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Journal of Clinical Sleep Medicine :... Jun 2024We performed a systematic review of long-term health outcomes of continuous positive airway pressure (CPAP) use in adults with obstructive sleep apnea.
STUDY OBJECTIVES
We performed a systematic review of long-term health outcomes of continuous positive airway pressure (CPAP) use in adults with obstructive sleep apnea.
METHODS
We updated prior systematic reviews with searches in multiple databases through January 3, 2023. We included randomized controlled trials (RCTs) and adjusted nonrandomized comparative studies that reported prespecified long-term (mostly > 1 year) health outcomes. We assessed risk of bias, conducted meta-analyses, and evaluated strength of evidence.
RESULTS
We found 38 eligible studies (16 trials, 22 observational). All conclusions were of low strength of evidence given study and data limitations. RCTs found no evidence of effect of CPAP on mortality (summary effect size [ES] 0.89; 95% confidence interval [CI] 0.66, 1.21); inclusion of adjusted nonrandomized comparative studies yields an association with reduced risk of death (ES 0.57; 95% CI 0.44, 0.73). RCTs found no evidence of effects of CPAP for cardiovascular death (ES 0.99; 95% CI 0.64, 1.53), stroke (ES 0.99; 95% CI 0.73, 1.35), myocardial infarction (ES 1.05; 95% CI 0.78, 1.41), incident atrial fibrillation (ES 0.89; 95% CI 0.48, 1.63), or composite cardiovascular outcomes (all statistically nonsignificant). RCTs found no evidence of effects for incident diabetes (ES 1.02; 95% CI 0.69, 1.51) or accidents (all nonsignificant) and no clinically significant effects on depressive symptoms, anxiety symptoms, or cognitive function.
CONCLUSIONS
Whether CPAP use for obstructive sleep apnea affects long-term health outcomes remains largely unanswered. RCTs and nonrandomized comparative studies are inconsistent regarding the effect of CPAP on mortality. Current studies are underpowered, with relatively short duration follow-up and methodological limitations.
CITATION
Balk EM, Adam GP, Cao W, Bhuma MR, D'Ambrosio C, Trikalinos TA. Long-term effects on clinical event, mental health, and related outcomes of CPAP for obstructive sleep apnea: a systematic review. . 2024;20(6):895-909.
Topics: Humans; Sleep Apnea, Obstructive; Continuous Positive Airway Pressure; Mental Health; Treatment Outcome
PubMed: 38300818
DOI: 10.5664/jcsm.11030 -
Asian Cardiovascular & Thoracic Annals Mar 2024Abdominal aortic aneurysm (AAA) is a cardiovascular disease characterized by a high mortality rate when ruptured. Some studies suggest a potential inverse correlation... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Abdominal aortic aneurysm (AAA) is a cardiovascular disease characterized by a high mortality rate when ruptured. Some studies suggest a potential inverse correlation between AAA and diabetes patients, especially those undergoing metformin treatment. However, this relationship remains unclear. This paper offers a systematic review and meta-analysis with the objective of clarifying the influence of metformin on AAA.
METHODS
A search for relevant articles was performed across multiple databases including PubMed, ScienceDirect, Cochrane and Scopus. The focus was on studies that examined the comparative effects of metformin and non-metformin treatments on AAA patients. Data from appropriate studies were consolidated to estimate the effects. Our study encompassed 11 articles, comprising 13 cohorts that compared metformin ( = 32,250) with a control group ( = 116,339).
RESULTS
The random effects meta-analysis revealed that metformin was associated with a slower growth rate (weighted mean difference (WMD) -0.86 mm; 95% CI: -1.21 to -0.52; < 0.01; I: 81.4%) and fewer AAA-related events (OR: 0.54; 95% CI: 0.34 to 0.86; = 0.01; I: 60.9%). The findings suggest that metformin may be linked to a reduced risk of aortic aneurysm. A meta-regression analysis indicated that the association between metformin and AAA growth was significantly influenced by male gender ( = 0.027), but not by age ( = 0.801), hypertension ( = 0.256), DM ( = 0.689), smoking history ( = 0.786), use of lipid-lowering agents ( = 0.715), or baseline diameter ( = 0.291).
CONCLUSION
These results hint at a potential role for metformin in limiting annual AAA growth, AAA-related events, and the risk of AAA.
Topics: Humans; Male; Metformin; Risk Factors; Diabetes Mellitus; Cardiovascular Diseases; Aortic Aneurysm, Abdominal
PubMed: 38239055
DOI: 10.1177/02184923231225794 -
Journal of the American College of... May 2024Black and underinsured women in the United States are more likely than their counterparts to develop uterine fibroids (UFs) and experience more severe symptoms. Uterine... (Meta-Analysis)
Meta-Analysis Comparative Study
INTRODUCTION
Black and underinsured women in the United States are more likely than their counterparts to develop uterine fibroids (UFs) and experience more severe symptoms. Uterine artery embolization (UAE), a uterine-sparing therapeutic procedure, is less invasive than the common alternative, open hysterectomy. To determine whether demographic disparities persist in UF treatment utilization, we reviewed patient characteristics associated with UAE versus hysterectomy for UF among studies of US clinical practices.
METHODS
A systematic literature review was conducted via PubMed, Embase, and CINAHL (PROSPERO CRD42023455051), yielding 1,350 articles (January 1, 1995, to July 15, 2023) that outlined demographic characteristics of UAE compared with hysterectomy. Two readers screened for inclusion criteria, yielding 13 full-text US-based comparative studies specifying at least one common demographic characteristic. Random effects meta-analysis was performed on the data (STATA v18.0). Egger's regression test was used to quantify publication bias.
RESULTS
Nine (138,960 patients), four (183,643 patients), and seven (312,270 patients) studies were analyzed for race, insurance status, and age as predictors of treatment modality, respectively. Black race (odds ratio = 3.35, P < .01) and young age (P < .05) were associated with UAE, whereas private insurance (relative to Medicare and/or Medicaid) was not (odds ratio = 1.06, P = .52). Between-study heterogeneity (I > 50%) was detected in all three meta-analyses. Small-study bias was detected for age but not race or insurance.
CONCLUSIONS AND IMPLICATIONS
Knowledge of demographic characteristics of patients with UFs receiving UAE versus hysterectomy is sparse (n = 13 studies). Among these studies, which seem to be racially well distributed, Black and younger women are more likely to receive UAE than their counterparts.
Topics: Female; Leiomyoma; Humans; Uterine Artery Embolization; Hysterectomy; Uterine Neoplasms; United States
PubMed: 38191081
DOI: 10.1016/j.jacr.2023.12.018 -
Gynecologic Oncology Feb 2024This systematic review aimed to investigate what are the most relevant social determinants of health (SDH), how they are measured, how they interact among themselves and... (Review)
Review
OBJECTIVE
This systematic review aimed to investigate what are the most relevant social determinants of health (SDH), how they are measured, how they interact among themselves and what is their impact on the outcomes of cervical cancer patients.
METHODS
Search was performed in PubMed, Scopus, Web of Science, Embase, Cochrane, and Google Scholar databases from January 2001 to September 2022. The protocol was registered at PROSPERO (CRD42022346854). We followed the PICOS strategy: Population- Patients treated for cervical cancer in the United States; Intervention - Any SDH; Comparison- None; Outcome measures- Cancer treatment outcomes related to the survival of the patients; Types of studies- Observational studies. Two reviewers extracted the data following the PRISMA guidelines. Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies was used for risk of bias (ROB) assessment.
RESULTS
Twenty-four studies were included (22 had low and 2 had moderate ROB). Most manuscripts analyzed data from public registries (83.3%) and only one SDH (54.17%). The SDH category of Neighborhood was not included in any study. Although the SDH were measured differently across the studies, not being married, receiving treatment at a low-volume hospital, and having public insurance (Medicaid or Medicare) or not being insured was associated with shorter survival of cervical cancer patients in most studies.
CONCLUSIONS
There is a deficit in the number of studies comprehensively assessing the impact of SDH on cervical cancer treatment-related outcomes. Marital status, hospital volume and health insurance status are potential predictors of worse outcome.
Topics: Female; Humans; Aged; United States; Uterine Cervical Neoplasms; Social Determinants of Health; Cross-Sectional Studies; Medicare; Hospitals, Low-Volume
PubMed: 38163384
DOI: 10.1016/j.ygyno.2023.12.020 -
Urology Practice Mar 2024UTIs are some of the most common infections in geriatric patients, with many women experiencing recurrent infections after menopause. In the US, annual UTI-related costs...
INTRODUCTION
UTIs are some of the most common infections in geriatric patients, with many women experiencing recurrent infections after menopause. In the US, annual UTI-related costs are $2 billion, with recurrent infections creating a significant economic burden. Given the data published on topical estrogen in reducing the number of infections for postmenopausal women with recurrent UTI, we sought to evaluate how this would translate to cost savings.
METHODS
We performed a systematic literature review of UTI reduction secondary to topical estrogen utilization in postmenopausal female patients. The cost per UTI was determined based on published Medicare spending on UTI per beneficiary, weighted on reported likelihood of complicated and resistant infections. For a patient with recurrent infections, topical estrogen therapy reported on average can reduce infections from 5 to 0.5 to 2 times per person per year.
RESULTS
At a calculated cost per UTI of $1222, the reduction in UTI spending can range between $3670 and $5499 per beneficiary per year. Per-beneficiary spending on topical estrogen therapies was $1013 on average ($578-$1445) in 2020. After including the cost of the therapy, overall cost savings for topical estrogen therapies were $1226 to $4888 annually per patient.
CONCLUSIONS
Topical estrogens are a cost-conscious way to improve the burden of UTI on postmenopausal women with the potential for billions of dollars in Medicare savings. System-wide efforts should be made to have these therapies available as prophylaxis for postmenopausal patients and to ensure they are affordable for patients.
Topics: Aged; Humans; Female; United States; Postmenopause; Reinfection; Cost Savings; Medicare; Urinary Tract Infections; Estrogens
PubMed: 38154005
DOI: 10.1097/UPJ.0000000000000513 -
Journal of Managed Care & Specialty... Jan 2024The use of potentially inappropriate medications (PIMs) is prevalent, costly, and harmful for older adults. These medications are to be avoided among older adults...
BACKGROUND
The use of potentially inappropriate medications (PIMs) is prevalent, costly, and harmful for older adults. These medications are to be avoided among older adults because they generally have (1) a high risk of adverse events in this population and/or (2) limited evidence of benefits in the presence of safer or more effective alternatives. Medication therapy management (MTM) programs can help address PIM use; however, there has not been a synthesis of studies examining the impact of MTM programs on PIM use.
OBJECTIVE
To review published literature evaluating the impact of MTM on PIM use in older adults.
METHODS
A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines using MEDLINE (PubMed) studies were included if they (1) had a Medicare population, (2) were based in the United States, (3) examined an MTM program (ie, used the term "medication therapy management"), (4) focused on the impact of MTM programs on PIM use as the primary outcome, (5) had a randomized controlled trial or an observational study design, and (6) were available in English.
RESULTS
Of 221 articles identified, 31 full-text articles were assessed, and 7 met all inclusion and exclusion criteria. The studies took place in various settings, ranging from single-site tertiary medical centers to multisite outpatient clinics, community pharmacies, and nationwide telehealth MTM providers. Patient populations were majority female sex (ranging from 61% to 71%) and majority White (ranging from 81% to 94%), with a mean age of 73 to 78 years. In 5 of the 7 studies, MTM reduced the use of PIMs; however, 3 did not adjust for confounding or apply a comparator group. Measurement of MTM impacts on PIM use varied across studies. Patient-level and plan-level studies mostly assessed shorter-term PIM usage reduction (4 months or less), whereas studies performed at the provider and institutional level assessed PIM usage reduction trends across consecutive measurement years.
CONCLUSIONS
Based on the current limited evidence, MTM programs in older adults appear to have a positive impact on reducing PIM use. However, evidence was limited by study design, the lack of consistency in outcome measures, and a short follow-up period. Future work should adjust for confounding, apply comparator groups, include longer-term outcomes, and develop a core set of measures that can be consistently applied across studies.
Topics: Aged; Female; Humans; Medicare; Medication Therapy Management; Observational Studies as Topic; Pharmacies; Potentially Inappropriate Medication List; Randomized Controlled Trials as Topic; Research Design; United States
PubMed: 38153866
DOI: 10.18553/jmcp.2024.30.1.03 -
Population Health Management Feb 2024Out-of-pocket (OOP) health care expenditures in the United States have increased significantly in the past 5 decades. Most research on OOP costs focuses on expenditures... (Review)
Review
Out-of-pocket (OOP) health care expenditures in the United States have increased significantly in the past 5 decades. Most research on OOP costs focuses on expenditures related to insurance and cost-sharing payments or on costs related to specific conditions or settings, and does not capture the full picture of the financial burden on patients and unpaid caregivers. The aim for this systematic literature review was to identify and categorize the multitude of OOP costs to patients and unpaid caregivers, aid in the development of a more comprehensive catalog of OOP costs, and highlight potential gaps in the literature. The authors found that OOP costs are multifarious and underestimated. Across 817 included articles, the authors identified 31 subcategories of OOP costs related to direct medical (eg, insurance premiums), direct nonmedical (eg, transportation), and indirect spending (eg, absenteeism). In addition, 42% of articles studied an expenditure that the authors did not label as "OOP." A holistic and comprehensive catalog of OOP costs can inform future research, interventions, and policies related to financial barriers to health care in the United States to ensure the full range of costs for patients and unpaid caregivers are acknowledged and addressed.
Topics: Humans; United States; Caregivers; Health Expenditures; Delivery of Health Care; Cost Sharing
PubMed: 38099925
DOI: 10.1089/pop.2023.0238 -
Journal of Clinical Sleep Medicine :... Mar 2024We explored the variability of sleep apnea indices and definitions of obstructive sleep apnea in clinical studies of continuous positive airway pressure.
STUDY OBJECTIVES
We explored the variability of sleep apnea indices and definitions of obstructive sleep apnea in clinical studies of continuous positive airway pressure.
METHODS
In a systematic review of the long-term clinical effects of continuous positive airway pressure, we noted variability across studies in how sleep apnea was defined. We, thus, sought to quantify the heterogeneity.
RESULTS
Across 57 comparative studies of long-term clinical outcomes of continuous positive airway pressure, only 40% fully and explicitly reported their definitions of apnea and hypopnea. Most studies defined apnea as 100% airflow cessation, but a minority used 90% or even down to 75% thresholds. Almost half of the studies defined hypopnea as ≥ 50% airflow cessation, but the majority used 30% or even 25% thresholds. Similarly, about half of the studies used a 4% desaturation threshold to define oxygen desaturation and about half used a 3% threshold, with 2 studies using both thresholds for different purposes. Randomized trials were no more consistent or better-reported than observational studies. Studies that cited published criteria generally reported definitions that were different from the cited criteria.
CONCLUSIONS
The criteria used to define sleep apnea indices (apnea, hypopnea, and oxygen desaturation) were highly variable, even among studies stating that definitions were based on the same standard criteria. It was often difficult to discern the actual criteria used. The great variability across studies and lack of transparency about their sleep study methods hampers the interpretability and utility of the studies and calls into question whether studies are generalizable from one setting to another.
CITATION
Balk EM, Adam GP, D'Ambrosio CM. Large variability in definitions of sleep apnea indices used in clinical studies. . 2024;20(3):461-468.
Topics: Humans; Sleep Apnea Syndromes; Sleep; Sleep Apnea, Obstructive; Polysomnography; Oxygen
PubMed: 38054476
DOI: 10.5664/jcsm.10918 -
AANA Journal Dec 2023This systematic review was conducted to examine the value of the preoperative history and physical (H&P) examination and preoperative care prior to cataract extraction...
This systematic review was conducted to examine the value of the preoperative history and physical (H&P) examination and preoperative care prior to cataract extraction and the resulting outcomes of adverse events, patient experience, and cost. Four databases were searched using appropriate keywords from 2012 to 2022. Observational studies, randomized controlled trials, and quality improvement studies with data on the precataract H&P were included. Outcome measures were adverse events, cost, and patient experience. Of the 4,170 studies screened, 12 studies were included. Risk stratification of patients into a high-risk group with an H&P and a low-risk group without an H&P resulted in an increased incidence of minor adverse events in the low-risk group but did not increase the incidence of major adverse events or surgical adverse events. A short-term cost savings was reported, and patient experience was unchanged. In 2020, the Centers for Medicare and Medicaid Services removed the requirement for the precataract H&P within 30 days prior to ambulatory surgery, which has implications for surgery center policy. More research on the role of the preoperative H&P on patient experience, adverse events, cost, and outcomes should be conducted, given the methodological heterogeneity of this review.
Topics: Aged; United States; Humans; Medicare; Cataract Extraction; Cost Savings; Physical Examination; Cataract
PubMed: 37987726
DOI: No ID Found -
Journal of Vascular Surgery Feb 2024In the United States, an estimated $2.8 billion annually is spent on vascular access and its complications. Endovascular arteriovenous fistula (endoAVF) creation is a...
OBJECTIVE
In the United States, an estimated $2.8 billion annually is spent on vascular access and its complications. Endovascular arteriovenous fistula (endoAVF) creation is a novel, minimally invasive alternative to traditional surgical AV fistula (sAVF) creation in ≤60% of patients. Although cost effective in single-payer systems, the clinical and financial impact of endoAVF in the United States remains uncertain.
METHODS
We constructed a decision tree followed by a probabilistic cohort state-transition model to study the cost effectiveness of endoAVF vs sAVF creation. We conducted a systematic review to obtain input parameters including technical success, maturation, patency, and utility values. We derived costs from the Medicare 2022 fee schedule and from the literature. We used a 5-year time horizon, an annual discount rate of 3% for costs and utilities (measured in quality-adjusted life-years [QALYs]), and the common willingness-to-pay threshold of $50,000. One-way and Monte Carlo probabilistic sensitivity analyses were performed varying technical success, patency, reintervention, cost, and utility parameters.
RESULTS
In the base-case scenario, endoAVF ($30,129 average per-person costs, 2.19 QALYs gained, 65% patent at 5 years) was not cost effective compared with sAVF ($12.987 average per-person costs, 2.11 QALYs gained, 66% patent at 5 years), generating an incremental cost-effectiveness ratio of $227,504 per QALY gained. In one-way sensitivity analyses, endoAVF becomes cost effective when the initial cost of sAVF creation exceeds endoAVF by ≥$600 (eg, if endoAVF creation costs ≤$3000 relative to the base-case sAVF cost of $3600), the additional QALYs gained from endoAVF exceeds 0.12 QALYs/year (eg, 0.81 QALYs gained/year from endoAVF compared with base-case sAVF 0.69 QALYs/year), the endoAVF maturation rate is >90% (base case 78%), or the sAVF maturation rate is <65% (base case 78%). Probabilistic sensitivity analysis demonstrated that sAVF remained the optimal strategy in 71% of iterations.
CONCLUSIONS
EndoAVF is not cost effective compared with sAVF when modeling 5-year outcomes. The main driver of sAVF remaining cost effective is the four times higher up-front cost for endoAVF creation, as well as a relatively low additional increase in quality of life for endoAVF. It will be important to establish how the endoAVF learning curve contributes to upfront costs and, given the annual cost attributed to vascular access nationally, a randomized controlled trial is warranted.
Topics: Humans; Arteriovenous Fistula; Cost-Effectiveness Analysis; Medicare; Quality of Life; Quality-Adjusted Life Years; United States
PubMed: 37952783
DOI: 10.1016/j.jvs.2023.11.009