Dietary interventions may best be delivered at supermarkets, which offer convenience, accessibili... more Dietary interventions may best be delivered at supermarkets, which offer convenience, accessibility, full food inventories and, increasingly, in-store registered dietitians, online shopping and delivery services. In collaboration with a large retail supermarket chain, we conducted a multisite supermarket and web-based intervention targeting nutrition trial (no. NCT03895580), randomizing participants (n = 247 (139 women and 108 men)) 2:2:1 to two levels of dietary education (Strategy 1 and Strategy 2) or an enhanced control group that included educational components beyond the routine standard of care. Both Strategies 1 and 2 included individualized, in-person, dietitian-led, purchasing data-guided interventions. Strategy 2 also included online tools for shopping, home delivery, selection of healthier purchases, meal planning and healthy recipes. The primary endpoint was change in dietary approaches to stop hypertension (DASH) score (a measure of adherence to the DASH diet) from base...
Background Patients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transp... more 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...
Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from... more 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.
RATIONALE & OBJECTIVE Non-adherence to medical regimens increases the risk of graft loss amon... more RATIONALE & OBJECTIVE Non-adherence 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(S) Usual post-transplant care versus usual care plus MAPS. OUTCOMES 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/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 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.
Background Clinician burnout is a prevalent issue in healthcare, with detrimental implications in... more 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 do...
Objective: Psoriatic arthritis (PsA) and scleroderma (SSc) are chronic rheumatic disorders with d... more Objective: Psoriatic arthritis (PsA) and scleroderma (SSc) are chronic rheumatic disorders with detrimental effects on health-related quality of life. Our objective was to assess health values (utilities) from the general public for health states common to people with PsA and SSc for economic evaluations. Methods: Adult subjects from the general population in a Midwestern city (N = 218) completed the SF-12 Health Survey and computer-assisted 0-100 rating scale (RS), time trade-off (TTO, range: 0.0-1.0) and standard gamble (SG, range: 0.0-1.0) utility assessments for several hypothetical PsA and SSc health states. Results: Subjects included 135 (62%) females, 143 (66%) Caucasians, and 62 (28%) African-Americans. The mean (SD) scores for the SF-12 Physical Component Summary scale were 52.9 (8.3) and for the SF-12 Mental Component Summary scale were 49.0 (9.1), close to population norms. The mean RS, TTO, and SG scores for PsA health states varied with severity, ranging from 20.2 to 63...
BACKGROUND COPD exacerbations lead to excessive health care utilization, morbidity, and mortality... more 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.
Background: While patients (pts) with atrial fibrillation (AF) face a risk of ischemic events, AF... more Background: While patients (pts) with atrial fibrillation (AF) face a risk of ischemic events, AF pts with intracerebral hemorrhage (ICH) are at increased risk of bleeding with anticoagulation (AC). Optimal decision-making must weigh the tradeoffs between these competing risks. Our goal was to analyze the impact of AC decisions on projected quality-adjusted life years (QALYs) pts with both ICH and AF within a population. Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study is a population-based evaluation of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky study region. The study period was 7/08-12/12. Pts with ICH and AF surviving the hospital stay were included. Medical history and demographics were entered into the Atrial Fibrillation Decision Support Tool, which is a 29-state Markov decision analytic model that projects patient-level QALYs for 7 thromboprophylaxis treatment strategies, using publishe...
Background. The Gambler II is a web-based utility assessment tool supporting visual analogue scal... more 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 Sys...
Background and Purpose— Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF)... more Background and Purpose— Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF) are at risk for ischemic events. While risk calculators (CHA 2 DS 2 -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. CHA 2 DS 2 -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 benef...
Circulation: Cardiovascular Quality and Outcomes, 2019
Background: While guidelines recommend anticoagulation for all atrial fibrillation (AF) patients ... more 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 d...
In a registry of volunteer bone marrow donors, the relation between registry size and probability... more In a registry of volunteer bone marrow donors, the relation between registry size and probability of finding an exact or partial match for a random recipient cannot be theoretically derived because it depends on specifics of the human leukocyte antigen (HLA) haplotype frequencies in the donor and recipient populations. The relation must be explicitly calculated using empirically determined HLA haplotype frequency data for all possible pairings between a donor and a recipient population. This report describes a general solution to this problem. The method shows that the relation of the probability of matching to registry size is sigmoidal, with small increases in probability at the extremes of registry size and a middle range of registry size within which the probability of matching increases most sharply. This range determines the approximate size of the most cost-effective registry. In addition, for any pairing of donor and recipient populations, there is a maximum probability of i...
Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, Jan 30, 2018
American Stroke Association guidelines for prehospital acute ischemic stroke recommend against by... more American Stroke Association guidelines for prehospital acute ischemic stroke recommend against bypassing an intravenous tPA-ready hospital (IRH), if additional transportation time to an endovascular-ready hospital (ERH) exceeds 15-20 min. However, it is unknown when the benefit of potential endovascular therapy at an ERH outweighs the harm from delaying intravenous therapy at a closer IRH, especially since large vessel occlusion (LVO) status is initially unknown. We hypothesized that current time recommendations for IRH bypass are too short to achieve optimal outcomes for certain patient populations. A decision analysis model was constructed using population-based databases, a detailed literature review, and interventional trial data containing time-dependent modified Rankin Scale distributions. The base case was triaged by Emergency Medical Services (EMS) 110 min after stroke onset and had a 23.6% LVO rate. Base case triage choices were (1) transport to the closest IRH (12 min), (2...
The journal of trauma and acute care surgery, Nov 1, 2016
Recent guidelines from the Eastern Association for the Surgery of Trauma conditionally recommend ... more Recent guidelines from the Eastern Association for the Surgery of Trauma conditionally recommend cervical collar removal after a negative cervical computed tomography in obtunded adult blunt trauma patients. Although the rates of missed injury are extremely low, the impact of chronic care costs and litigation upon decision making remains unclear. We hypothesize that the cost-effectiveness of strategies that include additional imaging may contradict current guidelines. A cost-effectiveness analysis was performed for a base-case 40-year-old, obtunded man with a negative computed tomography. Strategies compared included adjunct imaging with cervical magnetic resonance imaging (MRI), collar maintenance for 6 weeks, or removal. Data on the probability for long-term collar complications, spine injury, imaging costs, complications associated with MRI, acute and chronic care, and litigation were obtained from published and Medicare data. Outcomes were expressed as 2014 US dollars and qualit...
Dietary interventions may best be delivered at supermarkets, which offer convenience, accessibili... more Dietary interventions may best be delivered at supermarkets, which offer convenience, accessibility, full food inventories and, increasingly, in-store registered dietitians, online shopping and delivery services. In collaboration with a large retail supermarket chain, we conducted a multisite supermarket and web-based intervention targeting nutrition trial (no. NCT03895580), randomizing participants (n = 247 (139 women and 108 men)) 2:2:1 to two levels of dietary education (Strategy 1 and Strategy 2) or an enhanced control group that included educational components beyond the routine standard of care. Both Strategies 1 and 2 included individualized, in-person, dietitian-led, purchasing data-guided interventions. Strategy 2 also included online tools for shopping, home delivery, selection of healthier purchases, meal planning and healthy recipes. The primary endpoint was change in dietary approaches to stop hypertension (DASH) score (a measure of adherence to the DASH diet) from base...
Background Patients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transp... more 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...
Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from... more 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.
RATIONALE & OBJECTIVE Non-adherence to medical regimens increases the risk of graft loss amon... more RATIONALE & OBJECTIVE Non-adherence 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(S) Usual post-transplant care versus usual care plus MAPS. OUTCOMES 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/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 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.
Background Clinician burnout is a prevalent issue in healthcare, with detrimental implications in... more 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 do...
Objective: Psoriatic arthritis (PsA) and scleroderma (SSc) are chronic rheumatic disorders with d... more Objective: Psoriatic arthritis (PsA) and scleroderma (SSc) are chronic rheumatic disorders with detrimental effects on health-related quality of life. Our objective was to assess health values (utilities) from the general public for health states common to people with PsA and SSc for economic evaluations. Methods: Adult subjects from the general population in a Midwestern city (N = 218) completed the SF-12 Health Survey and computer-assisted 0-100 rating scale (RS), time trade-off (TTO, range: 0.0-1.0) and standard gamble (SG, range: 0.0-1.0) utility assessments for several hypothetical PsA and SSc health states. Results: Subjects included 135 (62%) females, 143 (66%) Caucasians, and 62 (28%) African-Americans. The mean (SD) scores for the SF-12 Physical Component Summary scale were 52.9 (8.3) and for the SF-12 Mental Component Summary scale were 49.0 (9.1), close to population norms. The mean RS, TTO, and SG scores for PsA health states varied with severity, ranging from 20.2 to 63...
BACKGROUND COPD exacerbations lead to excessive health care utilization, morbidity, and mortality... more 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.
Background: While patients (pts) with atrial fibrillation (AF) face a risk of ischemic events, AF... more Background: While patients (pts) with atrial fibrillation (AF) face a risk of ischemic events, AF pts with intracerebral hemorrhage (ICH) are at increased risk of bleeding with anticoagulation (AC). Optimal decision-making must weigh the tradeoffs between these competing risks. Our goal was to analyze the impact of AC decisions on projected quality-adjusted life years (QALYs) pts with both ICH and AF within a population. Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study is a population-based evaluation of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky study region. The study period was 7/08-12/12. Pts with ICH and AF surviving the hospital stay were included. Medical history and demographics were entered into the Atrial Fibrillation Decision Support Tool, which is a 29-state Markov decision analytic model that projects patient-level QALYs for 7 thromboprophylaxis treatment strategies, using publishe...
Background. The Gambler II is a web-based utility assessment tool supporting visual analogue scal... more 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 Sys...
Background and Purpose— Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF)... more Background and Purpose— Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF) are at risk for ischemic events. While risk calculators (CHA 2 DS 2 -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. CHA 2 DS 2 -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 benef...
Circulation: Cardiovascular Quality and Outcomes, 2019
Background: While guidelines recommend anticoagulation for all atrial fibrillation (AF) patients ... more 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 d...
In a registry of volunteer bone marrow donors, the relation between registry size and probability... more In a registry of volunteer bone marrow donors, the relation between registry size and probability of finding an exact or partial match for a random recipient cannot be theoretically derived because it depends on specifics of the human leukocyte antigen (HLA) haplotype frequencies in the donor and recipient populations. The relation must be explicitly calculated using empirically determined HLA haplotype frequency data for all possible pairings between a donor and a recipient population. This report describes a general solution to this problem. The method shows that the relation of the probability of matching to registry size is sigmoidal, with small increases in probability at the extremes of registry size and a middle range of registry size within which the probability of matching increases most sharply. This range determines the approximate size of the most cost-effective registry. In addition, for any pairing of donor and recipient populations, there is a maximum probability of i...
Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, Jan 30, 2018
American Stroke Association guidelines for prehospital acute ischemic stroke recommend against by... more American Stroke Association guidelines for prehospital acute ischemic stroke recommend against bypassing an intravenous tPA-ready hospital (IRH), if additional transportation time to an endovascular-ready hospital (ERH) exceeds 15-20 min. However, it is unknown when the benefit of potential endovascular therapy at an ERH outweighs the harm from delaying intravenous therapy at a closer IRH, especially since large vessel occlusion (LVO) status is initially unknown. We hypothesized that current time recommendations for IRH bypass are too short to achieve optimal outcomes for certain patient populations. A decision analysis model was constructed using population-based databases, a detailed literature review, and interventional trial data containing time-dependent modified Rankin Scale distributions. The base case was triaged by Emergency Medical Services (EMS) 110 min after stroke onset and had a 23.6% LVO rate. Base case triage choices were (1) transport to the closest IRH (12 min), (2...
The journal of trauma and acute care surgery, Nov 1, 2016
Recent guidelines from the Eastern Association for the Surgery of Trauma conditionally recommend ... more Recent guidelines from the Eastern Association for the Surgery of Trauma conditionally recommend cervical collar removal after a negative cervical computed tomography in obtunded adult blunt trauma patients. Although the rates of missed injury are extremely low, the impact of chronic care costs and litigation upon decision making remains unclear. We hypothesize that the cost-effectiveness of strategies that include additional imaging may contradict current guidelines. A cost-effectiveness analysis was performed for a base-case 40-year-old, obtunded man with a negative computed tomography. Strategies compared included adjunct imaging with cervical magnetic resonance imaging (MRI), collar maintenance for 6 weeks, or removal. Data on the probability for long-term collar complications, spine injury, imaging costs, complications associated with MRI, acute and chronic care, and litigation were obtained from published and Medicare data. Outcomes were expressed as 2014 US dollars and qualit...
Uploads
Papers