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Heart (British Cardiac Society) Aug 2022Studies of the epidemiology of heart failure in the general population can inform assessments of disease burden, research, public health policy and health system care... (Review)
Review
Studies of the epidemiology of heart failure in the general population can inform assessments of disease burden, research, public health policy and health system care delivery. We performed a systematic review of prevalence, incidence and survival for all available population-representative studies to inform the Global Burden of Disease 2020. We examined population-based studies published between 1990 and 2020 using structured review methods and database search strings. Studies were sought in which heart failure was defined by clinical diagnosis using structured criteria such as the Framingham or European Society of Cardiology criteria, with studies using alternate case definitions identified for comparison. Study results were extracted with descriptive characteristics including age range, location and case definition. Search strings identified 42 360 studies over a 30-year period, of which 790 were selected for full-text review and 125 met criteria for inclusion. 45 sources reported estimates of prevalence, 41 of incidence and 58 of mortality. Prevalence ranged from 0.2%, in a Hong Kong study of hospitalised heart failure patients in 1997, to 17.7%, in a US study of Medicare beneficiaries aged 65+ from 2002 to 2013. Collapsed estimates of incidence ranged from 0.1%, in the EPidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine (EPICAL) study of acute heart failure in France among those aged 20-80 years in 1994, to 4.3%, in a US study of Medicare beneficiaries 65+ from 1994 to 2003. One-year heart failure case fatality ranged from 4% to 45% with an average of 33% overall and 24% for studies across all adult ages. Diagnostic criteria, case ascertainment strategy and demographic breakdown varied widely between studies. Prevalence, incidence and survival for heart failure varied widely across countries and studies, reflecting a range of study design. Heart failure remains a high prevalence disease among older adults with a high risk of death at 1 year.
Topics: Aged; Cost of Illness; Heart Failure; Humans; Incidence; Medicare; Prevalence; United States
PubMed: 35042750
DOI: 10.1136/heartjnl-2021-320131 -
JAMA Jan 2020The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence....
IMPORTANCE
The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence. Deterrence, in theory, occurs because clinicians know that they may experience adverse consequences if they negligently injure patients.
OBJECTIVE
To review empirical findings regarding the association between malpractice liability risk (ie, the extent to which clinicians face the threat of being sued and having to pay damages) and health care quality and safety.
DATA SOURCES AND STUDY SELECTION
Systematic search of multiple databases for studies published between January 1, 1990, and November 25, 2019, examining the relationship between malpractice liability risk measures and health outcomes or structural and process indicators of health care quality.
DATA EXTRACTION AND SYNTHESIS
Information on the exposure and outcome measures, results, and acknowledged limitations was extracted by 2 reviewers. Meta-analytic pooling was not possible due to variations in study designs; therefore, studies were summarized descriptively and assessed qualitatively.
MAIN OUTCOMES AND MEASURES
Associations between malpractice risk measures and health care quality and safety outcomes. Exposure measures included physicians' malpractice insurance premiums, state tort reforms, frequency of paid claims, average claim payment, physicians' claims history, total malpractice payments, jury awards, the presence of an immunity from malpractice liability, the Centers for Medicare & Medicaid Services' Medicare malpractice geographic practice cost index, and composite measures combining these measures. Outcome measures included patient mortality; hospital readmissions, avoidable admissions, and prolonged length of stay; receipt of cancer screening; Agency for Healthcare Research and Quality patient safety indicators and other measures of adverse events; measures of hospital and nursing home quality; and patient satisfaction.
RESULTS
Thirty-seven studies were included; 28 examined hospital care only and 16 focused on obstetrical care. Among obstetrical care studies, 9 found no significant association between liability risk and outcomes (such as Apgar score and birth injuries) and 7 found limited evidence for an association. Among 20 studies of patient mortality in nonobstetrical care settings, 15 found no evidence of an association with liability risk and 5 found limited evidence. Among 7 studies that examined hospital readmissions and avoidable initial hospitalizations, none found evidence of an association between liability risk and outcomes. Among 12 studies of other measures (eg, patient safety indicators, process-of-care quality measures, patient satisfaction), 7 found no association between liability risk and these outcomes and 5 identified significant associations in some analyses.
CONCLUSIONS AND RELEVANCE
In this systematic review, most studies found no association between measures of malpractice liability risk and health care quality and outcomes. Although gaps in the evidence remain, the available findings suggested that greater tort liability, at least in its current form, was not associated with improved quality of care.
Topics: Humans; Insurance, Liability; Liability, Legal; Malpractice; Obstetrics; Outcome Assessment, Health Care; Postoperative Complications; Quality of Health Care
PubMed: 31990319
DOI: 10.1001/jama.2019.21411 -
Research in Social & Administrative... May 2021Technology in the form of Automated Dispensing Cabinets (ADCs), Barcode Medication Administration (BCMA), and closed-loop Electronic Medication Management Systems (EMMS)... (Review)
Review
The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review.
BACKGROUND
Technology in the form of Automated Dispensing Cabinets (ADCs), Barcode Medication Administration (BCMA), and closed-loop Electronic Medication Management Systems (EMMS) are implemented in hospitals to assist with the supply, use and monitoring of medications. Although there is evidence to suggest that these technologies can reduce errors and improve monitoring of medications in general, little is known about their impact on controlled medications such as opioids.
OBJECTIVES
This review aimed to fill this knowledge gap by synthesising literature to determine the impact of ADCs, BCMA and closed-loop EMMS on clinical work processes, medication safety, and drug diversion associated with controlled medications in the inpatient setting.
METHODS
Eight databases (Medline, Pubmed, Embase, Scopus, Web of Science, PsycINFO, CINAHL, and ScienceDirect) were searched for relevant papers published between January 2000 and May 2019. Qualitative, quantitative, and mixed-methods empirical studies published in English that reported findings on the impact of ADCs, BCMA and/or closed-loop EMMS on controlled medications in the inpatient setting were included.
RESULTS
In total, 16 papers met the inclusion criteria. Eleven studies reported on ADCs, four on BCMA, and only one on closed-loop EMMS. Only four studies focused on controlled medications, with the remainder reporting only incidental findings. Studies reported the elimination of manual end-of-shift counts of controlled medications after ADC implementation but cases of drug diversion were reported despite introducing ADCs. Three quantitative studies reported reductions in medication errors after implementing BCMA, but medications labelled with wrong barcodes and unreadable barcodes led to confusion and administration errors.
CONCLUSIONS
More quality, targeted research is needed to provide evidence on the benefits and also risks of implementing technology to safeguard against inappropriate use of controlled medications in the inpatient setting. Processes need to be in place to supplement technological capabilities, and resources should be made available for post-implementation evaluations and interventions.
Topics: Electronic Data Processing; Electronics; Hospitals; Humans; Medication Systems; Medication Therapy Management
PubMed: 32891535
DOI: 10.1016/j.sapharm.2020.08.001 -
Journal of the American Medical... Feb 2020Polypharmacy is widespread among older people, but the adverse outcomes associated with it are unclear. We aim to synthesize current evidence on the adverse health,...
OBJECTIVE
Polypharmacy is widespread among older people, but the adverse outcomes associated with it are unclear. We aim to synthesize current evidence on the adverse health, social, medicines management, and health care utilization outcomes of polypharmacy in older people.
DESIGN
A systematic review, of systematic reviews and meta-analyses of observational studies, was conducted. Eleven bibliographic databases were searched from 1990 to February 2018. Quality was assessed using AMSTAR (A Measurement Tool to Assess Systematic Reviews).
SETTING AND PARTICIPANTS
Older people in any health care setting, residential setting, or country.
RESULTS
Twenty-six reviews reporting on 230 unique studies were included. Almost all reviews operationalized polypharmacy as medication count, and few examined medication classes or disease states within this. Evidence for an association between polypharmacy and many adverse outcomes, including adverse drug events and disability, was conflicting. The most consistent evidence was found for hospitalization and inappropriate prescribing. No research had explored polypharmacy in the very old (aged ≥85 years), or examined the potential social consequences associated with medication use, such as loneliness and isolation.
CONCLUSIONS AND IMPLICATIONS
The literature examining the adverse outcomes of polypharmacy in older people is complex, extensive, and conflicting. Until polypharmacy is operationalized in a more clinically relevant manner, the adverse outcomes associated with it will not be fully understood. Future studies should work toward this approach in the face of rising multimorbidity and population aging.
Topics: Aged; Aged, 80 and over; Drug-Related Side Effects and Adverse Reactions; Humans; Inappropriate Prescribing; Medication Therapy Management; Patient Acceptance of Health Care; Polypharmacy
PubMed: 31926797
DOI: 10.1016/j.jamda.2019.10.022 -
The Cochrane Database of Systematic... Sep 2018Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.
OBJECTIVES
To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.
SELECTION CRITERIA
We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).
DATA COLLECTION AND ANALYSIS
Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.
MAIN RESULTS
We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.
AUTHORS' CONCLUSIONS
It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.
Topics: Aged; Controlled Before-After Studies; Drug Prescriptions; Drug-Related Side Effects and Adverse Reactions; Humans; Medication Therapy Management; Non-Randomized Controlled Trials as Topic; Polypharmacy; Quality Improvement; Randomized Controlled Trials as Topic
PubMed: 30175841
DOI: 10.1002/14651858.CD008165.pub4 -
PLoS Medicine Jan 2020The United States is the only high-income nation without universal, government-funded or -mandated health insurance employing a unified payment system. The US...
BACKGROUND
The United States is the only high-income nation without universal, government-funded or -mandated health insurance employing a unified payment system. The US multi-payer system leaves residents uninsured or underinsured, despite overall healthcare costs far above other nations. Single-payer (often referred to as Medicare for All), a proposed policy solution since 1990, is receiving renewed press attention and popular support. Our review seeks to assess the projected cost impact of a single-payer approach.
METHODS AND FINDINGS
We conducted our literature search between June 1 and December 31, 2018, without start date restriction for included studies. We surveyed an expert panel and searched PubMed, Google, Google Scholar, and preexisting lists for formal economic studies of the projected costs of single-payer plans for the US or for individual states. Reviewer pairs extracted data on methods and findings using a template. We quantified changes in total costs standardized to percentage of contemporaneous healthcare spending. Additionally, we quantified cost changes by subtype, such as costs due to increased healthcare utilization and savings due to simplified payment administration, lower drug costs, and other factors. We further examined how modeling assumptions affected results. Our search yielded economic analyses of the cost of 22 single-payer plans over the past 30 years. Exclusions were due to inadequate technical data or assuming a substantial ongoing role for private insurers. We found that 19 (86%) of the analyses predicted net savings (median net result was a savings of 3.46% of total costs) in the first year of program operation and 20 (91%) predicted savings over several years; anticipated growth rates would result in long-term net savings for all plans. The largest source of savings was simplified payment administration (median 8.8%), and the best predictors of net savings were the magnitude of utilization increase, and savings on administration and drug costs (R2 of 0.035, 0.43, and 0.62, respectively). Only drug cost savings remained significant in multivariate analysis. Included studies were heterogeneous in methods, which precluded us from conducting a formal meta-analysis.
CONCLUSIONS
In this systematic review, we found a high degree of analytic consensus for the fiscal feasibility of a single-payer approach in the US. Actual costs will depend on plan features and implementation. Future research should refine estimates of the effects of coverage expansion on utilization, evaluate provider administrative costs in varied existing single-payer systems, analyze implementation options, and evaluate US-based single-payer programs, as available.
Topics: Economics; Health Care Costs; Healthcare Financing; Humans; Single-Payer System; United States
PubMed: 31940342
DOI: 10.1371/journal.pmed.1003013 -
Health Services Research Oct 2017To update a past systematic review on whether Medicare Part D changed drug utilization and out-of-pocket (OOP) costs overall and within subpopulations, and to identify... (Review)
Review
OBJECTIVE
To update a past systematic review on whether Medicare Part D changed drug utilization and out-of-pocket (OOP) costs overall and within subpopulations, and to identify evidence gaps.
DATA SOURCES/STUDY SETTING
Published and gray literature from 2010 to 2015 meeting prespecified screening criteria, including having a comparison group, and utilization or OOP cost outcomes.
STUDY DESIGN
We conducted a systematic literature review with a quality assessment.
DATA COLLECTION/EXTRACTION METHODS
For each study, we extracted information on study design, data sources, analytic methods, outcomes, and limitations. Because outcome measures vary across studies, we did a qualitative synthesis rather than meta-analysis.
PRINCIPAL FINDINGS
Sixty-five studies met screening criteria. Overall, Medicare Part D enrollees have increased drug utilization and decreased OOP costs, but coverage gaps limit the program's impact. Beneficiaries whose insurance becomes more generous after enrollment had disproportionately increased drug utilization and decreased OOP costs. Outcomes among dual-eligibles were mixed.
CONCLUSIONS
There is strong evidence on how Medicare Part D and the donut hole coverage gap affect utilization and OOP costs, but weak evidence on how effects vary among dual-eligibles or across diseases. Findings suggest that the Affordable Care Act's provisions to expand coverage and reduce the donut hole should improve patient outcomes.
Topics: Aged; Benzodiazepines; Drug Utilization; Financing, Personal; Humans; Inappropriate Prescribing; Medicaid; Medicare Part D; United States
PubMed: 27480577
DOI: 10.1111/1475-6773.12534 -
The American Journal of Managed Care Sep 2021To compare Medicare Advantage (MA) and traditional Medicare (TM) performance on quality, health, and cost outcomes in peer-reviewed literature published since 2010.
OBJECTIVES
To compare Medicare Advantage (MA) and traditional Medicare (TM) performance on quality, health, and cost outcomes in peer-reviewed literature published since 2010.
STUDY DESIGN
Systematic review of peer-reviewed papers published between January 1, 2010, and May 1, 2020.
METHODS
To identify relevant research papers, we searched MEDLINE, EBSCO, and ProQuest. We excluded any studies that did not meet several inclusion criteria. Titles, abstracts, and full-text articles were independently reviewed by 1 author and several trained research assistants. Disagreements were resolved through discussion. We also reviewed the bibliographies of included studies and consulted subject matter experts to identify additional papers.For each eligible study, we extracted the first author, year published, study design, data sources, study years, sample sizes, relevant measures, and study quality. To ensure consistent and complete data extraction, each article was reviewed by 2 reviewers. Study quality was assessed using a modified Newcastle-Ottawa Scale.
RESULTS
Thirty-five studies including 208 analyses were included. All included studies were observational. Two-thirds of studies were of high methodological quality for observational studies, and 49% addressed selection bias. Analyses compared quality of care (41%), health outcomes (44%), and spending (15%). Overall, 65% of analyses found a statistically significant relationship: 52% favored MA and 13% favored TM.
CONCLUSIONS
More than half of recent analyses comparing MA and TM find that MA delivers significantly better quality of care, better health outcomes, and lower costs compared with TM.
Topics: Aged; Humans; Medicare Part C; United States
PubMed: 34533909
DOI: 10.37765/ajmc.2021.88641 -
Sports Health 2023To determine optimal treatment strategies for shoulder impingement syndrome (SIS). (Meta-Analysis)
Meta-Analysis Review
CONTEXT
To determine optimal treatment strategies for shoulder impingement syndrome (SIS).
OBJECTIVE
To compare subacromial nonsteroidal anti-inflammatory injections (SNIs) and subacromial corticosteroid injections (SCIs) on pain relief and functional improvement in individuals with SIS. Second, to perform a cost analysis of the 2 injections.
DATA SOURCES
MEDLINE, SPORTDiscus, CINAHL, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials using several keywords.
STUDY SELECTION
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized, and 10 studies comparing changes in pain or function in humans with SIS receiving SNIs or SCIs were included. Quality and risk of bias were assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 scale and the Cochrane Collaboration tool.
STUDY DESIGN
Systematic review and meta-analysis.
LEVEL OF EVIDENCE
Level 1.
DATA EXTRACTION
Baseline and follow-up scores of the visual analog, Constant-Murley, and University of California Los Angeles shoulder scales were extracted to calculate effect sizes (ESs), represented as Cohen . Metaregression and publication bias analyses were performed. Procedural and medication costs were extracted from Medicare guidelines.
RESULTS
A total of 7 high and 3 good quality studies were included, with a mean score of 21.1. Only 1 study had a high risk of bias. The meta-analyses produced pooled ESs of 0.05 ( = 0.83), 0.12 ( = 0.71), and 0.07 ( = 0.79) for each scale, respectively, with CIs crossing 0. Procedural costs were equal between groups, whereas ketorolac was the least costly medication ($0.47). There was no significant difference in side effects between the 2 injections.
CONCLUSION
SNIs are as effective as SCIs for short-term pain relief and improving function in patients with subacromial impingement syndrome. In addition, they are less expensive and cause no major difference in complications, providing a viable, cost-effective alternative for injection therapy in patients with SIS.
Topics: Aged; United States; Humans; Shoulder Impingement Syndrome; Injections, Intra-Articular; Medicare; Anti-Inflammatory Agents, Non-Steroidal; Adrenal Cortex Hormones; Pain
PubMed: 35897160
DOI: 10.1177/19417381221108726 -
Journal of the American Geriatrics... Oct 2011To evaluate the literature regarding the effect of Medicare Part D on the under- and overuse of specific medications and corresponding health outcomes. (Review)
Review
OBJECTIVES
To evaluate the literature regarding the effect of Medicare Part D on the under- and overuse of specific medications and corresponding health outcomes.
DESIGN
Systematic review.
SETTING
Medline search of the peer-reviewed literature from January 1, 2006, to October 8, 2010.
PARTICIPANTS
Medicare beneficiaries who obtained drug insurance from the Part D program.
MEASUREMENTS
The review evaluated changes in the use of specific drugs or drug classes after implementation of Part D, as described in original, peer-reviewed articles.
RESULTS
Nineteen articles met inclusion criteria. Part D's implementation was associated with greater use of essential medications such as clopidogrel and statins, especially in beneficiaries who had been previously uninsured, but increases in inappropriate antibiotic use for the treatment of acute respiratory tract infections and increases in claims for the often overused proton pump inhibitor drug class were also observed. In the Part D transition period, dually eligible beneficiaries' drug use remained largely unchanged. When beneficiary cost sharing increased in the coverage gap, use of essential and overused medications declined.
CONCLUSION
Increasing drug coverage led to greater use of underused essential medications and inappropriate, or overused, medications under Medicare Part D. Despite efforts to have it do so, the Part D benefit did not sufficiently discriminate between essential and nonessential medication use.
Topics: Aged; Aged, 80 and over; Chronic Disease; Comorbidity; Cost Sharing; Drug Costs; Drug Utilization Review; Female; Humans; Long-Term Care; Male; Medicare Part D; United States
PubMed: 21806563
DOI: 10.1111/j.1532-5415.2011.03537.x