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American Journal of Health-system... Oct 2019To systematically evaluate and summarize evidence across multiple systematic reviews (SRs) examining interventions addressing polypharmacy.
PURPOSE
To systematically evaluate and summarize evidence across multiple systematic reviews (SRs) examining interventions addressing polypharmacy.
SUMMARY
MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (DARE) were searched for SRs evaluating interventions addressing polypharmacy in adults published from January 2004 to February 2017. Two authors independently screened, appraised, and extracted information. SRs with Assessment of Multiple Systematic Reviews (AMSTAR) scores below 8 were excluded. After extraction of relevant conclusions from each SR, evidence was summarized and conclusions compared. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess evidence quality. Six SRs met the inclusion criteria, 4 of which used meta-analytic pooling. Five SRs focused on older adults. Four were not restricted to any specific disease type, whereas 1 focused on proton pump inhibitors and another focused on patients with severe dementia. Care settings and measured outcomes varied widely. SRs examining the impact on patient-centered outcomes, including morbidity, mortality, patient satisfaction, and utilization, found inconsistent evidence regarding the benefit of polypharmacy interventions, but most concluded that interventions had either null or uncertain impact. Two SRs assessing medication appropriateness found very low-quality evidence of modest improvements with polypharmacy interventions.
CONCLUSION
An overview of SRs of interventions to address polypharmacy found 6 recent and high-quality SRs, mostly focused on older adults, in which both process and outcome measures were used to evaluate interventions. Despite the low quality of evidence in the underlying primary studies, both SRs that assessed medication appropriateness found evidence that polypharmacy interventions improved it. However, there was no consistent evidence of any impact on downstream patient-centered outcomes such as healthcare utilization, morbidity, or mortality.
Topics: Clinical Trials as Topic; Humans; Inappropriate Prescribing; Medication Therapy Management; Patient Acceptance of Health Care; Patient Discharge; Patient Transfer; Polypharmacy; Systematic Reviews as Topic; Treatment Outcome
PubMed: 31612924
DOI: 10.1093/ajhp/zxz196 -
The American Journal of Managed Care Dec 2021To understand the investments that Medicare Shared Savings Program accountable care organizations (ACOs) in the ACO Investment Model (AIM) made to participate in the...
OBJECTIVES
To understand the investments that Medicare Shared Savings Program accountable care organizations (ACOs) in the ACO Investment Model (AIM) made to participate in the program and the costs that they incurred as a result of their efforts to lower spending and improve quality.
STUDY DESIGN
We conducted a systematic review and categorization of all available and approved quarterly expenses reported by AIM ACOs.
METHODS
We reviewed final approved quarterly expense reports submitted by ACOs detailing how they spent funds in the quarter. All distinct line-item descriptions were classified into a more informative and consistent set of categories. We then applied higher conceptual dimensions (type of care input and type of ACO strategy) to these newly categorized expenses to facilitate additional analysis of spending patterns.
RESULTS
AIM ACOs reported expenses of $264.8 million over the 3 performance years (2016-2018). The majority of the $264.8 million in expenditures was incurred for personnel (55.5%), followed by infrastructure (22.3%), management firm expenses (15.3%), and internal programs and systems (6.9%). The dominant identifiable ACO strategy was care coordination and management, accounting for 52.9% of related ACO expenses.
CONCLUSIONS
AIM ACOs invested most heavily in personnel, information technology, and care management, with less than half of the investments explicitly tied to a strategy for improving quality or reducing spending. Efforts to change clinician practice patterns, alter the way patients access the health care system, and institute other practice redesigns were not primary targets for investment.
Topics: Accountable Care Organizations; Aged; Cost Savings; Health Expenditures; Humans; Medicare; United States
PubMed: 34889580
DOI: 10.37765/ajmc.2021.88795 -
Arthroplasty (London, England) Oct 2022Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the... (Review)
Review
BACKGROUND
Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty.
METHODS
A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, "disparities", "arthroplasty", "income", "insurance", "outcomes", and "hospital volume" in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data.
RESULTS
A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients.
CONCLUSION
This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients' access to, utilization of, and outcomes after TJA.
LEVEL OF EVIDENCE
IV.
PubMed: 36184658
DOI: 10.1186/s42836-022-00137-4 -
Journal of the American Pharmacists... 2022The Centers for Medicare and Medicaid (CMS) established the Hospital Readmissions Reduction Program (HRRP) to reduce reimbursement payments to hospitals with excessive... (Review)
Review
BACKGROUND
The Centers for Medicare and Medicaid (CMS) established the Hospital Readmissions Reduction Program (HRRP) to reduce reimbursement payments to hospitals with excessive patient readmissions. Because of this program, hospitals have developed transitions of care (TOC) programs to improve patient outcomes.
OBJECTIVES
To identify and uniformly summarize the impact of pharmacy-led TOC interventions on 30-day readmission rates since the implementation of CMS HRRP.
METHODS
This study followed an a-priori protocol that was registered to International Prospective Register of Systematic Reviews. A systematic search was conducted using PubMed, EMBASE, International Pharmaceutical Abstracts, and CINAHL from January 1, 2013 through January 14, 2022. Studies were included if they met the following criteria: pharmacy-led intervention, 30-day readmission outcomes, patients at least 18 years old, original research performed in the United States, and English language only articles. Descriptive statistics were used to summarize study characteristics, outcomes, and elements of the study interventions.
RESULTS
A total of 1964 abstracts were screened with 123 studies being included in the review. A total of 110 (89.4%) studies showed a decrease in readmission rates. The largest decrease in readmission rates was 44.5% (range 0.2%-44.5%, median = 7.4%) and the most common pharmacy-led intervention was patient counseling (n = 119, 96.7%) followed by medication reconciliation (n = 111, 90.2%). High-risk patient populations were commonly targeted with 52 studies (42.3%) focusing on CMS HRRP related diagnoses.
CONCLUSION
Most pharmacist-led TOC interventions contributed to lower rates of 30-day readmission. Future studies should investigate the types of interventions that most significantly impact readmission rates.
Topics: Adolescent; Aged; Humans; Hospitals; Medicare; Patient Discharge; Patient Readmission; Patient Transfer; Pharmacy; United States
PubMed: 35718715
DOI: 10.1016/j.japh.2022.05.017 -
The American Journal of Managed Care Aug 2019We conducted a systematic review of studies reporting the direct healthcare costs of treating older adults with diagnosed Alzheimer disease and related dementias (ADRD)...
OBJECTIVES
We conducted a systematic review of studies reporting the direct healthcare costs of treating older adults with diagnosed Alzheimer disease and related dementias (ADRD) within private Medicare managed care plans.
STUDY DESIGN
A systematic review of all studies published in English reporting original empirical analyses of direct costs for older adults with ADRD in Medicare managed care.
METHODS
All papers indexed in PubMed or Web of Science reporting ADRD costs within Medicare managed care plans from 1983 through 2018 were identified and reviewed.
RESULTS
Despite the growth in Medicare managed care enrollment, only 9 papers report the costs of care for individuals with ADRD within these plans, and only 1 study reports data less than 10 years old. This limited literature reports wide ranges for ADRD-attributable costs, with estimates varying from $3738 to $8726 in annual prevalent costs and $8938 to $38,794 in 1-year immediate postdiagnosis incident costs. Reviewed studies also used varied study populations, case and cost ascertainment methods, and analytic methods, making cross-study comparisons difficult.
CONCLUSIONS
The expected continued growth in Medicare managed care enrollment, coupled with the large and growing impact of ADRD on America's healthcare delivery and finance systems, requires more research on the cost of ADRD within managed care. This research should use more consistent approaches to identify ADRD prevalence and provide more detail regarding which components of care are included in analyses and how the costs of care are captured and measured.
Topics: Aged; Aged, 80 and over; Alzheimer Disease; Dementia; Health Expenditures; Humans; Managed Care Programs; Medicare; United States
PubMed: 31419102
DOI: No ID Found -
Journal of General Internal Medicine Jun 2021To align patient preferences and understanding with harm-benefit perception, the Centers for Medicare & Medicaid Services (CMS) mandates that providers engage patients...
INTRODUCTION
To align patient preferences and understanding with harm-benefit perception, the Centers for Medicare & Medicaid Services (CMS) mandates that providers engage patients in a collaborative shared decision-making (SDM) visit before LDCT. Nonetheless, patients and providers often turn instead to the web for help making decisions. Several web-based lung cancer risk calculators (LCRCs) provide risk predictions and screening recommendations; however, the accuracy, consistency, and subsequent user interpretation of these predictions between LCRCs is ambiguous. We conducted a systematic review to assess this variability.
DESIGN
Through a systematic Internet search, we identified 10 publicly available LCRCs and categorized their input variables: demographic factors, cancer history, smoking status, and personal/environmental factors. To assess variance in LCRC risk prediction outputs, we developed 16 hypothetical patients along a risk continuum, illustrated by randomly assigned input variables, and individually compared them to each LCRC against the empirically validated "gold-standard" PLCO risk model in order to evaluate the accuracy of the LCRCs within identical time-windows.
RESULTS
From the inclusion criteria, 11 calculators were initially identified. The analyzed calculators also vary in output characteristics and risk depiction for hypothetical patients. There were 13 total instances across ten hypothetical patients in which the sample standard error exceeded the mean risk percentage across all general samples and set standard calculations. The largest measured difference is 16.49% for patient 8, and the smallest difference is 0.01% for patient 2. The largest measured difference is 16.49% for patient 8, and the smallest difference is 0.01% for patient 2.
CONCLUSION
Substantial variability in the depiction of lung cancer risk for hypothetical patients exists across the web-based LCRCs due to their respective inputs and risk prediction models. To foster informed decision-making in the SDM-LDCT context, the input variables, risk prediction models, risk depiction, and screening recommendations must be standardized to best practice.
Topics: Aged; Decision Making, Shared; Early Detection of Cancer; Humans; Internet; Lung Neoplasms; Medicare; United States
PubMed: 33835312
DOI: 10.1007/s11606-021-06754-0 -
Medical Care May 2024Home health care serves millions of Americans who are "Aging in Place," including the rapidly growing population of Medicare Advantage (MA) enrollees. This study...
OBJECTIVES
Home health care serves millions of Americans who are "Aging in Place," including the rapidly growing population of Medicare Advantage (MA) enrollees. This study systematically reviewed extant evidence illustrating home health care (HHC) services to MA enrollees.
METHODS
A comprehensive literature search was conducted in 6 electronic databases to identify eligible studies, which resulted in 386 articles. Following 2 rounds of screening, 30 eligible articles were identified. Each study was also assessed independently for study quality using a validated quality assessment checklist.
RESULTS
Of the 30 studies, nearly half (n=13) were recently published between January 1, 2017 - January 6, 2022. Among various issues related to HHC to MA enrollees examined, which were often compared with Traditional Medicare (TM) enrollees, the 2 most studied issues were HHC use rate (including access) and care dosage/intensity. Inconsistencies were common in findings across reviewed studies, with slight variations in the level of inconsistency by studied outcomes. Several critical issues, such as heterogeneity of MA plans, influence of MA-specific features, and program response to policy and quality improvement initiatives, were only examined by 1 or 2 studies. The depth and scope of scientific investigation were also limited by the scale and details available in MA data in addition to other methodological limits.
CONCLUSIONS
Wild variations and conflicting findings on HHC to MA beneficiaries exist across studies. More research with rigorous designs and robust MA encounter data is warranted to determine home health care for MA enrollees and the relevant outcomes.
Topics: Humans; Aged; United States; Medicare Part C; Independent Living; Home Care Services; Quality Improvement; Policy
PubMed: 38546388
DOI: 10.1097/MLR.0000000000001992 -
Surgery Feb 2022The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain...
BACKGROUND
The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery.
METHODS
The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11, 2020.
RESULTS
Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain.
CONCLUSION
The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.
Topics: Centers for Medicare and Medicaid Services, U.S.; Databases, Factual; Humans; Medicare; Pain Management; Pain, Postoperative; Practice Guidelines as Topic; Practice Patterns, Physicians'; Professional Practice Gaps; United States; United States Agency for Healthcare Research and Quality
PubMed: 34538340
DOI: 10.1016/j.surg.2021.08.004 -
PharmacoEconomics Nov 2020Heart failure presents a growing clinical and economic burden in the USA. Robust cost data on the burden of illness are critical to inform economic evaluations of new... (Review)
Review
BACKGROUND
Heart failure presents a growing clinical and economic burden in the USA. Robust cost data on the burden of illness are critical to inform economic evaluations of new therapeutic interventions.
OBJECTIVES
This systematic literature review of heart failure-related costs in the USA aimed to assess the quality of the published evidence and provide a narrative synthesis of current data.
METHODS
Four electronic databases (MEDLINE, EMBASE, EconLit, and the Centre for Reviews and Dissemination York Database, including the NHS Economic Evaluation Database and Health Technology Assessment Database) were searched for journal articles published between January 2014 and March 2020. The review, registered with PROSPERO (CRD42019134201), was restricted to cost-of-illness studies in adults with heart failure events in the USA.
RESULTS
Eighty-seven studies were included, 41 of which allowed a comparison of cost estimates across studies. The annual median total medical costs for heart failure care were estimated at $24,383 per patient, with heart failure-specific hospitalizations driving costs (median $15,879 per patient). Analyses of subgroups revealed that heart failure-related costs are highly sensitive to individual patient characteristics (such as the presence of comorbidities and age) with large variations even within a subgroup. Additionally, differences in study design and a lack of standardized reporting limited the ability to compare cost estimates. The finding that costs are higher for patients with heart failure with reduced ejection fraction compared with patients with preserved ejection fraction highlights the need for differentiating among different heart failure types.
CONCLUSIONS
The review underpins the conclusion drawn in earlier reviews, namely that hospitalization costs are the key driver of heart failure-related costs. Analyses of subgroups provide a clearer understanding of sources of heterogeneity in cost data. While current cost estimates provide useful indications of economic burden, understanding the nuances of the data is critical to support its application.
Topics: Aged; Aged, 80 and over; Cost-Benefit Analysis; Heart Failure; Humans; Medicare; Middle Aged; Technology Assessment, Biomedical; United States
PubMed: 32812149
DOI: 10.1007/s40273-020-00952-0 -
Journal of Clinical Medicine Jul 2022Venous thromboembolism (VTE) is a serious complication that can occur during and after postoperative treatment, including in treatment after orthopedic surgery. The... (Review)
Review
Venous thromboembolism (VTE) is a serious complication that can occur during and after postoperative treatment, including in treatment after orthopedic surgery. The current guidelines for VTE prophylaxis in postoperative patients recommend the use of LMWHs, one of which is enoxaparin. Another recommendation for use in pharmacological VTE prophylaxis is rivaroxaban, which has better efficacy than enoxaparin but a higher bleeding risk. The aim of this systematic review is to provide an update on the profile of rivaroxaban for VTE prophylaxis after orthopedic surgery. PubMed, SCOPUS, EMBASE, and EBSCOhost were searched up until May 2022. The outcome sought was efficacy and safety, described by the incidence of VTE and incidence of bleeding, respectively. Five randomized controlled trials (RCT) were finally included. Rivaroxaban was confirmed to have better efficacy by significantly reducing the risk of VTE and all-cause mortality (RR = 0.38; 95% CI = 0.27-0.54) compared to enoxaparin. However, regarding the safety variable, no significant difference was found between the incidence of major bleeding in rivaroxaban and enoxaparin (RR = 0.97; 95% CI = 0.56-1.68). The results of the analysis show that rivaroxaban has better efficacy than enoxaparin but the same safety profile, so when used, the bleeding of patients should still be monitored.
PubMed: 35887834
DOI: 10.3390/jcm11144070