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The Cochrane Database of Systematic... Sep 2018This review focuses on non-dispensing services from pharmacists, i.e. pharmacists in community, primary or ambulatory-care settings, to non-hospitalised patients, and is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This review focuses on non-dispensing services from pharmacists, i.e. pharmacists in community, primary or ambulatory-care settings, to non-hospitalised patients, and is an update of a previously-published Cochrane Review.
OBJECTIVES
To examine the effect of pharmacists' non-dispensing services on non-hospitalised patient outcomes.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, two other databases and two trial registers in March 2015, together with reference checking and contact with study authors to identify additional studies. We included non-English language publications. We ran top-up searches in January 2018 and have added potentially eligible studies to 'Studies awaiting classification'.
SELECTION CRITERIA
Randomised trials of pharmacist services compared with the delivery of usual care or equivalent/similar services with the same objective delivered by other health professionals.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures of Cochrane and the Effective Practice and Organisation of Care Group. Two review authors independently checked studies for inclusion, extracted data and assessed risks of bias. We evaluated the overall certainty of evidence using GRADE.
MAIN RESULTS
We included 116 trials comprising 111 trials (39,729 participants) comparing pharmacist interventions with usual care and five trials (2122 participants) comparing pharmacist services with services from other healthcare professionals. Of the 116 trials, 76 were included in meta-analyses. The 40 remaining trials were not included in the meta-analyses because they each reported unique outcome measures which could not be combined. Most trials targeted chronic conditions and were conducted in a range of settings, mostly community pharmacies and hospital outpatient clinics, and were mainly but not exclusively conducted in high-income countries. Most trials had a low risk of reporting bias and about 25%-30% were at high risk of bias for performance, detection, and attrition. Selection bias was unclear for about half of the included studies.Compared with usual care, we are uncertain whether pharmacist services reduce the percentage of patients outside the glycated haemoglobin target range (5 trials, N = 558, odds ratio (OR) 0.29, 95% confidence interval (CI) 0.04 to 2.22; very low-certainty evidence). Pharmacist services may reduce the percentage of patients whose blood pressure is outside the target range (18 trials, N = 4107, OR 0.40, 95% CI 0.29 to 0.55; low-certainty evidence) and probably lead to little or no difference in hospital attendance or admissions (14 trials, N = 3631, OR 0.85, 95% CI 0.65 to 1.11; moderate-certainty evidence). Pharmacist services may make little or no difference to adverse drug effects (3 trials, N = 590, OR 1.65, 95% CI 0.84 to 3.24) and may slightly improve physical functioning (7 trials, N = 1329, mean difference (MD) 5.84, 95% CI 1.21 to 10.48; low-certainty evidence). Pharmacist services may make little or no difference to mortality (9 trials, N = 1980, OR 0.79, 95% CI 0.56 to 1.12, low-certaintly evidence).Of the five studies that compared services delivered by pharmacists with other health professionals, no studies evaluated the impact of the intervention on the percentage of patients outside blood pressure or glycated haemoglobin target range, hospital attendance and admission, adverse drug effects, or physical functioning.
AUTHORS' CONCLUSIONS
The results demonstrate that pharmacist services have varying effects on patient outcomes compared with usual care. We found no studies comparing services delivered by pharmacists with other healthcare professionals that evaluated the impact of the intervention on the six main outcome measures. The results need to be interpreted cautiously because there was major heterogeneity in study populations, types of interventions delivered and reported outcomes.There was considerable heterogeneity within many of the meta-analyses, as well as considerable variation in the risks of bias.
Topics: Ambulatory Care; Community Pharmacy Services; Delivery of Health Care; Drug-Related Side Effects and Adverse Reactions; Glycated Hemoglobin; Hospitalization; Humans; Hypertension; Medication Therapy Management; Mortality; Outpatients; Pharmaceutical Services; Pharmacy Service, Hospital; Physical Fitness; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 30178872
DOI: 10.1002/14651858.CD013102 -
Health Affairs (Project Hope) Jun 2023During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing...
During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.
Topics: Aged; Humans; United States; Medicare; Value-Based Purchasing; Medicaid; Quality of Health Care
PubMed: 37276480
DOI: 10.1377/hlthaff.2022.01455 -
Journal of Vascular Surgery Jan 2016Acute limb ischemia (ALI) is one of the most common vascular emergencies, with high risk for limb loss if it is not treated expediently. Endovascular therapy is less... (Review)
Review
Acute limb ischemia (ALI) is one of the most common vascular emergencies, with high risk for limb loss if it is not treated expediently. Endovascular therapy is less invasive and used increasingly because of patient factors that disfavor open surgery despite limited quality data to support its safety and efficacy. This evidence summary reviews literature from 1990 to 2014, comparing contemporary surgical and endovascular revascularization. Systematic review was performed with emphasis on acuity of presentation, study design, revascularization techniques, limb salvage and mortality rates, and complications. There were 2999 articles identified and 563 abstracts reviewed; 68 articles were reviewed fully and 26 critically appraised. Limb salvage, amputation-free survival, overall survival and mortality, and treatment complications were elucidated, including Medicare outcomes data. Risk factors for amputation and mortality were identified. Surgical or endovascular revascularization for ALI is achievable with acceptable limb salvage and amputation rates, which are not markedly different between the two modalities in the short term. Endovascular therapy and surgery are complementary rather than competing strategies for ALI. Further good-quality clinical trial data are needed to define longer term outcomes.
Topics: Acute Disease; Amputation, Surgical; Disease-Free Survival; Endovascular Procedures; Humans; Ischemia; Limb Salvage; Lower Extremity; Patient Selection; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Vascular Surgical Procedures
PubMed: 26603542
DOI: 10.1016/j.jvs.2015.09.055 -
Journal of Managed Care & Specialty... Nov 2016Diabetes care is associated with a considerable burden to the health care system in the United States, and measuring the quality of health care is an important... (Review)
Review
BACKGROUND
Diabetes care is associated with a considerable burden to the health care system in the United States, and measuring the quality of health care is an important development goal of the Department of Health and Human Services and the Centers for Medicare & Medicaid Services. Diabetes is a priority disease within the National Quality Strategy and should therefore remain a focus in the measurement of health care quality. Despite the importance of measuring quality in diabetes care management, no quality measure is currently associated with adherence to insulin treatment, and measuring adherence to insulin is known to be complicated.
OBJECTIVES
To (a) identify methods to measure insulin adherence in patients with diabetes and (b) evaluate whether identified methods could be considered for testing as a quality measure.
METHODS
Systematic searches were conducted in the online electronic databases Embase, MEDLINE, and the Cochrane Library, supplemented with additional manual searches to identify publications on insulin adherence from the year 2000 onward. Identified citations were screened for relevance against predefined eligibility criteria, and methods to measure adherence to insulin were extracted from relevant studies into data extraction tables. Methods were critiqued on the feasibility for consideration as a quality measure.
RESULTS
Seventy-eight publications met the inclusion criteria and were reviewed. Included studies reported various indirect methods to measure adherence to insulin, using prescription claims or self-report questionnaires. Commonly reported methods included the (adjusted) medication possession ratio, proportion of days covered, persistence, daily average consumption, and the Morisky Medication Adherence Scale. All types of identified methods were associated with measuring challenges varying from accuracy of estimated adherence, complexity of data collection, absence of validated threshold for good adherence, and reliability of adherence outcomes.
CONCLUSIONS
Without additional research, none of the identified methods are appropriate for use as a quality measure for insulin adherence. We suggest patient involvement in future research and additional quality measure development.
DISCLOSURES
Novo Nordisk paid DRG Abacus to complete the systematic review and manuscript and was involved in the study design, interpretation of data, and decision to publish the findings of the systematic review. Kroes and Webb report personal fees from Novo Nordisk during the conduct of the study and personal fees from DRG Abacus, outside of the submitted work. Webb is employed by DRG Abacus, and Kroes was employed by DRG Abacus at the time of this study. Wisniewski is an employee of Novo Nordisk, which funded the systematic review reported in this article, and also owns stocks in Novo Nordisk. Stolpe has nothing to disclose. Study concept and design were contributed by Kroes, Webb, and Wisniewski, with assistance from Stolpe. Webb took the lead in data collection, along with Kroes, and data interpretation was performed by all the authors. The manuscript was written by Kroes, Webb, and Wisniewski, with assistance from Stolpe, and revised by Kroes, Stolpe, Wisniewski, and Webb.
Topics: Databases, Factual; Diabetes Mellitus; Humans; Insulin; Medication Adherence; Quality of Health Care; United States
PubMed: 27783551
DOI: 10.18553/jmcp.2016.22.11.1224 -
Medical Care Jun 2013Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system. (Review)
Review
BACKGROUND
Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system.
OBJECTIVE
To compare rates of overuse in different health care systems and examine whether certain systems of care or insurers have lower rates of overuse of health care services.
DATA SOURCES
Articles published in MEDLINE between 1978, the year of publication of the first framework to measure quality, and June 21, 2012.
STUDY SELECTION
Included studies compared rates of overuse of procedures, diagnostic tests, or medications in at least 2 systems of care.
DATA EXTRACTION
Four reviewers screened titles; 2 reviewers screened abstracts and full articles and extracted data.
RESULTS
We identified 7 studies which compared rates of overuse of 5 services across multiple different health care settings. National rates of inappropriate coronary angiography were similar in Medicare HMOs and Medicare FFS (13% vs. 13%, P=0.33) and in a state-based study comparing 15 hospitals in New York and 4 hospitals in a Massachusetts-managed care plan (4% vs. 6%, P>0.1). Rates of carotid endarterectomy in New York State were similar in Medicare HMOs and Medicare FFS plans (8.4% vs. 8.6%, P=0.55) but nonrecommended use of antibiotics for the treatment of upper respiratory infection was higher in a managed care organization than a FFS private plan (31% vs. 21%, P=0.02). Rates of inappropriate myocardial perfusion imaging were similar in VA and private settings (22% vs. 16.6%, P=0.24), but rates of inappropriate surveillance endoscopy in the management of gastric ulcers were higher in the VA compared with private settings (37.4% vs. 20.4%-23.3%, P<0.0001).
CONCLUSIONS
The available evidence is limited but there is no consistent evidence that any 1 system of care has been more effective at minimizing the overuse of health care services. More research is necessary to inform current health care reform efforts directed at reducing overuse.
Topics: Delivery of Health Care; Fee-for-Service Plans; Health Care Reform; Health Maintenance Organizations; Health Services Misuse; Humans; Medicare; United States; United States Department of Veterans Affairs
PubMed: 23552430
DOI: 10.1097/MLR.0b013e31828dbafe -
Journal of the American Medical... Oct 2022Home health care agencies (HHAs) are skilled care providers for Medicare home health beneficiaries in the United States. Rural HHAs face different challenges from their... (Review)
Review
OBJECTIVE
Home health care agencies (HHAs) are skilled care providers for Medicare home health beneficiaries in the United States. Rural HHAs face different challenges from their urban counterparts in delivering care (eg, longer distances to travel to patient homes leading to higher fuel/travel costs and fewer number of visits in a day, impacting the quality of home health care for rural beneficiaries). We review evidence on differences in care outcomes provided by urban and rural HHAs.
DESIGN
Systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using the Newcastle-Ottawa Scale (NOS) for quality appraisal.
SETTING
Care provided by urban and rural HHAs.
METHODS
We conducted a systematic search for English-language peer-reviewed articles after 2010 on differences in urban and rural care provided by U.S. HHAs. We screened 876 studies, conducted full-text abstraction and NOS quality review on 36 articles and excluded 2 for poor study quality.
RESULTS
Twelve studies were included; 7 focused on patient-level analyses and 5 were HHA-level. Nine studies were cross-sectional and 3 used cohorts. Urban and rural differences were measured primarily using a binary variable. All studies controlled for agency-level characteristics, and two-thirds also controlled for patient characteristics. Rural beneficiaries, compared with urban, had lower home health care utilization (4 of 5 studies) and fewer visits for physical therapy and/or rehabilitation (3 of 5 studies). Rural agencies had lower quality of HHA services (3 of 4 studies). Rural patients, compared with urban, visited the emergency room more often (2 of 2 studies) and were more likely to be hospitalized (2 of 2 studies), whereas urban patients with heart failure were more likely to have 30-day preventable hospitalizations (1 study).
CONCLUSION AND IMPLICATIONS
This review highlights similar urban/rural disparities in home health care quality and utilization as identified in previous decades. Variables used to measure the access to and quality of care by HHAs varied, so consensus was limited. Articles that used more granular measures of rurality (rather than binary measures) revealed additional differences. These findings point to the need for consistent and refined measures of rurality in studies examining urban and rural differences in care from HHAs.
Topics: Aged; Home Care Agencies; Home Care Services; Hospitalization; Humans; Medicare; Rural Population; United States
PubMed: 36108785
DOI: 10.1016/j.jamda.2022.08.011 -
The British Journal of Surgery Jun 2013Any possible long-term benefit from endovascular (EVAR) versus open surgical repair for abdominal aortic aneurysm (AAA) remains unproven. Long-term data from the Open... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Any possible long-term benefit from endovascular (EVAR) versus open surgical repair for abdominal aortic aneurysm (AAA) remains unproven. Long-term data from the Open Versus Endovascular Repair (OVER) trial add to the debate regarding long-term all-cause and aneurysm-related mortality. The aim of this study was to investigate 30-day and long-term mortality, reintervention, rupture and morbidity after EVAR and open repair for AAA in a systematic review.
METHODS
Standard PRISMA guidelines were followed. Random-effects Mantel-Haenszel meta-analysis was performed to evaluate mortality and morbidity outcomes.
RESULTS
The existing published randomized trials, together with information from Medicare and SwedVasc databases, were included in a meta-analysis. This included 25 078 patients undergoing EVAR and 27 142 undergoing open repair for AAA. Patients who had EVAR had a significantly lower 30-day or in-hospital mortality rate (1·3 per cent versus 4·7 per cent for open repair; odds ratio (OR) 0·36, 95 per cent confidence interval 0·21 to 0·61; P < 0·001). By 2-year follow-up there was no difference in all-cause mortality (14·3 versus 15·2 per cent; OR 0·87, 0·72 to 1·06; P = 0·17), which was maintained after at least 4 years of follow-up (34·7 versus 33·8 per cent; OR 1·11, 0·91 to 1·35; P = 0·30). There was no significant difference in aneurysm-related mortality by 2 years or longer follow-up. A significantly higher proportion of patients undergoing EVAR required reintervention (P = 0·003) and suffered aneurysm rupture (P < 0·001).
CONCLUSION
There is no long-term survival benefit for patients who have EVAR compared with open repair for AAA. There are also significantly higher risks of reintervention and aneurysm rupture after EVAR.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Endovascular Procedures; Humans; Postoperative Complications; Randomized Controlled Trials as Topic; Reoperation; Survival Analysis; Treatment Outcome
PubMed: 23475697
DOI: 10.1002/bjs.9101 -
Journal of the American Geriatrics... May 2010In the months before and years since Medicare Part D's implementation in January 2006, many have been concerned with beneficiaries' ability to benefit from the complex... (Review)
Review
In the months before and years since Medicare Part D's implementation in January 2006, many have been concerned with beneficiaries' ability to benefit from the complex program. A systematic review of published Medline and gray literature from January 1, 2005, to August 20, 2009, was undertaken to evaluate Medicare beneficiaries' knowledge about Part D and how this knowledge informed decisions regarding enrollment and plan choice. Thirty articles that reported original results describing seniors' knowledge of the Part D benefit, decision to enroll, or selection of plans; results from patient surveys addressing these issues; or results that analyzed enrollment data or plan selection patterns were included. Of these 30 articles, 10 described beneficiaries' knowledge, 12 described enrollment and plan choices, and eight described knowledge and choice. Across studies and years, beneficiaries' knowledge of the Part D program and benefit structure and design was poor, particularly with regard to the coverage gap and the low-income subsidy. Beneficiaries had great difficulty choosing the lowest-cost Part D plans and were disinclined to switch plans to improve their benefits. Knowledge deficits, enrollment problems, and plan choice difficulties were most pronounced during Part D implementation in early 2006 but persisted in subsequent years of the benefit. Beneficiaries' knowledge and choices should be monitored on an ongoing basis to inform potential changes to the Part D program.
Topics: Aged; Health Knowledge, Attitudes, Practice; Humans; Medicare Part D; Middle Aged; United States
PubMed: 20406313
DOI: 10.1111/j.1532-5415.2010.02812.x -
Journal of the American Heart... Oct 2017Time in the therapeutic range (TTR) is associated with the effectiveness and safety of vitamin K antagonist (VKA) therapy. To optimize prescribing of VKA, we aimed to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Time in the therapeutic range (TTR) is associated with the effectiveness and safety of vitamin K antagonist (VKA) therapy. To optimize prescribing of VKA, we aimed to develop and validate a prediction model for TTR in older adults taking VKA for nonvalvular atrial fibrillation and venous thromboembolism.
METHODS AND RESULTS
The study cohort comprised patients aged ≥65 years who were taking VKA for atrial fibrillation or venous thromboembolism and who were identified in the 2 US electronic health record databases linked with Medicare claims data from 2007 through 2014. With the predictors identified from a systematic review and clinical knowledge, we built a prediction model for TTR, using one electronic health record system as the training set and the other as the validation set. We compared the performance of the new models to that of a published prediction score for TTR, SAMe-TTR. Based on 1663 patients in the training set and 1181 in the validation set, our optimized score included 42 variables and the simplified model included 7 variables, abbreviated as PROSPER (Pneumonia, Renal dysfunction, Oozing blood [prior bleeding], Staying in hospital ≥7 days, Pain medication use, no Enhanced [structured] anticoagulation services, Rx for antibiotics). The PROSPER score outperformed SAMe-TTR when predicting both TTR ≥70% (area under the receiver operating characteristic curve 0.67 versus 0.55) and the thromboembolic and bleeding outcomes (area under the receiver operating characteristic curve 0.62 versus 0.52).
CONCLUSIONS
Our geriatric TTR score can be used as a clinical decision aid to select appropriate candidates to receive VKA therapy and as a research tool to address confounding and treatment effect heterogeneity by anticoagulation quality.
Topics: Age Factors; Aged; Analgesics; Anti-Bacterial Agents; Anticoagulants; Area Under Curve; Atrial Fibrillation; Blood Coagulation; Clinical Decision-Making; Databases, Factual; Decision Support Techniques; Drug Monitoring; Electronic Health Records; Female; Hemorrhage; Humans; International Normalized Ratio; Length of Stay; Male; Patient Selection; Predictive Value of Tests; Quality Control; Quality Indicators, Health Care; ROC Curve; Reproducibility of Results; Risk Factors; Time Factors; Treatment Outcome; Venous Thromboembolism
PubMed: 28982676
DOI: 10.1161/JAHA.117.006814