubMed, IEEE Xplore, ACM, and Google Scholar. The retrieved papers and their references were screened for eligibility by using developed inclusion and exclusion criteria. Data were extracted from included papers and summarized either statistically or qualitatively to demonstrate patterns. RESULTS After narrowing down the initial 945 papers, 36 papers were included. All papers were published between 2013 and 2020; nearly half of them focused on primary care (n = 16; 44.4%). The most commonly studied variable was electronic health record (EHR) practices (e.g., number of clicks). The most common study population was physicians. HIT played multiple roles in burnout studies: it can contribute to burnout; it can be used to measure burnout; or it can intervene and mitigate burnout levels. CONCLUSION This scoping review presents trends in HIT-centered burnout studies and synthesizes three roles for HIT in contributing to, measuring, and mitigating burnout. Four recommendations were generated accordingly for future burnout studies: (1) validate and standardize HIT burnout measures; (2) focus on EHR-based solutions to mitigate clinician burnout; (3) expand burnout studies to other specialties and types of healthcare providers, and (4) utilize mobile and tracking technology to study time efficiency.
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Affiliation(s)
- Danny T. Y. Wu
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Ohio, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Catherine Xu
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Ohio, United States
- Medical Science Baccalaureate Program, University of Cincinnati College of Medicine, Ohio, United States
| | - Abraham Kim
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Ohio, United States
- Medical Science Baccalaureate Program, University of Cincinnati College of Medicine, Ohio, United States
| | - Shwetha Bindhu
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, Ohio, United States
- Medical Science Baccalaureate Program, University of Cincinnati College of Medicine, Ohio, United States
| | - Kenneth E. Mah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Mark H. Eckman
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Ohio, United States
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Eckman MH, Reed JL, Trent M, Goyal MK. Cost-effectiveness of Sexually Transmitted Infection Screening for Adolescents and Young Adults in the Pediatric Emergency Department. JAMA Pediatr 2021; 175:81-89. [PMID: 33136149 PMCID: PMC7607492 DOI: 10.1001/jamapediatrics.2020.3571] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 11/14/2022]
Abstract
IMPORTANCE Adolescents and young adults compose almost 50% of all diagnosed sexually transmitted infection (STI) cases annually in the US. Given that these individuals frequently access health care through the emergency department (ED), the ED could be a strategic venue for examining the identification and treatment of STIs. OBJECTIVE To examine the cost-effectiveness of screening strategies for Chlamydia trachomatis and Neisseria gonorrhoeae (chlamydia and gonorrhea) in adolescents and young adults who seek acute care at pediatric EDs. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation is a component of an ongoing, larger multicenter clinical trial at the Pediatric Emergency Care Applied Research Network. A decision analytic model, created using literature-based estimates for the key parameters, was developed to simulate the events and outcomes associated with 3 strategies for screening and testing chlamydial and gonococcal infections in individuals aged 15 to 21 years who sought acute care at pediatric EDs. Data sources included published (from January 1, 1997, to December 31, 2019) English-language articles indexed in MEDLINE, bibliographies in relevant articles, insurance claims data in the MarketScan database, and reimbursement payments from the Centers for Medicare and Medicaid Services. Because the events and outcomes were simulated, a hypothetical population of 10 000 ED visits by adolescents and young adults was used. INTERVENTIONS The 3 screening strategies were (1) no screening, (2) targeted screening, and (3) universally offered screening. Targeted screening involved the completion of a sexual health survey, which yielded an estimated STI risk (at risk, high risk, or low risk). MAIN OUTCOMES AND MEASURES Outcome metrics included cost (measured in 2019 US dollars) and the detection and successful treatment of STIs. The incremental cost-effectiveness ratio (ICER) of each strategy was calculated in a base case analysis. The ICER reflects the cost per case detected and successfully treated. RESULTS A 3.6% prevalence of chlamydia and gonorrhea was applied to a hypothetical population of 10 000 ED visits by adolescents and young adults. Targeted screening resulted in the detection and successful treatment of 95 of 360 STI cases (26.4%) at a cost of $313 063, and universally offered screening identified and treated 112 of 360 STI cases (31.1%) at a cost of $515 503. The ICER for targeted screening vs no screening was $6444, and the ICER for universally offered screening vs targeted screening was $12 139. CONCLUSIONS AND RELEVANCE This economic evaluation found that targeted screening and universally offered screening compared with no screening appeared to be cost-effective strategies for identifying and treating chlamydial and gonococcal infections in adolescents and young adults who used the ED for acute care. Universally offered screening was associated with detecting and successfully treating a higher proportion of STIs in this population.
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Affiliation(s)
- Mark H. Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Jennifer L. Reed
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maria Trent
- Department of Pediatrics, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Monika K. Goyal
- Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, DC
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Hurford WE, Welge JA, Eckman MH. Sugammadex versus neostigmine for routine reversal of rocuronium block in adult patients: A cost analysis. J Clin Anesth 2020; 67:110027. [DOI: 10.1016/j.jclinane.2020.110027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/30/2020] [Accepted: 08/15/2020] [Indexed: 12/17/2022]
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Hurford WE, Eckman MH, Welge JA. Data and meta-analysis for choosing sugammadex or neostigmine for routine reversal of rocuronium block in adult patients. Data Brief 2020; 32:106241. [PMID: 32944599 PMCID: PMC7481821 DOI: 10.1016/j.dib.2020.106241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/25/2020] [Indexed: 12/17/2022] Open
Abstract
This meta-analysis was conducted to define clinical efficacy and side effects (bradycardia and post-operative nausea and vomiting [PONV]) in trials comparing sugammadex with neostigmine or placebo for reversal of rocuronium-induced neuromuscular blockade in adult patients. A search of PubMed, Google Scholar, and Cochrane Library electronic databases identified 111 clinical trials for potential inclusion. We performed a meta-analysis of 32 studies that quantitatively compared the efficacy and side effects of sugammadex with either neostigmine or placebo in adult patients requiring general anesthesia. Analyzed outcomes were reversal time, anesthesia time, duration of stay in the post-anesthesia care unit (PACU), and the occurrence of bradycardia or PONV. Odds ratios and 95% confidence intervals (CI) were calculated for binary data. Mean differences and 95% CI were calculated for continuous outcome data. Meta-analyses were performed using random and fixed-effects models. Heterogeneity across studies was assessed using Cochran's Q test and the I2 statistic. Quantification of these outcomes can better inform anesthetists and health systems of the relative costs and benefits of the two reversal agents. This information also forms a basis for a comparative cost analysis in a co-submitted manuscript [1].
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Affiliation(s)
- William E. Hurford
- Department of Anesthesiology, University of Cincinnati, PO Box 670531, Cincinnati, OH, United States
| | - Mark H. Eckman
- Department of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Jeffrey A. Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, United States
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Eckman MH, Woodle ES, Thakar CV, Alloway RR, Sherman KE. Cost-effectiveness of Using Kidneys From HCV-Viremic Donors for Transplantation Into HCV-Uninfected Recipients. Am J Kidney Dis 2020; 75:857-867. [PMID: 32081494 DOI: 10.1053/j.ajkd.2019.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 11/13/2019] [Indexed: 12/19/2022]
Abstract
RATIONALE & OBJECTIVE Less than 4% of patients with kidney failure receive kidney transplants. Although discard rates of hepatitis C virus (HCV)-viremic kidneys are declining, ~39% of HCV-viremic kidneys donated between 2018 and 2019 were discarded. Highly effective antiviral agents are now available to treat chronic HCV infection. Thus, our objective was to examine the cost-effectiveness of transplanting kidneys from HCV-viremic donors into HCV-uninfected recipients. STUDY DESIGN Markov state transition decision model. Data sources include Medline search results, bibliographies from relevant English language articles, Scientific Registry of Transplant Recipients, and the US Renal Data System. SETTING & POPULATION US patients receiving maintenance hemodialysis who are on kidney transplant waiting lists. INTERVENTION(S) Transplantation with an HCV-unexposed kidney versus transplantation with an HCV-viremic kidney and HCV treatment. OUTCOMES Effectiveness measured in quality-adjusted life-years and costs measured in 2018 US dollars. MODEL, PERSPECTIVE, AND TIMEFRAME We used a health care system perspective with a lifelong time horizon. RESULTS In the base-case analysis, transplantation with an HCV-viremic kidney was more effective and less costly than transplantation with an HCV-unexposed kidney because of the longer waiting times for HCV-unexposed kidneys, the substantial excess mortality risk while receiving dialysis, and the high efficacy of direct-acting antiviral agents for HCV infection. Transplantation with an HCV-viremic kidney was also preferred in sensitivity analyses of multiple model parameters. The strategy remained cost-effective unless waiting list time for an HCV-viremic kidney exceeded 3.1 years compared with the base-case value of 1.56 year. LIMITATIONS Estimates of waiting times for patients willing to accept an HCV-viremic kidney were based on data for patients who received HCV-viremic kidney transplants. CONCLUSIONS Transplanting kidneys from HCV-viremic donors into HCV-uninfected recipients increased quality-adjusted life expectancy and reduced costs compared with a strategy of transplanting kidneys from HCV-unexposed donors.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH.
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH
| | - Charuhas V Thakar
- Division of Nephrology, University of Cincinnati Medical Center, Cincinnati, OH
| | - Rita R Alloway
- Division of Nephrology, University of Cincinnati Medical Center, Cincinnati, OH
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH
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22
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Stanton RJ, Eckman MH, Woo D, Moomaw CJ, Haverbusch M, Flaherty ML, Kleindorfer DO. Ischemic Stroke and Bleeding: Clinical Benefit of Anticoagulation in Atrial Fibrillation After Intracerebral Hemorrhage. Stroke 2020; 51:808-814. [PMID: 32000590 DOI: 10.1161/strokeaha.119.027370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/16/2022]
Abstract
Background and Purpose- Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF) are at risk for ischemic events. While risk calculators (CHA2DS2-VASc and HAS-BLED) have been validated to assess risk for ischemic stroke and major bleeding in AF patients, decisions about anticoagulation must consider the net clinical benefit of anticoagulation. Furthermore, stroke and bleeding risk are highly correlated, making decisions more difficult. Methods- We examined patients in the GERFHS III study (Genetic and Environmental Risk Factors for Hemorrhagic Stroke)-a population-based retrospective study of spontaneous ICH patients without a structural or traumatic cause in the Greater Cincinnati/Northern Kentucky region between July 2008 and December 2012. CHA2DS2-VASc and HAS-B(L)ED (minus L because labile international normalized ratio was unavailable) scores were calculated for ICH patients with AF. Using a Markov state transition model, we estimated net clinical benefit of anticoagulation relative to no treatment in quality-adjusted life years (QALYs). We defined minimal clinically relevant benefit as 0.1 QALYs. Results- Among 1186 cases of spontaneous ICH, 95 cases had AF and met our survival criteria. Within 1 year, 8 of 95 (8%) would be expected to have a major bleeding event on anticoagulation, and 5 of 95 (5%) of patients would be expected to have an ischemic stroke off anticoagulation. Sixty-eight of 95 (71%) patients would have higher risk for major bleeding than for ischemic stroke. Anticoagulation with directly acting anticoagulants would result in no clinically significant gain or loss in 73%. Roughly 12% would gain >0.1 QALYs, and 15% would lose >0.1 QALYs. Among patients receiving aspirin, most have no significant net clinical benefit or loss. Overall, anticoagulation of the entire cohort would result in an aggregate loss of 0.92 QALYs. Conclusions- Our analysis suggests that universal anticoagulation after ICH would be associated with a net loss of QALY. Additional factors should be considered before anticoagulating patients with AF after ICH. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00930280.
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Affiliation(s)
- Robert J Stanton
- From the Department of Neurology and Rehabilitation Medicine (R.J.S., D.W., C.J.M., M.H., M.L.F., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Mark H Eckman
- Department of Internal Medicine (M.H.E.), University of Cincinnati College of Medicine, OH
| | - Daniel Woo
- From the Department of Neurology and Rehabilitation Medicine (R.J.S., D.W., C.J.M., M.H., M.L.F., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Charles J Moomaw
- From the Department of Neurology and Rehabilitation Medicine (R.J.S., D.W., C.J.M., M.H., M.L.F., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Mary Haverbusch
- From the Department of Neurology and Rehabilitation Medicine (R.J.S., D.W., C.J.M., M.H., M.L.F., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Matthew L Flaherty
- From the Department of Neurology and Rehabilitation Medicine (R.J.S., D.W., C.J.M., M.H., M.L.F., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Dawn O Kleindorfer
- From the Department of Neurology and Rehabilitation Medicine (R.J.S., D.W., C.J.M., M.H., M.L.F., D.O.K.), University of Cincinnati College of Medicine, OH
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Abstract
Background. The Gambler II is a web-based utility assessment tool supporting visual analogue scale (VAS), standard gamble (SG), and time trade-off (TTO) utility assessments. It contains novel features, including an easy to use project development authoring tool and use of multimedia clips for health state descriptions. Objectives. Evaluate the usability and understandability of the patient-facing side of The Gambler. Investigate the feasibility of using The Gambler and evaluate its impact on patient knowledge regarding the relevant health states. Materials and Methods. We used The Gambler to assess utilities on a convenience sample of 55 users for common long-term complications of type 2 diabetes mellitus: diabetic neuropathy, diabetic retinopathy, and diabetic foot infection requiring transmetatarsal amputation. Using VAS, SG, and TTO, we collected metadata, such as time spent on each assessment and the entire assessment process. We evaluated usability with an adaptation of the System Usability Scale survey and understandability. We evaluated impact on knowledge gained through knowledge assessments about these complications before and after use of The Gambler. Results. Overall satisfaction with The Gambler was high, 4.02 on a 5-point scale. Usability rated highly at 84.93 on a normalized scale between 0 and 100. Knowledge scores increased significantly following use of The Gambler from pretest mean of 68% to posttest mean of 76% (P < 0.01). Average time using the software: ∼7½ minutes. Conclusions. The Gambler is an easy to use and understand computer-based tool for utility assessment. It is feasible to use within clinical encounters to support shared decision making, and it has unique features that make it a powerful tool for investigators interested in research on health utilities.
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Affiliation(s)
- Adeboye A. Adejare
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Mark H. Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio
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Overmann KM, Robinson BRH, Eckman MH. Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis. Am J Emerg Med 2019; 38:2347-2355. [PMID: 31870674 DOI: 10.1016/j.ajem.2019.11.051] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 11/26/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury. METHODS We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0-17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year. RESULTS The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%. CONCLUSION A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.
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Affiliation(s)
- Kevin M Overmann
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, USA; Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, USA.
| | - Bryce R H Robinson
- Department of Surgery, University of Washington School of Medicine, Harborview Medical Center, Seattle, 325 Ninth Ave, Seattle, WA, USA.
| | - Mark H Eckman
- Department of Internal Medicine, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, USA.
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Abstract
Systemic anticoagulation may be beneficial in pulmonary arterial hypertension, but there is no randomized clinical trial data to guide therapeutic decision making, and current guidelines do not account for patient preferences or quality of life. Decision analytic models to evaluate the potential risks and benefits of systemic anticoagulation in pulmonary arterial hypertension patients, focusing on the benefit in quality-adjusted life years, may be helpful in clarifying this uncertainty. We constructed a 31-state Markov decision analytic model to explore anticoagulation and no anticoagulation strategies. Modeled patient characteristics included gender, use of central catheter-based pulmonary arterial hypertension therapy, type of pulmonary arterial hypertension (idiopathic, idiopathic pulmonary arterial hypertension, or connective-tissue associated, connective tissue disease-pulmonary arterial hypertension), and use of oral contraceptive medication by females. Modeled events included mortality, thromboembolic complications, atrial fibrillation, stroke, and anticoagulation bleeding. Deterministic and probabilistic sensitivity analyses were performed. Anticoagulation was favored in all idiopathic pulmonary arterial hypertension cases, with a gain of 0.43-0.51 quality-adjusted life years, and detrimental in all connective tissue disease-pulmonary arterial hypertension cases, with a loss of 0.66-1.89 quality-adjusted life years. Anticoagulation would need to demonstrate a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better to be favored. In our model, idiopathic pulmonary arterial hypertension patients benefit from anticoagulation in terms of quality-adjusted life years, and connective tissue disease-pulmonary arterial hypertension patients were harmed, with a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better being required to favorably impact quality-adjusted life years. These results suggest that anticoagulation significantly improves quality adjusted life years and should be offered to all idiopathic pulmonary arterial hypertension patients. Shared decision models based on these results may help clarify therapeutic decision-making uncertainty in pulmonary arterial hypertension patients.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mark H Eckman
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Abstract
BACKGROUND While guidelines recommend anticoagulation for all atrial fibrillation (AF) patients ≥75 years, evidence for the net clinical benefit (NCB) of anticoagulant in older adults is sparse. We sought to determine the association between age and NCB of anticoagulation in older adults with AF. METHODS AND RESULTS We examined adults ≥75 years with incident AF in the Anticoagulation and Risk Factors in Atrial Fibrillation-Cardiovascular Research Network cohort. Using a Markov state transition model, we estimated the lifetime NCB of warfarin and apixaban relative to no treatment in quality-adjusted life years (QALYs). In the decision model, each month patients face a chance of stroke, hemorrhage, or death from a competing cause; the likelihood of each is a function of individual patients' stroke risk, hemorrhage risk, and life expectancy. We defined minimal clinically relevant lifetime benefit as 0.10 QALYs. In a sensitivity analysis, we examined the effect of competing risks of death on NCB using 2 models, one including competing risks and the second without competing risks. We included 14 946 patients, with a median age of 81 years and median CHA2DS2-VASc score of 4. In the main analysis, after age 87, NCB associated with warfarin decreased below 0.10 lifetime QALYs while NCB associated with apixaban did not decrease below 0.10 lifetime QALYs until after age 92. In sensitivity analyses, over a 3-year horizon, removing competing risks of death resulted in higher NCB (at 90 years, median difference using warfarin 0.010 QALYs [95% CI, 0.009-0.013], median difference using apixaban 0.025 QALYs [95% CI, 0.024-0.026]). CONCLUSIONS The NCB of anticoagulation decreases with advancing age. The competing risk of death diminishes the NCB of anticoagulation for older patients with AF. Physicians should consider competing mortality risks when recommending anticoagulants to older adults with AF.
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Affiliation(s)
- Sachin J Shah
- University of California, San Francisco (S.J.S., M.C.F., A.S.G.)
| | - Daniel E Singer
- Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.)
| | - Margaret C Fang
- University of California, San Francisco (S.J.S., M.C.F., A.S.G.)
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA (K.R.)
| | - Alan S Go
- University of California, San Francisco (S.J.S., M.C.F., A.S.G.).,Division of Research, Kaiser Permanente Northern California, Oakland, CA (A.S.G.)
| | - Mark H Eckman
- University of Cincinnati College of Medicine, OH (M.H.E.)
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Shah SJ, Eckman MH. Restarting Anticoagulants after a Gastrointestinal Hemorrhage-Between Rockall and a Hard Place. J Hosp Med 2019; 14:448-449. [PMID: 31251722 DOI: 10.12788/jhm.3221] [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: 03/13/2019] [Accepted: 04/02/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Sachin J Shah
- Division of Hospital Medicine, University of California, San Francisco, California
| | - Mark H Eckman
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Eckman MH, Woodle ES, Thakar CV, Paterno F, Sherman KE. Transplanting Hepatitis C Virus-Infected or Uninfected Kidneys Into Hepatitis C Virus-Infected Recipients. Ann Intern Med 2018; 169:898-899. [PMID: 30557435 DOI: 10.7326/l18-0566] [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] [Indexed: 11/22/2022] Open
Affiliation(s)
- Mark H Eckman
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
| | - E Steve Woodle
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
| | - Charuhas V Thakar
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
| | - Flavio Paterno
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
| | - Kenneth E Sherman
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
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Shah SJ, Eckman MH, Aspberg S, Go AS, Singer DE. Effect of Variation in Published Stroke Rates on the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation. Ann Intern Med 2018; 169:517-527. [PMID: 30264130 DOI: 10.7326/m17-2762] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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 Stroke rates in patients with nonvalvular atrial fibrillation (AF) who are not receiving anticoagulant therapy vary widely across published studies; the resulting effect on the net clinical benefit of anticoagulation in AF is unknown. OBJECTIVE To determine the effect of variation in published AF stroke rates on the net clinical benefit of anticoagulation. DESIGN Markov model decision analysis. Warfarin was the base case, and non-vitamin K antagonist oral anticoagulants (NOACs) were modeled in a secondary analysis. SETTING Community-dwelling adults. PATIENTS 33 434 adults with incident AF. MEASUREMENTS Quality-adjusted life-years (QALYs). RESULTS Of the 33 434 patients, 27 179 had a CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes, stroke, and vascular disease) score of 2 or more. The population benefit of warfarin anticoagulation for these patients was least using stroke rates from the ATRIA (AnTicoagulation and Risk Factors In Atrial Fibrillation) study and greatest using those from the Danish National Patient Registry (6290 QALYs [95% CI, ±2.3%] vs. 24 110 QALYs [CI, ±1.9%]; P < 0.001). The optimal CHA2DS2-VASc score threshold for anticoagulation was 3 or more using stroke rates from ATRIA, 2 or more using those from the Swedish AF cohort study, 1 or more using those from the SPORTIF (Stroke Prevention using ORal Thrombin Inhibitor in atrial Fibrillation) study, and 0 or more using those from the Danish National Patient Registry. Accounting for lower rates of NOAC-associated intracranial hemorrhage decreased optimal CHA2DS2-VASc score thresholds, but these thresholds still varied widely. LIMITATION Measured benefit may not generalize to other populations. CONCLUSION Variation in published AF stroke rates for patients not receiving anticoagulant therapy results in multifold variation in the net clinical benefit of anticoagulation. Guidelines should better reflect the uncertainty in current thresholds of stroke risk score for recommending anticoagulation. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Sachin J Shah
- University of California, San Francisco, San Francisco, California (S.J.S.)
| | - Mark H Eckman
- University of Cincinnati College of Medicine, Cincinnati, Ohio (M.H.E.)
| | - Sara Aspberg
- Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (S.A.)
| | - Alan S Go
- University of California, San Francisco, San Francisco, and Kaiser Permanente Northern California, Oakland, California (A.S.G.)
| | - Daniel E Singer
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (D.E.S.)
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Eckman MH, Woodle ES, Thakar CV, Paterno F, Sherman KE. Transplanting Hepatitis C Virus-Infected Versus Uninfected Kidneys Into Hepatitis C Virus-Infected Recipients: A Cost-Effectiveness Analysis. Ann Intern Med 2018; 169:214-223. [PMID: 29987322 DOI: 10.7326/m17-3088] [Citation(s) in RCA: 23] [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 Direct-acting antiviral agents are now available to treat chronic hepatitis C virus (HCV) infection in patients with end-stage renal disease (ESRD). OBJECTIVE To examine whether it is more cost-effective to transplant HCV-infected or HCV-uninfected kidneys into HCV-infected patients. DESIGN Markov state-transition decision model. DATA SOURCES MEDLINE searches and bibliographies from relevant English-language articles. TARGET POPULATION HCV-infected patients with ESRD receiving hemodialysis in the United States. TIME HORIZON Lifetime. PERSPECTIVE Health care system. INTERVENTION Transplant of an HCV-infected kidney followed by HCV treatment versus transplant of an HCV-uninfected kidney preceded by HCV treatment. OUTCOME MEASURES Effectiveness, measured in quality-adjusted life-years (QALYs), and costs, measured in 2017 U.S. dollars. RESULTS OF BASE-CASE ANALYSIS Transplant of an HCV-infected kidney followed by HCV treatment was more effective and less costly than transplant of an HCV-uninfected kidney preceded by HCV treatment, largely because of longer wait times for uninfected kidneys. A typical 57.8-year-old patient receiving hemodialysis would gain an average of 0.50 QALY at a lifetime cost savings of $41 591. RESULTS OF SENSITIVITY ANALYSIS Transplant of an HCV-infected kidney followed by HCV treatment continued to be preferred in sensitivity analyses of many model parameters. Transplant of an HCV-uninfected kidney preceded by HCV treatment was not preferred unless the additional wait time for an uninfected kidney was less than 161 days. LIMITATION The study did not consider the benefit of decreased HCV transmission from treating HCV-infected patients. CONCLUSION Transplanting HCV-infected kidneys into HCV-infected patients increased quality-adjusted life expectancy and reduced costs compared with transplanting HCV-uninfected kidneys into HCV-infected patients. PRIMARY FUNDING SOURCE Merck Sharp & Dohme and the National Center for Advancing Translational Sciences.
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Affiliation(s)
- Mark H Eckman
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
| | - E Steve Woodle
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
| | - Charuhas V Thakar
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
| | - Flavio Paterno
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
| | - Kenneth E Sherman
- University of Cincinnati, Cincinnati, Ohio (M.H.E., E.S.W., C.V.T., F.P., K.E.S.)
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McGrady ME, Eckman MH, O'Brien MM, Pai ALH. Cost-Effectiveness Analysis of an Adherence-Promotion Intervention for Children With Leukemia: A Markov Model-Based Simulation. J Pediatr Psychol 2018; 43:758-768. [PMID: 29771338 DOI: 10.1093/jpepsy/jsy022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/28/2018] [Indexed: 12/22/2022] Open
Abstract
Objective Improving medication adherence among children with B-cell precursor acute lymphoblastic leukemia (B-ALL) has the potential to reduce relapse rates but requires an investment in resources. An economic evaluation is needed to understand the potential costs and benefits of delivering adherence-promotion interventions (APIs) as part of standard clinical care. Methods A Markov decision analytic model was used to simulate the potential incremental cost-effectiveness per quality-adjusted life year (QALY) to be gained from an API for children with B-ALL in first continuous remission compared with treatment as usual (TAU, no intervention). Model parameter estimates were informed by previously published studies. The primary outcome was incremental cost (2015 US$) per QALY gained for API compared with TAU. Results The model predicts the API to result in superior health outcomes (4.87 vs. 4.86 QALYs) and cost savings ($43,540.73 vs. $46,675.71) as compared with TAU, and simulations indicate that, across a range of plausible parameter estimates, there is a 95% chance that the API is more effective and less costly than TAU. The API was estimated to remain more effective and less costly than TAU in situations where the prevalence of nonadherence exceeds 32% and when API improves baseline adherence in at least 3% of patients. Conclusions Providing APIs to children with B-ALL may improve health outcomes and save costs over a 6-year period.
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Affiliation(s)
- Meghan E McGrady
- Division of Behavioral Medicine and Clinical Psychology, Patient and Family Wellness Center
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - Mark H Eckman
- Department of Internal Medicine, University of Cincinnati
| | - Maureen M O'Brien
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center
| | - Ahna L H Pai
- Division of Behavioral Medicine and Clinical Psychology, Patient and Family Wellness Center
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
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Benoit JL, Khatri P, Adeoye OM, Broderick JP, McMullan JT, Scheitz JF, Vagal AS, Eckman MH. Prehospital Triage of Acute Ischemic Stroke Patients to an Intravenous tPA-Ready versus Endovascular-Ready Hospital: A Decision Analysis. PREHOSP EMERG CARE 2018; 22:722-733. [DOI: 10.1080/10903127.2018.1465500] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Sonnenberg FA, Eckman MH. Health Outcomes Research and Its Interfaces with Medical Decision Making. Med Decis Making 2018. [DOI: 10.1177/0272989x9101104s03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Shah SJ, Eckman MH, Aspberg S, Go AS, Singer DE. Abstract 4: Variation in Published Stroke Rates Results in Wide Variation in the Net Clinical Benefit of Anticoagulation for Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The risk of ischemic stroke without anticoagulation for a given CHA
2
DS
2
-VASc score varies significantly across published cohorts. The resulting impact on the net clinical benefit of anticoagulation in atrial fibrillation (AF) is not known. We aimed to determine the effect of variation in published stroke rates on the net clinical benefit of anticoagulation.
Methods:
A decision analysis study. We used ischemic strokes rates corresponding to CHA
2
DS
2
-VASc scores from four studies - ATRIA study, SPORTIF, Swedish AF study, and the Danish National Patient Registry - in a 28-state Markov state transition model that compared the benefit of oral anticoagulation vs. no anticoagulation. During each monthly cycle, patients face a chance of stroke and hemorrhage, either of which may lead to death, neurologic sequelae, or symptom resolution. The simulation ran for the entire life expectancy of the patient. We applied this decision analytic model to a cohort of 33434 patients with incident AF (Jan 06 to Jun 09) in the Kaiser Permanente Northern and Southern California integrated health care delivery systems.
Results:
Of the 33434 patients, 27122 had a CHA
2
DS
2
-VASc score ≥2. Among those with CHA
2
DS
2
-VASc score ≥2, use of ATRIA Study stroke rates yielded the lowest population benefit (2576 QALYs, 0.06 expected median per person, IQR -0.02 to 0.18), while the Danish National Patient Registry stroke rates yielded the greatest population benefit (28934 QALYs, 0.70 expected median per person, IQR 0.38 to 1.47). The CHA
2
DS
2
-VASc threshold at or above which the population derives the greatest net clinical benefit from anticoagulation varies based on the stroke rates used: CHA
2
DS
2
-VASc ≥3 using ATRIA Study stroke rates, ≥2 using Swedish AF study stroke rates, ≥1 using SPORTIF and ≥0 using the Danish National Patient Registry stroke rates.
Conclusion:
Using current guidelines, variation in published off-anticoagulation stroke rates results in tenfold variation in the estimated net clinical benefit of anticoagulation. Guidelines should better reflect the uncertainty of the current approach that uses a CHA
2
DS
2
-VASc threshold to recommend anticoagulation.
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Affiliation(s)
- Sachin J Shah
- Univ of California, San Francisco, San Francisco, CA
| | - Mark H Eckman
- Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Sara Aspberg
- Danderyd Hosp, Karolinska Institutet, Stockholm, Sweden
| | - Alan S Go
- Kaiser Permanente Northern California Div of Rsch and Univ of California, San Francisco, Oakland, CA
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Chidambaran V, Subramanyam R, Ding L, Sadhasivam S, Geisler K, Stubbeman B, Sturm P, Jain V, Eckman MH. Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery. Paediatr Anaesth 2018; 28:237-248. [PMID: 29377376 PMCID: PMC6004284 DOI: 10.1111/pan.13329] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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] [Accepted: 12/19/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Enhanced recovery after surgery protocols increasingly use multimodal analgesia after major surgeries with intravenous acetaminophen and ketorolac, despite no documented cost-effectiveness of these strategies. AIMS The goal of this prospective cohort study was to model cost-effectiveness of adding acetaminophen or acetaminophen + ketorolac to opioids for postoperative outcomes in children having scoliosis surgery. METHODS Of 106 postsurgical children, 36 received only opioids, 26 received intravenous acetaminophen, and 44 received acetaminophen + ketorolac as analgesia adjuncts. Costs were calculated in 2015 US $. Decision analytic model was constructed with Decision Maker® software. Base-case and sensitivity analyses were performed with effectiveness defined as avoidance of opioid adverse effects. RESULTS The groups were comparable demographically. Compared with opioids-only strategy, subjects in the intravenous acetaminophen + ketorolac strategy consumed less opioids (P = .002; difference in mean morphine consumption on postoperative days 1 and 2 was -0.44 mg/kg (95% CI -0.72 to -0.16); tolerated meals earlier (P < .001; RR 0.250 (0.112-0.556)) and had less constipation (P < .001; RR 0.226 (0.094-0.546)). Base-case analysis showed that of the 3 strategies, use of opioids alone is both most costly and least effective, opioids + intravenous acetaminophen is intermediate in both cost and effectiveness; and opioids + intravenous acetaminophen and ketorolac is the least expensive and most effective strategy. The addition of intravenous acetaminophen with or without ketorolac to an opioid-only strategy saves $510-$947 per patient undergoing spine surgery and decreases opioid side effects. CONCLUSION Intravenous acetaminophen with or without ketorolac reduced opioid consumption, opioid-related adverse effects, length of stay, and thereby cost of care following idiopathic scoliosis in adolescents compared with opioids-alone postoperative analgesia strategy.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Rajeev Subramanyam
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Lili Ding
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kristie Geisler
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Bobbie Stubbeman
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Sturm
- Division of Orthopedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Viral Jain
- Division of Orthopedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Mark H. Eckman
- Department of Internal Medicine, Division of General Internal Medicine, and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
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Eckman MH, Costea A, Attari M, Munjal J, Wise RE, Knochelmann C, Flaherty ML, Baker P, Ireton R, Harnett BM, Leonard AC, Steen D, Rose A, Kues J. Atrial fibrillation decision support tool: Population perspective. Am Heart J 2017; 194:49-60. [PMID: 29223435 DOI: 10.1016/j.ahj.2017.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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] [Received: 05/16/2017] [Accepted: 08/21/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AF patients. METHODS This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient-specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality-adjusted life-years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs. RESULTS When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST. CONCLUSIONS Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH; Center for Health Informatics, University of Cincinnati, Cincinnati, OH.
| | - Alexandru Costea
- Division of Cardiology, University of Cincinnati, Cincinnati, OH
| | - Mehran Attari
- Division of Cardiology, University of Cincinnati, Cincinnati, OH
| | - Jitender Munjal
- Division of Cardiology, University of Cincinnati, Cincinnati, OH
| | - Ruth E Wise
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH
| | | | | | - Pete Baker
- Center for Health Informatics, University of Cincinnati, Cincinnati, OH
| | - Robert Ireton
- Center for Health Informatics, University of Cincinnati, Cincinnati, OH
| | - Brett M Harnett
- Center for Health Informatics, University of Cincinnati, Cincinnati, OH
| | - Anthony C Leonard
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH
| | - Dylan Steen
- Division of Cardiology, University of Cincinnati, Cincinnati, OH
| | - Adam Rose
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH
| | - John Kues
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH
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Eckman MH, Lip GYH, Wise RE, Speer B, Sullivan M, Walker N, Kissela B, Flaherty ML, Kleindorfer D, Baker P, Ireton R, Hoskins D, Harnett BM, Aguilar C, Leonard A, Arduser L, Steen D, Costea A, Kues J. Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age. J Am Geriatr Soc 2017; 64:1054-60. [PMID: 27225358 DOI: 10.1111/jgs.14099] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 12/18/2022]
Abstract
OBJECTIVES To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment. DESIGN Retrospective cohort study. SETTING Primary care practices of an academic healthcare system. PARTICIPANTS Adults (aged 28-93) with nonvalvular atrial fibrillation (AF) seen between March 2013 and February 2014 (N = 1,585). MEASUREMENTS Treatment recommendations were made using an AF decision support tool (AFDST) based on projections of quality-adjusted life expectancy calculated using a decision analytical model that integrates individual-specific risk factors for stroke and hemorrhage. RESULTS Treatment was discordant from AFDST-recommended treatment in 45% (326/725) of women and 39% (338/860) of men (P = .02). Although current treatment was discordant from recommended in 35% (89/258) of participants aged 85 and older and in 43% (575/1,328) of those younger than 85 (P = .01), many undertreated elderly adults were receiving aspirin as the sole antithrombotic agent. CONCLUSION Physicians should understand that female sex is a significant risk factor for AF-related stroke and incorporate this into decision-making about thromboprophylaxis. Treating older adults with aspirin instead of OAT exposes them to significant risk of bleeding with little to no reduction in AF-related stroke risk.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.,Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio.,Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Gregory Y H Lip
- Centre for Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Ruth E Wise
- Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.,Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio
| | - Barbara Speer
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Megan Sullivan
- Academic Health Center, University of Cincinnati, Cincinnati, Ohio
| | - Nita Walker
- Division of General Internal Medicine, University of Cincinnati, Cincinnati, Ohio.,Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, Ohio
| | - Brett Kissela
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | | | - Dawn Kleindorfer
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Peter Baker
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Robert Ireton
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Dave Hoskins
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Brett M Harnett
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Carlos Aguilar
- Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio
| | - Anthony Leonard
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lora Arduser
- Department of English, University of Cincinnati, Cincinnati, Ohio
| | - Dylan Steen
- Division of Cardiology, University of Cincinnati, Cincinnati, Ohio
| | - Alexandru Costea
- Division of Cardiology, University of Cincinnati, Cincinnati, Ohio
| | - John Kues
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio
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Abstract
The combined use of aspirin and oral anticoagulant therapy in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) has been questioned due to an increased risk of major bleeding with little to no benefit in preventing ischemic events. (1) To better understand patterns and indications for combined antiplatelet and anticoagulant therapy and identify patients who might reasonably be treated with oral anticoagulant (OAC) therapy alone. (2) To perform an updated literature review regarding the use of combined antiplatelet and OAC therapy in patients with AF and stable CAD. Retrospective review. Patients within the University of Cincinnati Health System with a diagnosis of non-valvular AF, excluding those with acute coronary syndrome or revascularization within the last 12 months. Numbers and indications for combined antiplatelet and anticoagulant therapy and sequence of events leading to the initiation of each. Of 948 patients receiving OAC, 430 (45 %) were receiving concomitant OAC and aspirin. Among patients receiving combined antiplatelet and anticoagulant therapy, 49 and 42 % of patients respectively, had CAD or DM. In a more detailed analysis including chart review of 219 patients receiving combined OAC and aspirin, 27 % had a diagnosis of CAD and 14 % had a diagnosis of DM prior to the development of AF. These patients were initially treated with aspirin. Warfarin was added when they subsequently developed AF but aspirin wasn't discontinued. A surprisingly large proportion of patients (22.8 %) had no obvious indication for dual therapy. Prior myocardial infarction, CAD, vascular disease and DM (among others) increase the likelihood of receiving combined antiplatelet and anticoagulant therapy among patients with AF. A literature review suggests this may lead to increased major bleeding with little benefit in decreasing either AF-related stroke or cardiovascular events.
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Affiliation(s)
- Charlotte H So
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, PO Box 670535, Cincinnati, OH, 45267-0535, USA
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, PO Box 670535, Cincinnati, OH, 45267-0535, USA.
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39
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Eckman MH, Sonnenberg FA. Twelfth Annual Meeting of the Society for Medical Decision Making. Med Decis Making 2017. [DOI: 10.1177/0272989x9001004s01] [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]
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40
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Abbott DE, Tzeng CWD, McMillan MT, Callery MP, Kent TS, Christein JD, Behrman SW, Schauer DP, Hanseman DJ, Eckman MH, Vollmer CM. Pancreas fistula risk prediction: implications for hospital costs and payments. HPB (Oxford) 2017; 19:140-146. [PMID: 27884544 DOI: 10.1016/j.hpb.2016.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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] [Received: 08/24/2016] [Revised: 10/13/2016] [Accepted: 10/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND As payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins. METHODS A multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US$, and payment data existed. An analytic model detailed POPF risk and post-operative sequelae, and their relationship with hospital cost and payment. RESULTS Per-patient hospital cost for negligible-risk patients was $37,855. Low-, moderate-, and high- risk patients had incrementally higher hospital costs of $38,125 ($270; 0.7% above negligible-risk), $41,128 ($3273; +8.6%), and $41,983 ($3858; +10.9%), respectively. Similarly, hospital payment for negligible-risk patients was $42,685/patient, with incrementally higher payments for low-risk ($43,265; +1.4%), moderate-risk ($45,439; +6.5%) and high-risk ($46,564; +9.1%) patients. The lowest 30-day readmission rates - with highest net profit - were found for negligible/low-risk patients (10.5%/11.1%), respectively, compared with readmission rates of moderate/high-risk patients (15%/15.7%). CONCLUSION Financial outcomes following PD can be predicted using the FRS. Such prediction may help hospitals and payers plan for resource allocation and payment matched to patient risk, while providing a benchmark for quality improvement initiatives.
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41
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Eckman MH, Kopras EJ, Montag-Leifling K, Kirby LP, Burns L, Indihar VM, Joseph PM. Shared Decision-Making Tool for Self-Management of Home Therapies for Patients With Cystic Fibrosis. MDM Policy Pract 2017; 2:2381468317715621. [PMID: 30288426 PMCID: PMC6136161 DOI: 10.1177/2381468317715621] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 05/15/2017] [Indexed: 12/11/2022] Open
Abstract
Objective: Patients with cystic fibrosis (CF) undertake time-consuming programs of home therapies. Our objective was to develop a tool to help CF patients prioritize personal goals for some of these treatments. We describe the development and results of initial evaluation of this shared decision-making tool. Methods: Multicriteria decision-making method to develop a shared decision-making tool that integrates patient's values and perceptions of treatment impact on functionality/sense of well-being. Treatment efficacy data obtained through comprehensive review of English language literature and Cochrane reviews. Field study of 21 patients was performed to assess acceptability of the approach, understandability of the tool, and to determine whether there was sufficient patient-to-patient variability in treatment goals and patient preferences to make use of a personalized tool worthwhile. Results: Patients found the tool easy to understand and felt engaged as active participants in their care. The tool was responsive to variations in patient preferences. Priority scores were calculated (0-1.0 ± SD). Patients' most important treatment goals for improving lung health included improving breathing function (0.27 ± 0.11), improving functionality/sense of well-being (0.24 ± 0.13), preventing lung infection (0.21 ± 0.08), minimizing time to complete treatments (0.16 ± 0.12), and minimizing cost (0.11 ± 0.09). Conclusions: A shared decision-making tool that integrates patients' values and best evidence is feasible and could result in improved patient engagement in their own care.
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Affiliation(s)
- Mark H. Eckman
- Mark H. Eckman, MD, MS University of
Cincinnati Medical Center, PO Box 670535, Cincinnati, OH 45267-0535, USA;
telephone: (513) 558-7581; e-mail:
| | - Elizabeth J. Kopras
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Karen Montag-Leifling
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Lari P. Kirby
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Lisa Burns
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Veronica M. Indihar
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
| | - Patricia M. Joseph
- Division of General Internal Medicine and the Center
for Clinical Effectiveness (MHE) and Division of Pulmonary Medicine and Critical
Care (EJK, KML, LPK, VMI, PMJ), University of Cincinnati, Cincinnati, Ohio
- Pediatric Pulmonology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio (LB, PMJ)
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Abbott DE, Sutton JM, Jernigan PL, Chang A, Frye P, Shah SA, Schauer DP, Eckman MH, Ahmad SA, Sussman JJ. How Much Should We Pay to Minimize Pancreatic Leak? The Cost-effectiveness of Pasireotide in Pancreatic Resection: RETRACTED. Ann Surg 2016; Publish Ahead of Print. [PMID: 28045714 DOI: 10.1097/sla.0000000000001411] [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: 11/26/2022]
Abstract
INTRODUCTION Pasireotide was recently shown to decrease leak rates after pancreatic resection, though the significant cost of the drug may be prohibitive. We conducted a cost-effectiveness analysis to determine whether prophylactic pasireotide possesses a reasonable cost profile by improving outcomes. METHODS A cost-effectiveness model was constructed to compare pasireotide administration after pancreatic resection versus usual care, populated by probabilities of clinical outcomes from a recent randomized trial and hospital costs (2013 US$) from a university pancreatic disease center. Sensitivity analyses were performed to identify the most influential clinical components of the model. RESULTS Without considering pasireotide cost, prophylactic use of the drug saved an average of $8,109 per patient. However, when the cost of pasireotide was included, per patient costs increased from $42,159 to $77,202. This was associated with a 56% reduction in pancreatic fistula/pancreatic leak/abscess (PF/PL/A) (21.9% to 9.2%). The resultant cost per PF/PL/A avoided was $301,628. Threshold analysis demonstrated that for this intervention to be cost neutral, either the purchase price of pasireotide ($43,172) must be reduced by 92.3% (to $3324) or drug reimbursement must be $39,848. Sensitivity analyses exploring variable perioperative mortality, rate of PF/PL/A, and readmission rates did not significantly alter model outcomes. CONCLUSIONS Our analyses demonstrate that when prophylactic pasireotide is administered, the cost per PF/PL/A avoided is approximately $300,000. Aggressive pricing negotiation, payer reimbursement for the drug, high-volume use, and consensus among the public, payers, and surgical community regarding the value of reducing morbidity will ultimately determine the utility of widespread pasireotide application in pancreatic resection.
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Affiliation(s)
- Daniel E Abbott
- *Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH †Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH
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Eckman MH, Lip GY, Wise RE, Speer B, Sullivan M, Walker N, Kissela B, Flaherty ML, Kleindorfer D, Baker P, Ireton R, Hoskins D, Harnett BM, Aguilar C, Leonard AC, Arduser L, Steen D, Costea A, Kues J. Impact of an Atrial Fibrillation Decision Support Tool on thromboprophylaxis for atrial fibrillation. Am Heart J 2016; 176:17-27. [PMID: 27264216 DOI: 10.1016/j.ahj.2016.02.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge. METHODS We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation. RESULTS Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance. CONCLUSIONS Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.
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Abbott DE, Sutton JM, Jernigan PL, Chang A, Frye P, Shah SA, Schauer DP, Eckman MH, Ahmad SA, Sussman JJ. Prophylactic pasireotide administration following pancreatic resection reduces cost while improving outcomes. J Surg Oncol 2016; 113:784-8. [DOI: 10.1002/jso.24239] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 03/16/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Daniel E. Abbott
- Department of Surgery; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Jeffrey M. Sutton
- Department of Surgery; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Peter L. Jernigan
- Department of Surgery; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Alex Chang
- Department of Surgery; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Patrick Frye
- Department of Surgery; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Shimul A. Shah
- Department of Surgery; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Daniel P. Schauer
- Department of Internal Medicine; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Mark H. Eckman
- Department of Internal Medicine; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Syed A. Ahmad
- Department of Surgery; University of Cincinnati Medical Center; Cincinnati Ohio
| | - Jeffrey J. Sussman
- Department of Surgery; University of Cincinnati Medical Center; Cincinnati Ohio
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Eckman MH, Alonso-Coello P, Guyatt GH, Ebrahim S, Tikkinen KAO, Lopes LC, Neumann I, McDonald SD, Zhang Y, Zhou Q, Akl EA, Jacobsen AF, Santamaría A, Annichino-Bizzacchi JM, Bitar W, Sandset PM, Bates SM. Women's values and preferences for thromboprophylaxis during pregnancy: a comparison of direct-choice and decision analysis using patient specific utilities. Thromb Res 2015; 136:341-7. [PMID: 26033397 DOI: 10.1016/j.thromres.2015.05.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 03/25/2015] [Revised: 05/07/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Women with a history of venous thromboembolism (VTE) have an increased recurrence risk during pregnancy. Low molecular weight heparin (LMWH) reduces this risk, but is costly, burdensome, and may increase risk of bleeding. The decision to start thromboprophylaxis during pregnancy is sensitive to women's values and preferences. Our objective was to compare women's choices using a holistic approach in which they were presented all of the relevant information (direct-choice) versus a personalized decision analysis in which a mathematical model incorporated their preferences and VTE risk to make a treatment recommendation. METHODS Multicenter, international study. Structured interviews were on women with a history of VTE who were pregnant, planning, or considering pregnancy. Women indicated their willingness to receive thromboprophylaxis based on scenarios using personalized estimates of VTE recurrence and bleeding risks. We also obtained women's values for health outcomes using a visual analog scale. We performed individualized decision analyses for each participant and compared model recommendations to decisions made when presented with the direct-choice exercise. RESULTS Of the 123 women in the study, the decision model recommended LMWH for 51 women and recommended against LMWH for 72 women. 12% (6/51) of women for whom the decision model recommended thromboprophylaxis chose not to take LMWH; 72% (52/72) of women for whom the decision model recommended against thromboprophylaxis chose LMWH. CONCLUSIONS We observed a high degree of discordance between decisions in the direct-choice exercise and decision model recommendations. Although which approach best captures individuals' true values remains uncertain, personalized decision support tools presenting results based on personalized risks and values may improve decision making.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, USA.
| | - Pablo Alonso-Coello
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Iberoamerican Cochrane Centre, CIBERESP-IIB Sant Pau, Barcelona, Spain
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shanil Ebrahim
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Anaesthesia, McMaster University, Hamilton, ON; Department of Medicine, Stanford University, Stanford; Department of Anaesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Kari A O Tikkinen
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Departments of Urology and Public Health, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Luciane Cruz Lopes
- Pharmaceutical Sciences, University of Sorocaba, UNISO, Sorocaba, Sao Paolo, Brazil
| | - Ignacio Neumann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sarah D McDonald
- Departments of Obstetrics & Gynecology, Radiology, and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, USA
| | - Qi Zhou
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department of Medicine, American University of Beirut, Beirut, Lebanon; Department of Medicine, State University of New York at Buffalo, New York, NY, USA
| | - Ann Flem Jacobsen
- Department of Obstetrics & Gynecology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Amparo Santamaría
- Unidad de Hemostasia y Trombosis, Hospital de la Vall d'hebron Sant Pau, Barcelona, Spain
| | | | - Wael Bitar
- Brooks Memorial Hospital, Dunkirk, NY, USA
| | - Per Morten Sandset
- Department of Haematology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
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Eckman MH, Wise RE, Naylor K, Arduser L, Lip GYH, Kissela B, Flaherty M, Kleindorfer D, Khan F, Schauer DP, Kues J, Costea A. Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making. Curr Med Res Opin 2015; 31:603-14. [PMID: 25690491 PMCID: PMC4708062 DOI: 10.1185/03007995.2015.1019608] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision. MATERIALS AND METHODS CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy. RESULTS Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups. KEY LIMITATIONS Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy. CONCLUSIONS We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati , Cincinnati, OH , USA
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Abstract
Background and Purpose—
Our objective was to use decision analytic modeling to compare 2 treatment strategies of intravenous recombinant tissue-type plasminogen activator (r-tPA) alone versus combined intravenous r-tPA/endovascular therapy in a subgroup of patients with large vessel (internal carotid artery terminus, M1, and M2) occlusion based on varying times to angiographic reperfusion and varying rates of reperfusion.
Methods—
We developed a decision model using Interventional Management of Stroke (IMS) III trial data and comprehensive literature review. We performed 1-way sensitivity analyses for time to reperfusion and 2-way sensitivity for time to reperfusion and rate of reperfusion success. We also performed probabilistic sensitivity analyses to address uncertainty in total time to reperfusion for the endovascular approach.
Results—
In the base case, endovascular approach yielded a higher expected utility (6.38 quality-adjusted life years) than the intravenous-only arm (5.42 quality-adjusted life years). One-way sensitivity analyses demonstrated superiority of endovascular treatment to intravenous-only arm unless time to reperfusion exceeded 347 minutes. Two-way sensitivity analysis demonstrated that endovascular treatment was preferred when probability of reperfusion is high and time to reperfusion is small. Probabilistic sensitivity results demonstrated an average gain for endovascular therapy of 0.76 quality-adjusted life years (SD 0.82) compared with the intravenous-only approach.
Conclusions—
In our post hoc model with its underlying limitations, endovascular therapy after intravenous r-tPA is the preferred treatment as compared with intravenous r-tPA alone. However, if time to reperfusion exceeds 347 minutes, intravenous r-tPA alone is the recommended strategy. This warrants validation in a randomized, prospective trial among patients with large vessel occlusions.
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Affiliation(s)
- Achala S. Vagal
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Pooja Khatri
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Joseph P. Broderick
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Thomas A. Tomsick
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Sharon D. Yeatts
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
| | - Mark H. Eckman
- From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.)
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Mestre TA, Espay AJ, Marras C, Eckman MH, Pollak P, Lang AE. Subthalamic nucleus-deep brain stimulation for early motor complications in Parkinson's disease-the EARLYSTIM trial: Early is not always better. Mov Disord 2014; 29:1751-6. [DOI: 10.1002/mds.26024] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 07/02/2014] [Accepted: 07/06/2014] [Indexed: 11/10/2022] Open
Affiliation(s)
- Tiago A. Mestre
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto; Toronto Ontario Canada
- Parkinson's Disease and Movement Disorders Clinic; Division of Neurology; University of Ottawa, The Ottawa Hospital; Ottawa Ontario Canada
| | - Alberto J. Espay
- James J. and Joan A. Gardner Family Center for Parkinson's Disease and, Movement Disorders, Department of Neurology, UC Neuroscience, Institute University of Cincinnati; Cincinnati Ohio USA
| | - Connie Marras
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto; Toronto Ontario Canada
| | - Mark H. Eckman
- James J. and Joan A. Gardner Family Center for Parkinson's Disease and, Movement Disorders, Department of Neurology, UC Neuroscience, Institute University of Cincinnati; Cincinnati Ohio USA
| | - Pierre Pollak
- Service de Neurologie; Département de Neurosciences Cliniques; Hôpitaux Universitaires de Genève; Genève Switzerland
| | - Anthony E. Lang
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto; Toronto Ontario Canada
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Eckman MH, Wise RE, Speer B, Sullivan M, Walker N, Lip GY, Kissela B, Flaherty ML, Kleindorfer D, Khan F, Kues J, Baker P, Ireton R, Hoskins D, Harnett BM, Aguilar C, Leonard A, Prakash R, Arduser L, Costea A. Integrating Real-Time Clinical Information to Provide Estimates of Net Clinical Benefit of Antithrombotic Therapy for Patients With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2014; 7:680-6. [DOI: 10.1161/circoutcomes.114.001163] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [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: 12/28/2022]
Abstract
Background—
Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS
2
or the CHA
2
DS
2
VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy.
Methods and Results—
This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool. Current treatment was discordant from treatment recommended by the Atrial Fibrillation Decision Support Tool in 931 patients. A clinically significant gain in quality-adjusted life expectancy (defined as ≥0.1 quality-adjusted life-years) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 quality-adjusted life-years could be gained were treatment changed to that recommended by the Atrial Fibrillation Decision Support Tool.
Conclusions—
Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with atrial fibrillation.
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Affiliation(s)
- Mark H. Eckman
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Ruth E. Wise
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Barbara Speer
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Megan Sullivan
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Nita Walker
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Gregory Y.H. Lip
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Brett Kissela
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Matthew L. Flaherty
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Dawn Kleindorfer
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Faisal Khan
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - John Kues
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Peter Baker
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Robert Ireton
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Dave Hoskins
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Brett M. Harnett
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Carlos Aguilar
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Anthony Leonard
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Rajan Prakash
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Lora Arduser
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
| | - Alexandru Costea
- From the Division of General Internal Medicine and Center for Clinical Effectiveness (M.H.E., R.E.W., N.W., R.P.), Center for Health Informatics (M.H.E., P.B., R.I., C.A., B.H., D.H.), Department of Neurology (B.K., M.F., D.K.), Division of Cardiology (F.K., A.C.), Department of Family and Community Medicine (J.K., B.S., A.L.), and Department of English (L.A.), University of Cincinnati, OH; University of Birmingham Centre for Cardiovascular Sciences, Birmingham, United Kingdom (G.Y.H.L.)
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Abstract
OBJECTIVE The primary outcome of this study was to examine the cost-effectiveness of the intraoperative combination of intravenous (IV) acetaminophen and IV opioids, versus IV opioids alone, as a part of an inhalational anesthetic technique for tonsillectomy in children. METHODS We used Decision Maker® software to construct and analyze a decision analytic model. Base-case and sensitivity analyses were performed. We studied the use of rescue analgesics in the postanesthesia care unit (PACU), adverse effects of acetaminophen and opioids, and costs associated with adverse effects. Costs were in 2013 US dollars, and effectiveness was measured as frequency of avoiding the need for rescue analgesics. Direct medical costs included medication, equipment, supplies, and labor associated with the treatment of adverse events from pain medications. Medication costs assumed single-dose vials. RESULTS In the base case, IV acetaminophen in combination with opioids was both less costly ($17.12) and more effective (3.3% fewer rescue events). In sensitivity analyses, the combination strategy remained cost-effective as long as the frequency of rescue analgesic administration was less than that in the opioid-alone strategy. Although medication costs of the combination strategy were higher, the overall costs were less than the competing strategy due to reduced adverse effects and reduced time spent in PACU. CONCLUSIONS The routine use of IV acetaminophen as an adjuvant to IV opioids for tonsillectomy with or without adenoidectomy in children aged <17 years should be considered as a means to reduce the need for rescue analgesia and in turn reduce costs.
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Affiliation(s)
- Rajeev Subramanyam
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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