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JAMA Network Open Feb 2024Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services...
IMPORTANCE
Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services research. Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are 2 of the most commonly used measures. There is also early interest in incorporating area-level measures to create more equitable alternative payment models.
OBJECTIVE
To review the evidence on the association of ADI and SVI with health care spending, including claims-based spending and patient-reported barriers to care due to cost.
EVIDENCE REVIEW
A systematic search for English-language articles and abstracts was performed in the PubMed, Web of Science, Embase, and Cochrane databases (from inception to March 1, 2023). Peer-reviewed articles and abstracts using a cross-sectional, case-control, or cohort study design and based in the US were identified. Data analysis was performed in March 2023.
FINDINGS
This review included 24 articles and abstracts that used a cross-sectional, case-control, or cohort study design. In 20 of 24 studies (83%), ADI and SVI were associated with increased health care spending. No association was observed in the 4 remaining studies, mostly with smaller sample sizes from single centers. In adjusted models, the increase in spending associated with higher ADI or SVI residence was $574 to $1811 for index surgical hospitalizations, $3003 to $24 075 for 30- and 90-day episodes of care, and $3519 for total annual spending for Medicare beneficiaries. In the studies that explored mechanisms, postoperative complications, readmission risk, and poor primary care access emerged as health care system-related drivers of increased spending.
CONCLUSIONS AND RELEVANCE
The findings of this systematic review suggest that both ADI and SVI can play important roles in efforts to understand drivers of health care spending and in the design of payment and care delivery programs that capture aspects of social risk. At the health care system level, higher health care spending and poor care access associated with ADI or SVI may represent opportunities to codesign interventions with patients from high ADI or SVI areas to improve access to high-value health care and health promotion more broadly.
Topics: United States; Humans; Aged; Cohort Studies; Cross-Sectional Studies; Health Expenditures; Medicare; Socioeconomic Disparities in Health
PubMed: 38358740
DOI: 10.1001/jamanetworkopen.2023.56121 -
European Journal of Heart Failure Jun 2020The primary objective of this systematic review was to estimate the prevalence and temporal changes in chronic comorbid conditions reported in heart failure (HF)...
AIMS
The primary objective of this systematic review was to estimate the prevalence and temporal changes in chronic comorbid conditions reported in heart failure (HF) clinical trials.
METHODS AND RESULTS
We searched MEDLINE for HF trials enrolling more than 400 patients published between 2001 and 2016.Trials were divided into HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or trials enrolling regardless of ejection fraction. The prevalence of baseline chronic comorbid conditions was categorized according to the algorithm proposed by the Chronic Conditions Data Warehouse, which is used to analyse Medicare data. To test for a trend in the prevalence of comorbid conditions, linear regression models were used to evaluate temporal trends in prevalence of comorbidities. Overall, 118 clinical trials enrolling a cumulative total of 215 508 patients were included. Across all comorbidities examined, data were reported in a mean of 35% of trials, without significant improvement during the study period. Reporting of comorbidities was more common in HFrEF trials (51%) compared with HFpEF trials (27%). Among trials reporting data, hypertension (63%), ischaemic heart disease (44%), hyperlipidaemia (48%), diabetes (33%), chronic kidney disease (25%) and atrial fibrillation (25%) were the major comorbidities. The prevalence of comorbidities including hypertension, atrial fibrillation and chronic kidney disease increased over time while the prevalence of smoking decreased in HFrEF trials.
CONCLUSION
Many HF trials do not report baseline comorbidities. A more rigorous, systematic, and standardized framework needs to be adopted for future clinical trials to ensure adequate comorbidity reporting and improve recruitment of multi-morbid HF patients.
Topics: Chronic Disease; Clinical Trials as Topic; Comorbidity; Heart Failure; Humans; Prevalence; Prognosis; United States
PubMed: 32293090
DOI: 10.1002/ejhf.1818 -
Journal of General Internal Medicine Oct 2019Evidence for the benefit of implantable cardioverter defibrillators (ICD) in preventing sudden cardiac death (SCD) in older adults is mixed; age alone may not predict...
BACKGROUND
Evidence for the benefit of implantable cardioverter defibrillators (ICD) in preventing sudden cardiac death (SCD) in older adults is mixed; age alone may not predict benefit. Frailty may help identify patients in whom an ICD does not improve overall mortality risk.
METHODS
Structured search of PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials on 1/31/2019, without language restriction, with terms for ICD, frailty, and mortality. Frailty was defined broadly using any validated single component (e.g., walking speed, weight loss) or multi-component tool (e.g., cumulative deficit index). Each study was assessed for quality and risk of bias.
RESULTS
We identified and screened 2649 titles, reviewed 280 abstracts, and extracted 71 articles. Nine articles, including two RCTs, one prospective cohort, and six retrospective cohort studies met all criteria. The most common reason for exclusion was a lack of frailty definition. Frailty definitions were heterogeneous, including cumulative deficit models, low weight, and walking speed. Follow-up time for mortality differed: from days to > 6 years. All studies indicated that mortality was higher amongst individuals identified as frail, regardless of definition. In one RCT, slow walkers did not benefit from ICD therapy after 3 years. A cohort of 83,792 Medicare beneficiaries in an ICD registry reported higher 1-year mortality following ICD in those with frailty or dementia. Four studies reported an association between being underweight and increased mortality following ICD placement.
CONCLUSION
Existing literature suggests that individuals with frailty may not benefit from ICD placement for primary prevention of SCD.
Topics: Aged; Aged, 80 and over; Contraindications, Procedure; Death, Sudden, Cardiac; Defibrillators, Implantable; Frailty; Humans; United States
PubMed: 31264082
DOI: 10.1007/s11606-019-05100-9 -
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 -
Blood Advances Jun 2020Risk assessment models (RAMs) for venous thromboembolism (VTE) and bleeding in hospitalized medical patients inform appropriate use of thromboprophylaxis. Our aim was to...
Risk assessment models (RAMs) for venous thromboembolism (VTE) and bleeding in hospitalized medical patients inform appropriate use of thromboprophylaxis. Our aim was to use a novel approach for selecting risk factors for VTE and bleeding to be included in RAMs. First, we used the results of a systematic review of all candidate factors. Second, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of the evidence for the identified factors. Third, we using a structured approach to select factors to develop the RAMs, by building on clinical and methodological expertise. The expert panel made judgments on whether to include, potentially include, or exclude risk factors, according to domains of the GRADE approach and the Delphi method. The VTE RAM included age >60 years, previous VTE, acute infections, immobility, acute paresis, active malignancy, critical illness, and known thrombophilia. The bleeding RAM included age ≥65 years, renal failure, thrombocytopenia, active gastroduodenal ulcers, hepatic disease, recent bleeding, and critical illness. We identified acute infection as a factor that was not considered in widely used RAMs. Also, we identified factors that require further research to confirm or refute their importance in a VTE RAM (eg, D-dimer). We excluded autoimmune disease which is included in the IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) bleeding RAM. Our results also suggest that sex, malignancy, and use of central venous catheters (factors in the IMPROVE bleeding RAM) require further research. In conclusion, our study presents a novel approach to systematically identifying and assessing risk factors to be included or further explored during RAM development.
Topics: Aged; Anticoagulants; Hemorrhage; Humans; Inpatients; Middle Aged; Risk Assessment; Venous Thromboembolism
PubMed: 32542391
DOI: 10.1182/bloodadvances.2020001937 -
Cureus Mar 2024Coronary artery disease (CAD) poses a global health challenge, necessitating effective preventive strategies. Despite the pivotal role of physical activity in... (Review)
Review
Coronary artery disease (CAD) poses a global health challenge, necessitating effective preventive strategies. Despite the pivotal role of physical activity in cardiovascular health, many fall short of recommended guidelines for daily physical activity. Simple and accessible, walking presents an opportunity, with increased pace emerging as a potential strategy for reducing the risk of cardiovascular diseases. Thus, we aimed to elucidate the potential association between walking pace and the risk of CAD events in adults without a prior history of CAD through a systematic review. We searched PubMed, Scopus, Web of Science, and ScienceDirect without publication date restrictions to identify prospective cohorts that analyzed walking pace and adult CAD events. The literature search conducted from April 02, 2023, to August 21, 2023, identified a total of four studies (six cohorts) for meta-analysis using random-effects models. The Newcastle-Ottawa Scale was used to assess study quality, and data extraction involved two independent reviewers. The analysis calculated overall relative risks (RRs) and 95% confidence intervals (CIs) for those with the quickest walking paces compared to those with the slowest walking paces. A funnel plot analysis for publication bias and subgroup analysis were also conducted. Results from the meta-analysis involving 160,519 participants and 3,351 CAD events demonstrated a 46% decreased risk for those walking at the quickest pace (pooled RR = 0.54, 95% CI = 0.45-0.66). No significant heterogeneity was observed. In conclusion, walking pace emerges as a significant risk factor for CAD events in adults without a prior history of CAD. It serves as a potential screening tool to identify individuals at higher risk. Promoting a faster walking pace as a daily activity may effectively mitigate the burden of CAD.
PubMed: 38665701
DOI: 10.7759/cureus.56926 -
The Cochrane Database of Systematic... Oct 2018Current treatment modalities for cancer have been successful in achieving improved survivorship; however, they come with a number of long-term adverse effects.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Current treatment modalities for cancer have been successful in achieving improved survivorship; however, they come with a number of long-term adverse effects. Accidental falls are a common and clinically significant adverse event in people living with and beyond cancer and rates are higher than in the rest of the population.
OBJECTIVES
To assess the effects of prescribed or provided exercise for reducing accidental falls, and falls risk factors of strength, flexibility and balance, in people living with and beyond cancer.
SEARCH METHODS
We searched the following electronic databases from inception to 10 July 2018, with no restrictions: CENTRAL, MEDLINE, Embase, and seven other databases. We searched clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform (ICTRP) for ongoing trials, and reference lists of reviews and retrieved articles for additional studies.
SELECTION CRITERIA
We included all randomised controlled trials investigating exercise interventions versus no treatment, usual care or non-exercise interventions on falls incidence or falls risk factors in adults living with and beyond cancer (18 years of age or older at diagnosis). We excluded cross-over studies and studies in acute or inpatient hospice care.
DATA COLLECTION AND ANALYSIS
At least two review authors independently completed data extraction for included papers. We used Covidence software to manage screening, data collection and extraction. We assessed evidence using GRADE and presented results in a 'Summary of findings' table.
MAIN RESULTS
Eleven studies (835 participants) compared exercise to usual care. No studies compared exercise with no treatment or non-exercise interventions. The quality of the evidence was very low for the primary outcome rates of falls, and very low to low for the secondary outcomes. We downgraded the evidence due to study limitations (risk of bias), and issues of imprecision due to small sample sizes, inconsistency and indirectness. All studies were at high risk of bias for blinding of participants and personnel due to inability to blind participants to an exercise intervention. Risk of bias was generally low or unclear for other categories.There was generally little information on the important outcomes comparing exercise to usual care.Rates of falls and number of fallers: one study (223 participants) measured accidental falls, but reported neither the rate of falls or the number of fallers; there was no difference in the number of falls between exercise and usual care (very low-quality evidence).Strength: 10 studies (813 participants) reported on strength outcomes. Two analyses favoured exercise over usual care: quadriceps strength (2 studies, 72 participants; mean difference (MD) 8.99 kg, 95% confidence interval (CI) 1.29 to 16.70; low-quality evidence), and leg press (4 studies, 388 participants; MD 21.1 kg, 95% CI 8.47 to 33.74; low-quality evidence). In one analysis of the Sit-to-Stand Test, there was no difference between exercise and usual care (4 studies, 214 participants; standardised mean difference (SMD) -0.45, 95% CI -1.05 to 0.14; very low-quality evidence).Flexibility: one study (21 participants) reported on flexibility for Sit-and-Reach Distance (MD 2.05 cm, 95% CI 0.59 to 3.51; very low-quality evidence).Balance: five studies (350 participants) measured three different balance outcomes. Two analyses favoured exercise over usual care: postural balance (4 studies, 127 participants; standardised mean difference (SMD) 0.44, 95% CI 0.08 to 0.79; very low-quality evidence), and Backward Walk Test (2 studies, 280 participants; SMD -0.24, 95% CI -0.48 to -0.01; low-quality evidence). There was no difference between exercise and usual care for the Timed Up-and-Go Test (1 study, 15 participants; MD -0.35 seconds, 95% CI -1.47 to 0.77; low-quality evidence).Number of people sustaining a fall-related fracture: the quality of the evidence for exercise reducing fall-related fractures was very low.Adverse events: a single study (223 participants) noted some temporary muscle soreness on initiation of exercise or when there was an increase in the weight lifted. As no occurrence data were reported, we could not assess this variable further. No studies reported musculoskeletal injury. Analysis indicated that there was very low-quality evidence that exercise did not increase fatigue.
AUTHORS' CONCLUSIONS
There is a paucity of evidence for exercise training to reduce fall rates in people living with and beyond cancer. Exercise training may improve strength, flexibility and balance for people in this population, but the evidence is very low quality.
Topics: Accidental Falls; Cancer Survivors; Exercise; Humans; Muscle Strength; Neoplasms; Postural Balance; Randomized Controlled Trials as Topic; Range of Motion, Articular
PubMed: 30320433
DOI: 10.1002/14651858.CD011687.pub2 -
Journal of the American Medical... 2012The US Agency for Healthcare Research and Quality funded an evidence report to address seven questions on multiple aspects of the effectiveness of medication management... (Review)
Review
OBJECTIVE
The US Agency for Healthcare Research and Quality funded an evidence report to address seven questions on multiple aspects of the effectiveness of medication management information technology (MMIT) and its components (prescribing, order communication, dispensing, administering, and monitoring).
MATERIALS AND METHODS
Medline and 11 other databases without language or date limitations to mid-2010. Randomized controlled trials (RCTs) assessing integrated MMIT were selected by two independent reviewers. Reviewers assessed study quality and extracted data. Senior staff checked accuracy.
RESULTS
Most of the 87 RCTs focused on clinical decision support and computerized provider order entry systems, were performed in hospitals and clinics, included primarily physicians and sometimes nurses but not other health professionals, and studied process changes related to prescribing and monitoring medication. Processes of care improved for prescribing and monitoring mostly in hospital settings, but the few studies measuring clinical outcomes showed small or no improvements. Studies were performed most frequently in the USA (n=63), Europe (n=16), and Canada (n=6).
DISCUSSION
Many studies had limited description of systems, installations, institutions, and targets of the intervention. Problems with methods and analyses were also found. Few studies addressed order communication, dispensing, or administering, non-physician prescribers or pharmacists and their MMIT tools, or patients and caregivers. Other study methods are also needed to completely understand the effects of MMIT.
CONCLUSIONS
Almost half of MMIT interventions improved the process of care, but few studies measured clinical outcomes. This large body of literature, although instructive, is not uniformly distributed across settings, people, medication phases, or outcomes.
Topics: Decision Support Systems, Clinical; Humans; Medical Informatics; Medical Order Entry Systems; Medication Therapy Management; Outcome and Process Assessment, Health Care; Randomized Controlled Trials as Topic; Systems Integration
PubMed: 21852412
DOI: 10.1136/amiajnl-2011-000304 -
Health Expectations : An International... Oct 2021Caregivers often undertake medication management for people living with dementia without formal training. There is a need to evaluate caregiver medication management... (Review)
Review
BACKGROUND
Caregivers often undertake medication management for people living with dementia without formal training. There is a need to evaluate caregiver medication management practices for people living with dementia to identify and address the key issues that contribute to caregiver burden.
OBJECTIVES
This study aimed to identify and summarize approaches that evaluate medication management for caregivers of people living with dementia and appraise caregiver's involvement in aspects of medication management.
SEARCH STRATEGY
A systematic search was undertaken in five databases: Medline, Embase, PsycINFO, Scopus and International Pharmaceutical Abstracts. Studies written in English that contained tools and surveys that evaluated aspects of medication management for caregivers of PWD were included.
RESULTS
A total of 10 studies were included. Medication selection was assessed in six studies, supply and monitoring/review was captured in seven studies, with administration assessed in nine studies. Caregivers were commonly involved in decision-making for medication changes (77.1%-86.8%) and in the ordering (55.9%-86.0%) and collection (87.0%-92.4%) of medications. Reported caregiver involvement in medication administration showed a wide range (44%-94.7%) between the studies. Challenges in administration were commonly related to polypharmacy and dosage regimen complexity.
CONCLUSIONS
Current tools capture specific aspects of medication management, with medication administration the most evaluated aspect of medication management. Future research is needed to develop a tool to holistically evaluate the complexities of medication management for caregivers of people living with dementia to minimize adverse events at transitions of care.
PUBLIC CONTRIBUTION
From the authors' previous research, caregivers highlighted the need to address key issues in medication management for people living with dementia.
Topics: Caregivers; Dementia; Humans; Medication Therapy Management; Polypharmacy; Surveys and Questionnaires
PubMed: 34289214
DOI: 10.1111/hex.13318 -
Journal of Vascular Surgery. Venous and... Jan 2017Duplex ultrasound (DUS) is performed by the majority of physicians after endovenous ablation (EVA) of the great saphenous vein to screen for endovenous heat-induced... (Review)
Review
BACKGROUND
Duplex ultrasound (DUS) is performed by the majority of physicians after endovenous ablation (EVA) of the great saphenous vein to screen for endovenous heat-induced thrombosis (EHIT) at the saphenofemoral junction extending into the femoral vein. Several factors should be considered in assessing the value and cost of routine DUS after EVA: the natural history of EHIT is poorly defined, the incidence appears low, and the majority are both asymptomatic and Kabnick type 2 (projecting only slightly into the femoral vein). Moreover, routine postoperative DUS screening is not recommended for procedures with higher thromboembolic complication rates, such as joint replacement or bariatric surgery.
METHODS
Data on the incidence of death, EHIT, and deep venous thrombosis (DVT) were derived from a systematic review after either radiofrequency or laser ablation of the saphenous vein from two sources: (1) EVA randomized controlled trials (N = 1482) and a (2) large (>150 patients) EVA case series (N = 12,363). The number of tests required to detect one case of EHIT/DVT was calculated from the incidence in the EVA and case series data bases; the cost to detect a case was estimated using the 2013 Medicare global fee schedule for the cost of a unilateral venous DUS study.
RESULTS
This analysis included 13,845 EVA-treated limbs. There were no reported deaths. The incidence of DUS-detected venous thromboembolism after EVA is 0.7%. The cost of unilateral DUS according to the Medicare global reimbursement fee for office-based studies is $106.71. The total cost of performing DUS in this study population is estimated to be at least $1,477,399, and the amount of dollars expended per venous thromboembolism detected is $14,667.
CONCLUSIONS
The current Society for Vascular Surgery/American Venous Forum recommendation is to perform screening DUS after EVA within 72 hours postoperatively with a weak level of recommendation (grade 2C). The current analysis demonstrates a low incidence of EHIT/DVT with a corresponding high cost to detect each case with routine DUS screening. These data combined with the unclear clinical significance of EHIT suggest that the policy of universal post-EVA screening should be revised in the near future.
Topics: Catheter Ablation; Costs and Cost Analysis; Health Care Costs; Humans; Postoperative Care; Ultrasonography, Doppler, Duplex; Venous Thrombosis
PubMed: 27987602
DOI: 10.1016/j.jvsv.2016.07.001