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PharmacoEconomics Nov 2020Heart failure presents a growing clinical and economic burden in the USA. Robust cost data on the burden of illness are critical to inform economic evaluations of new... (Review)
Review
BACKGROUND
Heart failure presents a growing clinical and economic burden in the USA. Robust cost data on the burden of illness are critical to inform economic evaluations of new therapeutic interventions.
OBJECTIVES
This systematic literature review of heart failure-related costs in the USA aimed to assess the quality of the published evidence and provide a narrative synthesis of current data.
METHODS
Four electronic databases (MEDLINE, EMBASE, EconLit, and the Centre for Reviews and Dissemination York Database, including the NHS Economic Evaluation Database and Health Technology Assessment Database) were searched for journal articles published between January 2014 and March 2020. The review, registered with PROSPERO (CRD42019134201), was restricted to cost-of-illness studies in adults with heart failure events in the USA.
RESULTS
Eighty-seven studies were included, 41 of which allowed a comparison of cost estimates across studies. The annual median total medical costs for heart failure care were estimated at $24,383 per patient, with heart failure-specific hospitalizations driving costs (median $15,879 per patient). Analyses of subgroups revealed that heart failure-related costs are highly sensitive to individual patient characteristics (such as the presence of comorbidities and age) with large variations even within a subgroup. Additionally, differences in study design and a lack of standardized reporting limited the ability to compare cost estimates. The finding that costs are higher for patients with heart failure with reduced ejection fraction compared with patients with preserved ejection fraction highlights the need for differentiating among different heart failure types.
CONCLUSIONS
The review underpins the conclusion drawn in earlier reviews, namely that hospitalization costs are the key driver of heart failure-related costs. Analyses of subgroups provide a clearer understanding of sources of heterogeneity in cost data. While current cost estimates provide useful indications of economic burden, understanding the nuances of the data is critical to support its application.
Topics: Aged; Aged, 80 and over; Cost-Benefit Analysis; Heart Failure; Humans; Medicare; Middle Aged; Technology Assessment, Biomedical; United States
PubMed: 32812149
DOI: 10.1007/s40273-020-00952-0 -
JMIR Medical Informatics May 2014The Health Information Technology for Economic and Clinical Health Act (HITECH) allocated $19.2 billion to incentivize adoption of the electronic health record (EHR).... (Review)
Review
BACKGROUND
The Health Information Technology for Economic and Clinical Health Act (HITECH) allocated $19.2 billion to incentivize adoption of the electronic health record (EHR). Since 2009, Meaningful Use Criteria have dominated information technology (IT) strategy. Health care organizations have struggled to meet expectations and avoid penalties to reimbursements from the Center for Medicare and Medicaid Services (CMS). Organizational theories attempt to explain factors that influence organizational change, and many theories address changes in organizational strategy. However, due to the complexities of the health care industry, existing organizational theories fall short of demonstrating association with significant health care IT implementations. There is no organizational theory for health care that identifies, groups, and analyzes both internal and external factors of influence for large health care IT implementations like adoption of the EHR.
OBJECTIVE
The purpose of this systematic review is to identify a full-spectrum of both internal organizational and external environmental factors associated with the adoption of health information technology (HIT), specifically the EHR. The result is a conceptual model that is commensurate with the complexity of with the health care sector.
METHODS
We performed a systematic literature search in PubMed (restricted to English), EBSCO Host, and Google Scholar for both empirical studies and theory-based writing from 1993-2013 that demonstrated association between influential factors and three modes of HIT: EHR, electronic medical record (EMR), and computerized provider order entry (CPOE). We also looked at published books on organizational theories. We made notes and noted trends on adoption factors. These factors were grouped as adoption factors associated with various versions of EHR adoption.
RESULTS
The resulting conceptual model summarizes the diversity of independent variables (IVs) and dependent variables (DVs) used in articles, editorials, books, as well as quantitative and qualitative studies (n=83). As of 2009, only 16.30% (815/4999) of nonfederal, acute-care hospitals had adopted a fully interoperable EHR. From the 83 articles reviewed in this study, 16/83 (19%) identified internal organizational factors and 9/83 (11%) identified external environmental factors associated with adoption of the EHR, EMR, or CPOE. The conceptual model for EHR adoption associates each variable with the work that identified it.
CONCLUSIONS
Commonalities exist in the literature for internal organizational and external environmental factors associated with the adoption of the EHR and/or CPOE. The conceptual model for EHR adoption associates internal and external factors, specific to the health care industry, associated with adoption of the EHR. It becomes apparent that these factors have some level of association, but the association is not consistently calculated individually or in combination. To better understand effective adoption strategies, empirical studies should be performed from this conceptual model to quantify the positive or negative effect of each factor.
PubMed: 25599673
DOI: 10.2196/medinform.3106 -
Journal of the American Heart... Apr 2014Control of blood pressure (BP) remains a major challenge in primary care. Innovative interventions to improve BP control are therefore needed. By updating and combining... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Control of blood pressure (BP) remains a major challenge in primary care. Innovative interventions to improve BP control are therefore needed. By updating and combining data from 2 previous systematic reviews, we assess the effect of pharmacist interventions on BP and identify potential determinants of heterogeneity.
METHODS AND RESULTS
Randomized controlled trials (RCTs) assessing the effect of pharmacist interventions on BP among outpatients with or without diabetes were identified from MEDLINE, EMBASE, CINAHL, and CENTRAL databases. Weighted mean differences in BP were estimated using random effect models. Prediction intervals (PI) were computed to better express uncertainties in the effect estimates. Thirty-nine RCTs were included with 14 224 patients. Pharmacist interventions mainly included patient education, feedback to physician, and medication management. Compared with usual care, pharmacist interventions showed greater reduction in systolic BP (-7.6 mm Hg, 95% CI: -9.0 to -6.3; I(2)=67%) and diastolic BP (-3.9 mm Hg, 95% CI: -5.1 to -2.8; I(2)=83%). The 95% PI ranged from -13.9 to -1.4 mm Hg for systolic BP and from -9.9 to +2.0 mm Hg for diastolic BP. The effect tended to be larger if the intervention was led by the pharmacist and was done at least monthly.
CONCLUSIONS
Pharmacist interventions - alone or in collaboration with other healthcare professionals - improved BP management. Nevertheless, pharmacist interventions had differential effects on BP, from very large to modest or no effect; and determinants of heterogeneity could not be identified. Determining the most efficient, cost-effective, and least time-consuming intervention should be addressed with further research.
Topics: Antihypertensive Agents; Blood Pressure; Community Pharmacy Services; Cooperative Behavior; Health Knowledge, Attitudes, Practice; Humans; Hypertension; Interdisciplinary Communication; Medication Therapy Management; Patient Care Team; Patient Education as Topic; Pharmacists; Professional Role; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 24721801
DOI: 10.1161/JAHA.113.000718 -
Journal of Clinical Medicine Jul 2022Venous thromboembolism (VTE) is a serious complication that can occur during and after postoperative treatment, including in treatment after orthopedic surgery. The... (Review)
Review
Venous thromboembolism (VTE) is a serious complication that can occur during and after postoperative treatment, including in treatment after orthopedic surgery. The current guidelines for VTE prophylaxis in postoperative patients recommend the use of LMWHs, one of which is enoxaparin. Another recommendation for use in pharmacological VTE prophylaxis is rivaroxaban, which has better efficacy than enoxaparin but a higher bleeding risk. The aim of this systematic review is to provide an update on the profile of rivaroxaban for VTE prophylaxis after orthopedic surgery. PubMed, SCOPUS, EMBASE, and EBSCOhost were searched up until May 2022. The outcome sought was efficacy and safety, described by the incidence of VTE and incidence of bleeding, respectively. Five randomized controlled trials (RCT) were finally included. Rivaroxaban was confirmed to have better efficacy by significantly reducing the risk of VTE and all-cause mortality (RR = 0.38; 95% CI = 0.27-0.54) compared to enoxaparin. However, regarding the safety variable, no significant difference was found between the incidence of major bleeding in rivaroxaban and enoxaparin (RR = 0.97; 95% CI = 0.56-1.68). The results of the analysis show that rivaroxaban has better efficacy than enoxaparin but the same safety profile, so when used, the bleeding of patients should still be monitored.
PubMed: 35887834
DOI: 10.3390/jcm11144070 -
BMC Health Services Research May 2023Medically uninsured groups, many of them migrants, reportedly delay using healthcare services due to costs and often face preventable health consequences. This...
BACKGROUND
Medically uninsured groups, many of them migrants, reportedly delay using healthcare services due to costs and often face preventable health consequences. This systematic review sought to assess quantitative evidence on health outcomes, health services use, and health care costs among uninsured migrant populations in Canada.
METHODS
OVID MEDLINE, Embase, Global Health, EconLit, and grey literature were searched to identify relevant literature published up until March 2021. The Cochrane Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool was used to assess the quality of studies.
RESULTS
Ten studies were included. Data showed that there are differences among insured and uninsured groups in reported health outcomes and health services use. No quantitative studies on economic costs were captured.
CONCLUSIONS
Our findings indicate a need to review policies regarding accessible and affordable health care for migrants. Increasing funding to community health centers may improve service utilization and health outcomes among this population.
Topics: Aged; Humans; Transients and Migrants; Medically Uninsured; Facilities and Services Utilization; National Health Programs; Health Care Costs; Outcome Assessment, Health Care
PubMed: 37138351
DOI: 10.1186/s12913-023-09417-4 -
Annals of the American Thoracic Society Mar 2014Approximately 20% of patients hospitalized for COPD exacerbations in the United States will be readmitted within 30 days. The Centers for Medicare and Medicaid Services... (Review)
Review
RATIONALE
Approximately 20% of patients hospitalized for COPD exacerbations in the United States will be readmitted within 30 days. The Centers for Medicare and Medicaid Services has recently proposed to revise the Hospital Readmissions Reduction Program to financially penalize hospitals with high all-cause 30-day rehospitalization rates after a hospitalization for COPD exacerbation on or after October 1, 2014.
OBJECTIVES
To report the results of a systematic review of randomized clinical trials evaluating interventions to reduce the rehospitalizations after COPD exacerbations.
METHODS
Multiple electronic databases were systematically searched to identify relevant studies published between January 1966 and June 2013. Titles, abstracts, and, subsequently, full-text articles were assessed for eligibility. Each study was appraised using predefined criteria.
MEASUREMENTS AND MAIN RESULTS
Among 913 titles and abstracts screened, 5 studies (1,393 participants) met eligibility criteria. All studies had a primary outcome of rehospitalization at 6 or 12 months. No study examined 30-day rehospitalization as the primary outcome. Each study tested a different set of interventions. Two studies (one conducted in Canada and one conducted in Spain and Belgium) showed a decrease in all-cause rehospitalization over 12 months in the intervention group versus comparator group (mean number of hospitalizations per patient, 1.0 vs. 1.8; P = 0.01; percent hospitalized, 45 vs. 67%; P = 0.028; respectively). The only study conducted in the United States found a greater than twofold higher risk of mortality in the intervention group (17 vs. 7%, P = 0.003) but no significant difference in rehospitalizations. It was unclear which set of interventions was effective or harmful.
CONCLUSIONS
The evidence base is inadequate to recommend specific interventions to reduce rehospitalizations in this population and does not justify penalizing hospitals for high 30-day rehospitalization rates after COPD exacerbations.
Topics: Aged; Clinical Trials as Topic; Female; Hospitalization; Humans; Male; Pulmonary Disease, Chronic Obstructive
PubMed: 24423379
DOI: 10.1513/AnnalsATS.201308-254OC -
Journal of Neurology Jun 2022Vagus nerve stimulation (VNS) Therapy® is an adjunctive neurostimulation treatment for people with drug-resistant epilepsy (DRE) who are unwilling to undergo resective... (Meta-Analysis)
Meta-Analysis Review
Vagus nerve stimulation (VNS) Therapy® is an adjunctive neurostimulation treatment for people with drug-resistant epilepsy (DRE) who are unwilling to undergo resective surgery, have had unsuccessful surgery or are unsuitable for surgery. A systematic review and meta-analysis were conducted to determine the treatment effects of VNS Therapy as an adjunct to anti-seizure medications (ASMs) for the management of adults with DRE. A literature search was performed in August 2020 of the Medline®, Medline® Epub Ahead of Print, Embase, and the Cochrane library databases. Outcomes examined included reduction in seizure frequency, seizure freedom, ASM load, discontinuations, and serious adverse events (SAEs). Comparators included best medical practice, ASMs, low-stimulation or sham VNS Therapy. Four RCTs and six comparative observational studies were identified for inclusion. Against comparators, individuals treated with VNS had a significantly better odds of experiencing a ≥ 50% reduction in seizure frequency (OR: 2.27 [95% CI 1.47, 3.51]; p = 0.0002), a ≥ 75% reduction in seizure frequency (OR: 3.56 [95% CI 1.59, 7.98]; p = 0.002) and a reduced risk for increased ASM load (risk ratio: 0.36 [95% CI 0.21, 0.62]; p = 0.0002). There was no difference in the odds of discontinuation or the rate of SAEs between VNS versus comparators. This meta-analysis demonstrated the benefits of VNS Therapy in people with DRE, which included improvement in seizure frequency without an increase in the rate of SAEs or discontinuations, thereby supporting the consideration of VNS Therapy for people who are not responding to ASMs and those unsuitable or unwilling to undergo surgery.
Topics: Adult; Drug Resistant Epilepsy; Humans; Medication Therapy Management; Seizures; Treatment Outcome; Vagus Nerve Stimulation
PubMed: 35034187
DOI: 10.1007/s00415-022-10967-6 -
Journal of Rehabilitation Research and... 2014The benefits of microprocessor-controlled prosthetic knees (MPKs) have been well established in community ambulators (Medicare Functional Classification Level [MFCL]-3)... (Review)
Review
The benefits of microprocessor-controlled prosthetic knees (MPKs) have been well established in community ambulators (Medicare Functional Classification Level [MFCL]-3) with a transfemoral amputation (TFA). A systematic review of the literature was performed to analyze whether limited community ambulators (MFCL-2) may also benefit from using an MPK in safety, performance-based function and mobility, and perceived function and satisfaction. We searched 10 scientific databases for clinical trials with MPKs and identified six publications with 57 subjects with TFA and MFCL-2 mobility grade. Using the criteria of a Cochrane Review on prosthetic components, we rated methodological quality moderate in four publications and low in two publications. MPK use may significantly reduce uncontrolled falls by up to 80% as well as significantly improve indicators of fall risk. Performance-based outcome measures suggest that persons with MFCL-2 mobility grade may be able to walk about 14% to 25% faster on level ground, be around 20% quicker on uneven surfaces, and descend a slope almost 30% faster when using an MPK. The results of this systematic review suggest that trial fittings may be used to determine whether or not individuals with TFA and MFCL-2 mobility grade benefit from MPK use. Criteria for patient selection and assessment of trial fitting success or failure are proposed.
Topics: Amputees; Humans; Knee Prosthesis; Microcomputers; Patient Selection; Prosthesis Design; Walking
PubMed: 25856664
DOI: 10.1682/JRRD.2014.05.0118 -
PloS One 2017Over 25 years, emergency medicine in the United States has amassed a large evidence base that has been systematically assessed and interpreted through ACEP Clinical... (Review)
Review
INTRODUCTION
Over 25 years, emergency medicine in the United States has amassed a large evidence base that has been systematically assessed and interpreted through ACEP Clinical Policies. While not previously studied in emergency medicine, prior work has shown that nearly half of all recommendations in medical specialty practice guidelines may be based on limited or inconclusive evidence. We sought to describe the proportion of clinical practice guideline recommendations in Emergency Medicine that are based upon expert opinion and low level evidence.
METHODS
Systematic review of clinical practice guidelines (Clinical Policies) published by the American College of Emergency Physicians from January 1990 to January 2016. Standardized data were abstracted from each Clinical Policy including the number and level of recommendations as well as the reported class of evidence. Primary outcomes were the proportion of Level C equivalent recommendations and Class III equivalent evidence. The primary analysis was limited to current Clinical Policies, while secondary analysis included all Clinical Policies.
RESULTS
A total of 54 Clinical Policies including 421 recommendations and 2801 cited references, with an average of 7.8 recommendations and 52 references per guideline were included. Of 19 current Clinical Policies, 13 of 141 (9.2%) recommendations were Level A, 57 (40.4%) Level B, and 71 (50.4%) Level C. Of 845 references in current Clinical Policies, 67 (7.9%) were Class I, 272 (32.3%) Class II, and 506 (59.9%) Class III equivalent. Among all Clinical Policies, 200 (47.5%) recommendations were Level C equivalent, and 1371 (48.9%) of references were Class III equivalent.
CONCLUSIONS
Emergency medicine clinical practice guidelines are largely based on lower classes of evidence and a majority of recommendations are expert opinion based. Emergency medicine appears to suffer from an evidence gap that should be prioritized in the national research agenda and considered by policymakers prior to developing future quality standards.
Topics: Emergency Medicine; Evidence-Based Medicine; Humans; Policy; Practice Guidelines as Topic; Research
PubMed: 28628660
DOI: 10.1371/journal.pone.0178456 -
American Journal of Preventive Medicine Nov 2012Melanoma is the most deadly form of skin cancer and an important public health concern. Given the substantial health burden associated with melanoma, it is important to... (Review)
Review
CONTEXT
Melanoma is the most deadly form of skin cancer and an important public health concern. Given the substantial health burden associated with melanoma, it is important to examine the economic costs associated with its treatment. The purpose of the current study was to systematically review the literature on the direct medical care costs of melanoma.
EVIDENCE ACQUISITION
A systematic review was performed using multiple databases including MEDLINE, Embase, CINAHL, and Econlit. Nineteen articles on the direct medical costs of melanoma were identified.
EVIDENCE SYNTHESIS
Detailed information on the study population, study country/setting, study perspective, costing approach, disease severity (stage), and key study results were abstracted. The overall costs of melanoma were examined as well as per-patient costs, costs by phase of care, stage of diagnosis, and setting/type of care. Among studies examining all stages of melanoma, annual treatment costs ranged from $44.9 million among Medicare patients with existing cases to $932.5 million among newly diagnosed cases across all age groups.
CONCLUSIONS
Melanoma leads to substantial direct medical care costs, with estimates varying widely because of the heterogeneity across studies in terms of the study setting, populations studied, costing approach, and study methods. Melanoma treatment costs varied by phase of care and stage at diagnoses; costs were highest among patients diagnosed with late-stage disease and in the initial and terminal phases of care. Aggregate treatment costs were generally highest in the outpatient/office-based setting; per-patient/per-case treatment costs were highest in the hospital inpatient setting. Given the substantial costs of treating melanoma, public health strategies should include efforts to enhance both primary prevention (reduction of ultraviolet light exposure) and secondary prevention (earlier detection) of melanoma.
Topics: Cost of Illness; Health Care Costs; Hospital Costs; Humans; Melanoma; Neoplasm Staging; Primary Prevention; Secondary Prevention; Skin Neoplasms
PubMed: 23079178
DOI: 10.1016/j.amepre.2012.07.031