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1.
Linus Aronsson Daniel Ansari Bodil Andersson Ulf Persson Adam Fridhammar Roland Andersson 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2018,20(12):1206-1214
Background
Branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) presents a clinical conundrum. Rigorous long-term surveillance or surgical resection is recommended. The economic consequences of the management have not been fully investigated.Methods
A Markov decision model compared 4 strategies for low-risk BD-IPMN: I = upfront total pancreatectomy, II = upfront partial pancreatectomy, III = initial surveillance, IV = watchful waiting. Surveillance was based on the Swedish Guidelines for Pancreatic Cancer. Probabilities and costs were obtained from the participating unit and from the scientific literature. The incremental cost-effectiveness ratios (ICERs) were calculated and sensitivity analyses were performed by varying relevant parameters. Survival was reported in quality-adjusted life-years (QALYs).Results
Strategy III was the most cost-effective strategy with an ICER of €31 682 compared to strategy IV. Strategy I was the most expensive but yielded the best QALY (9.32). Total number of years, annual risk of pancreatic cancer and annual risk of a low-risk BD-IPMN turning into a high-risk lesion had the greatest impact in the model.Conclusions
Initial surveillance seems to be the most cost-effective strategy in the management of low-risk asymptomatic BD-IPMN. However, the possibility of personalized approaches remains to be investigated. 相似文献2.
Yaron Arbel Maria C. Bennell Shaun G. Goodman Harindra C. Wijeysundera 《The Canadian journal of cardiology》2018,34(1):31-37
Background
There is uncertainty regarding the optimal duration of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). Our goal was to evaluate the cost-effectiveness of different durations of DAPT.Methods
We created a probabilistic patient-level Markov microsimulation model to assess the discounted lifetime costs and quality-adjusted life years (QALYs) of short duration (3-6 months: short-duration group) vs standard therapy (12 months: standard-duration group) vs prolonged therapy (30-36 months: long-duration group) in patients undergoing PCI.Results
The majority of patients in the model underwent PCI for stable angina (47.1%) with second-generation drug-eluting stents (62%) and were receiving clopidogrel (83.6%). Short-duration DAPT was the most effective strategy (7.163 ± 1.098 QALYs) compared with standard-duration DAPT (7.161 ± 1.097 QALYs) and long-duration DAPT (7.156 ± 1.097 QALYs). However, the magnitude of these differences was very small. Similarly, the average discounted lifetime cost was CAN$24,859 ± $6533 for short duration, $25,045 ± $6533 for standard duration, and $25,046 ± $6548 for long duration. Thus, in the base-case analysis, short duration was dominant, being more effective and less expensive. However, there was a moderate degree of uncertainty, because short duration was the preferred option in only ～ 55% of simulations at a willingness to pay threshold of $50,000.Conclusions
Based on a stable angina cohort receiving clopidogrel with second-generation stents, a short duration of DAPT was marginally better. However, the differences are minimal, and decisions about duration of therapy should be driven by clinical data, patient risk of adverse events, including bleeding, and cardiovascular events. 相似文献3.
Juan Turnes Raquel Domínguez-Hernández Miguel Ángel Casado 《Gastroenterologia y hepatologia》2017,40(7):433-446
Objective
To evaluate the cost-effectiveness of a strategy based on direct-acting antivirals (DAAs) following the marketing of simeprevir and sofosbuvir (post-DAA) versus a pre-direct-acting antiviral strategy (pre-DAA) in patients with chronic hepatitis C, from the perspective of the Spanish National Health System.Methods
A decision tree combined with a Markov model was used to estimate the direct health costs (€, 2016) and health outcomes (quality-adjusted life years, QALYs) throughout the patient's life, with an annual discount rate of 3%. The sustained virological response, percentage of patients treated or not treated in each strategy, clinical characteristics of the patients, annual likelihood of transition, costs of treating and managing the disease, and utilities were obtained from the literature. The cost-effectiveness analysis was expressed as an incremental cost-effectiveness ratio (incremental cost per QALY gained). A deterministic sensitivity analysis and a probabilistic sensitivity analysis were performed.Results
The post-DAA strategy showed higher health costs per patient (€30,944 vs. €23,707) than the pre-DAA strategy. However, it was associated with an increase of QALYs gained (15.79 vs. 12.83), showing an incremental cost-effectiveness ratio of €2,439 per QALY. The deterministic sensitivity analysis and the probabilistic sensitivity analysis showed the robustness of the results, with the post-DAA strategy being cost-effective in 99% of cases compared to the pre-DAA strategy.Conclusions
Compared to the pre-DAA strategy, the post-DAA strategy is efficient for the treatment of chronic hepatitis C in Spain, resulting in a much lower cost per QALY than the efficiency threshold used in Spain (€30,000 per QALY). 相似文献4.
Giuseppe Lepore Riccardo Bonfanti Lutgarda Bozzetto Vincenzo Di Blasi Angela Girelli Giorgio Grassi Dario Iafusco Luigi Laviola Ivana Rabbone Riccardo Schiaffini Daniela Bruttomesso 《Nutrition, metabolism, and cardiovascular diseases : NMCD》2018,28(4):335-342
Background and aim
The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).Methods and results
Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA1c) level was 60 mmol/mol (7.6%). The HbA1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA1c levels.The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.Conclusions
Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.5.
《Respirology (Carlton, Vic.)》2018,23(9):835-841
Background and objective
Bronchoscopic lung volume reduction using endobronchial valves (EBV) is an effective new treatment option for severe emphysema patients without interlobar collateral ventilation. The objective of this study was to perform an economic evaluation including the costs and cost‐effectiveness of EBV treatment compared with standard medical care (SoC) from the hospital perspective in the short term and long term.Methods
For the short‐term evaluation, incremental cost‐effectiveness ratios (ICER) were calculated based on the 6‐month end point data from the STELVIO randomized trial. For the long‐term evaluation, a Markov simulation model was constructed based on STELVIO and literature. The clinical outcome data were quality‐adjusted life‐years (QALY) based on the EuroQol5‐Dimensions (EQ5D) questionnaire, the 6‐min walking distance (6MWD) and the St George’s Respiratory Questionnaire (SGRQ).Results
The mean difference between the EBV group and controls was €16 721/patient. In the short‐term (6 months), costs per additional QALY was €205 129, the ICER for 6MWD was €160 and for SGRQ was €1241. In the long term, the resulting cost‐effectiveness ratios indicate additional costs of €39 000 per QALY gained with a 5‐year time horizon and €21 500 per QALY gained at 10 years. In comparison, historical costs per additional QALY 1 year after the coil treatment are €738 400, 5 years after lung volume reduction surgery are €48 415 and 15 years after double‐lung transplantation are €29 410.Conclusion
The positive clinical effects of EBV treatment are associated with increased costs compared with SoC. Our results suggest that the EBV treatment has a favourable cost‐effectiveness profile, also when compared with other treatment modalities for this patient group.6.
Bertha Wong Muhammad M. Mamdani Catherine H. Yu 《The American journal of medicine》2017,130(3):366.e1-366.e6
Background
The purpose of this study was to evaluate the impact of computerized provider order entry subcutaneous insulin order sets on inpatient glycemic control and ordering behavior.Methods
This was an interrupted time series study of non-intensive care patients at an urban teaching hospital. The primary outcome was proportion of capillary blood glucose in optimal range (4.0-10.0 mmol/L [72-180 mg/dL]) during the 6 months before and after a change to a computerized provider order entry-integrated insulin order set. Secondary outcomes included other measures of glycemia (hyperglycemia [>13.9mmol/L (250 mg/dL)], hypoglycemia [<4.0 mmol/L (72 mg/dL)], severe hypoglycemia [<2.2 mmol/L (40 mg/dL)]) and ordering behavior (use of basal-bolus-correctional insulin regimens). Comparisons of sensitivity-based versus generic correctional scale were also conducted.Results
A total of 63,393 measurements were obtained from June 2011 to June 2012. Order set usage was limited (51.5%). The weekly proportion of capillary blood glucose within the optimal range was not significantly different after the switch to computerized provider order entry order sets (pre-period: 64.9% vs post-period: 65.3%, P = .996). There were no differences in the proportions of moderate or severe hyperglycemia (pre-period: 10.9% vs post-period: 12.0%, P = .061) and hypoglycemia (pre-period: 1.9% vs post-period: 1.6%, P = .144). However, an increased proportion within the optimal range was seen in those with an order set featuring a sensitivity-based correctional scale versus orders without (65.3% vs 55.0%, P <.001). Increased basal-bolus-correctional ordering was observed after protocol implementation (20.3% vs 23.6%, P <.0001).Conclusions
With low institutional uptake, computerized insulin order sets did not improve inpatient glycemic control. 相似文献7.
Paola Lucidi Francesca Porcellati Geremia B. Bolli Carmine G. Fanelli 《Current diabetes reports》2018,18(10):83
Purpose of Review
In addition to assisting in achieving improved glucose control, continuous glucose monitoring (CGM) sensor technology may also aid in detection and prevention of hypoglycemia. In this paper, we report on the current scientific evidence on the effectiveness of this technology in the prevention of severe hypoglycemia and hypoglycemia unawareness.Recent Findings
Recent studies have found that the integration of CGM with continuous subcutaneous insulin infusion (CSII) therapy, a system known as sensor-augmented pump (SAP) therapy, very significantly reduces the occurrence of these conditions by providing real-time glucose readings/trends and automatically suspending insulin infusion when glucose is low (LGS) or, even, before glucose is low but is predicted to soon be low (PLGS). Initial data indicate that even for patients with type 1 diabetes treated with multiple daily injections, real-time CGM alone has been found to reduce both severe hypoglycemia and hypoglycemia unawareness. Closed loop systems (artificial pancreas) comprised of CGM and CSII without patient intervention to adjust basal insulin, which automatically reduce, increase, and suspend insulin delivery, represent a potential new option that is moving toward becoming a reality in the near future.Summary
Sensor technology promises to continue to improve patients’ lives not only by attaining glycemic control but also by reducing hypoglycemia, a goal best achieved in conjunction with structured individualized patient education.8.
Elaine Nguyen Craig I. Coleman Suresh Nair Erin R. Weeda 《Journal of diabetes and its complications》2018,32(2):210-215
Aims
In the Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes (EMPA-REG) trial, empagliflozin reduced cardiovascular and all-cause mortality in type 2 diabetes (T2D) patients at high cardiovascular risk. We sought to estimate the cost-effectiveness of empagliflozin versus standard treatment for the prevention of cardiovascular morbidity and mortality in patients with T2D.Methods
A Markov model was developed to assess the cost-effectiveness of empagliflozin (versus standard treatment) for the prevention of cardiovascular morbidity and mortality in patients with T2D using a 3-month cycle length and a lifetime horizon. Data sources included the EMPA-REG randomized clinical trial and other published epidemiological studies. Outcomes included treatment costs (in 2016 US$), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Probabilistic sensitivity analysis (PSA) was performed to test the robustness of conclusions.Results
Empagliflozin use resulted in higher total lifetime treatment costs ($371,450 versus $272,966) but yielded greater QALYs (10.712 vs. 9.419) compared to standard treatment. This corresponded to an ICER of $76,167 per QALY gained. PSA suggested empagliflozin would be cost-effective in 96% of 10,000 iterations assuming a willingness-to-pay threshold of $100,000 per QALY gained.Conclusion
Empagliflozin may be cost-effective compared to standard treatment in T2D patients at high cardiovascular risk. 相似文献9.
Wilbert B. van den Hout Zuzana de Jong Marten Munneke Johanna M. W. Hazes Ferdinand C. Breedveld Theodora P. M. Vliet Vlieland 《Arthritis care & research》2005,53(1):39-47
Objective
To estimate the cost utility and cost effectiveness of long‐term, high‐intensity exercise classes compared with usual care in rheumatoid arthritis (RA) patients.Methods
RA patients (n = 300) were randomly assigned to either exercise classes or UC; followup lasted for 2 years. Outcome measures were quality‐adjusted life years (QALYs) according to the EuroQol (EQ‐5D), Short Form 6D (SF‐6D), and a transformed visual analog scale (VAS) rating personal health; functional ability according to the Health Assessment Questionnaire (HAQ) and McMaster Toronto Arthritis Patient Preference Interview (MACTAR); and societal costs.Results
QALYs in both randomization groups were similar according to the EQ‐5D and SF‐6D, but were in favor of usual care according to the VAS (annual difference 0.037 QALY; 95% confidence interval [95% CI] 0.002, 0.069). Functional ability was similar according to the HAQ, but in favor of the exercise classes according to the MACTAR (annual difference 2.9 QALY; 95% CI 0.9, 4.9). Annual medical costs of the exercise program were estimated at €780 per participating patient (€1 ≈ $1.05). The increase per patient in total medical costs of physical therapy was estimated at €430 (95% CI €318, 577), and the increase in total societal costs at €602 (95% CI €?490, 1,664). For societal willingness‐to‐pay equal to €50,000 per QALY, usual care had better cost utility than exercise classes, and significantly so according to the VAS.Conclusion
From a societal perspective and without taking possible preventive health effects into account, long‐term, high‐intensity exercise classes provide insufficient improvement in the valuation of health to justify the additional costs.10.
Javier Escaned Nicola Ryan Hernán Mejía-Rentería Christopher M. Cook Hakim-Moulay Dehbi Eduardo Alegria-Barrero Ali Alghamdi Rasha Al-Lamee John Altman Alphonse Ambrosia Sérgio B. Baptista Maria Bertilsson Ravinay Bhindi Mats Birgander Waldemar Bojara Salvatore Brugaletta Christopher Buller Fredrik Calais Matthias Götberg 《JACC: Cardiovascular Interventions》2018,11(15):1437-1449
Objectives
The aim of this study was to investigate the clinical outcomes of patients deferred from coronary revascularization on the basis of instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) measurements in stable angina pectoris (SAP) and acute coronary syndromes (ACS).Background
Assessment of coronary stenosis severity with pressure guidewires is recommended to determine the need for myocardial revascularization.Methods
The safety of deferral of coronary revascularization in the pooled per-protocol population (n = 4,486) of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) and iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trials was investigated. Patients were stratified according to revascularization decision making on the basis of iFR or FFR and to clinical presentation (SAP or ACS). The primary endpoint was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year.Results
Coronary revascularization was deferred in 2,130 patients. Deferral was performed in 1,117 patients (50%) in the iFR group and 1,013 patients (45%) in the FFR group (p < 0.01). At 1 year, the MACE rate in the deferred population was similar between the iFR and FFR groups (4.12% vs. 4.05%; fully adjusted hazard ratio: 1.13; 95% confidence interval: 0.72 to 1.79; p = 0.60). A clinical presentation with ACS was associated with a higher MACE rate compared with SAP in deferred patients (5.91% vs. 3.64% in ACS and SAP, respectively; fully adjusted hazard ratio: 0.61 in favor of SAP; 95% confidence interval: 0.38 to 0.99; p = 0.04).Conclusions
Overall, deferral of revascularization is equally safe with both iFR and FFR, with a low MACE rate of about 4%. Lesions were more frequently deferred when iFR was used to assess physiological significance. In deferred patients presenting with ACS, the event rate was significantly increased compared with SAP at 1 year. 相似文献11.
Cost‐Effectiveness of Tight Control of Inflammation in Early Psoriatic Arthritis: Economic Analysis of a Multicenter Randomized Controlled Trial 
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下载免费PDF全文 John L. O'Dwyer David M. Meads Claire T. Hulme Lucy Mcparland Sarah Brown Laura C. Coates Anna R. Moverley Paul Emery Philip G. Conaghan Philip S. Helliwell 《Arthritis care & research》2018,70(3):462-468
Objective
Treat‐to‐target approaches have proved to be effective in rheumatoid arthritis, but have not been studied in psoriatic arthritis (PsA). This study was undertaken to examine the cost‐effectiveness of tight control (TC) of inflammation in early PsA compared to standard care.Methods
Cost‐effectiveness analyses were undertaken alongside a UK‐based, open‐label, multicenter, randomized controlled trial. Taking the perspective of the health care sector, effectiveness was measured using the 3‐level EuroQol 5‐domain, which allows for the calculation of quality‐adjusted life‐years (QALYs). Incremental cost‐effectiveness ratios (ICERs) are presented, which represent the additional cost per QALY gained over a 48‐week time horizon. Sensitivity analyses are presented assessing the impact of variations in the analytical approach and assumptions on the cost‐effectiveness estimates.Results
The mean cost and QALYs were higher in the TC group: £4,198 versus £2,000 and 0.602 versus 0.561. These values yielded an ICER of £53,948 per QALY. Bootstrapped uncertainty analysis suggests that the TC has a 0.07 probability of being cost‐effective at a £20,000 threshold. Stratified analysis suggests that with certain costs being controlled, an ICER of £24,639 can be calculated for patients with a higher degree of disease severity.Conclusion
A tight control strategy to treat PsA is an effective intervention in the treatment pathway; however, this study does not find tight control to be cost‐effective in most analyses. Lower drug prices, targeting polyarthritis patients, or reducing the frequency of rheumatology visits may improve value for money metrics in future studies.12.
Background
Severe acute pancreatitis (SAP) is characterised by two distinct clinical phases. Organ dysfunction and death is initially as a result of a systemic inflammatory response syndrome (SIRS). Systemic sepsis from infected pancreatic necrosis characterises the second phase, the so called 'second hit' of acute pancreatitis (AP). An immune imbalance during the second hit is postulated to contribute to the formation of the septic complications that occur in these patients. The pro-inflammatory T-helper (Th) 17 pathway has been shown to be an initiator of early SIRS in AP, however to date its role has not been established in the second hit in AP.Methods
Thirty-six patients with mild (n?=?16), moderate (n?=?10) and severe (n?=?10) acute pancreatitis were enrolled. Peripheral blood samples were drawn on days 7, 9, 11 and 13 of illness for analysis of routine clinical markers as well as cytokine analysis. Flow cytometry and a IL-17A ELISA was performed to determine cytokine concentrations.Results
There were no significant differences between days 7, 9, 11 and 13 for either the mild/moderate or SAP groups for IL-17A (CBA assay or ELISA), IFN-γ, TNF-α, IL-2 or IL-4. For each of the study days, the mean IL-6 and IL-10 concentrations were significantly higher in the SAP group compared to the mild/moderate group. WCC, CRP and PCT were all significantly higher in severe acute pancreatitis over the study days.Conclusions
An immune imbalance exists in patients with SAP, however secreted IL-17A is not responsible for the second hit in AP. 相似文献13.
Robert A. Vigersky 《Journal of diabetes science and technology》2015,9(2):320-330
Background:
Hypoglycemia mitigation is critical for appropriately managing patients with diabetes. Advanced technologies are becoming more prevalent in diabetes management, but their benefits have been primarily judged on the basis of hemoglobin A1c. A critical appraisal of the effectiveness and limitations of advanced technologies in reducing both A1c and hypoglycemia rates has not been previously performed.Methods:
The cost of hypoglycemia was estimated using literature rates of hypoglycemia events resulting in hospitalizations. A literature search was conducted on the effect on A1c and hypoglycemia of advanced technologies. The cost-effectiveness of continuous subcutaneous insulin infusion (CSII) and real-time continuous glucose monitors (RT-CGM) was reviewed.Results:
Severe hypoglycemia in insulin-using patients with diabetes costs $4.9-$12.7 billion. CSII reduces A1c in some but not all studies. CSII improves hypoglycemia in patients with high baseline rates. Bolus calculators improve A1c and improve the fear of hypoglycemia but not hypoglycemia rates. RT-CGM alone and when combined with CSII improve A1c with a neutral effect on hypoglycemia rates. Low-glucose threshold suspend systems reduce hypoglycemia with a neutral effect on A1c, and low-glucose predictive suspend systems reduce hypoglycemia with a small increase in plasma glucose levels. In short-term studies, artificial pancreas systems reduce both hypoglycemia rates and plasma glucose levels. CSII and RT-CGM are cost-effective technologies, but their wide adoption is limited by cost, psychosocial, and educational factors.Conclusions:
Most currently available technologies improve A1c with a neutral or improved rate of hypoglycemia. Advanced technologies appear to be cost-effective in diabetes management, especially when including the underlying cost of hypoglycemia. 相似文献14.
R. Brett McQueen Marc D. Breton Markus Ott Helena Koa Bruce Beamer Jonathan D. Campbell 《Journal of diabetes science and technology》2016,10(2):366-377
Objective:
The objective was to simulate and compare clinical and economic outcomes of self-monitoring of blood glucose (SMBG) devices along error ranges and strip price.Methods:
We programmed a type 1 diabetes natural history and treatment cost-effectiveness model. In phase 1, using past evidence from in silico modeling validated by the Food and Drug Administration, we associated changes in SMBG error to changes in hemoglobin A1c (HbA1c) and separately, changes in severe hypoglycemia requiring an inpatient stay. In phase 2, using Markov cohort simulation modeling, we estimated clinical and economic outcomes from the Canadian payer perspective. The primary comparison was a SMBG device with strip price $0.73 Canadian dollars (CAD) and 10% error (exceeding accuracy requirements by International Organization for Standardization (ISO) 15197:2013) versus a SMBG device with strip price $0.60 CAD and 15% error (accuracy meeting ISO 15197:2013). Outcomes for the average patient, were quality-adjusted life years (QALYs), incremental cost-effectiveness ratios (ICERs), and budget impact.Results:
Assuming benefits translate into HbA1c improvements only, the ICER with 10% error versus 15% was $11 500 CAD per QALY. Assuming the benefits translate into reduced severe hypoglycemia requiring an inpatient stay only, an SMBG device with 10% error dominated (ie, less costly, more effective) an SMBG device with 15% error. The 3-year budget impact findings ranged from $0.004 CAD per member per month for HbA1c improvements to cost-savings for severe hypoglycemia reductions.Conclusions:
From efficiency (cost-effectiveness) and affordability (budget impact) payer perspectives, investing in devices with improved accuracy (less error) appears to be an efficient and affordable strategy. 相似文献15.
Background
Although often recommended by experts, it is unclear if elevated troponin measurements have clinical utility in patients without chest pain or ischemic electrocardiographic changes.Objectives
The objective of this study was to determine clinical utility, and downstream testing in patients with elevated troponin values but without chest pain or electrocardiographic changes.Methods
We selected all patients aged 30-100 years hospitalized in cardiology and internal medicine departments from July 1, 2013 until July 31, 2016. We chose a subgroup of 723 consecutive subjects with elevated troponin values for chart review to determine the proportion of patients without chest pain or ischemic electrocardiographic changes, and resultant differential treatment and downstream testing. Clinical utility was defined as coronary artery interventions or treatment of life-threatening arrhythmias.Results
Troponin measurements were sent in 52.5% of all hospitalized patients (16,519/31,448), and were elevated in 29.9% (4938/16,519). Nearly two-thirds of the patients reviewed had neither chest pain nor ischemic electrocardiographic changes (63.3% [458/723]), and the elevated troponin values did not result in coronary artery interventions or treatment of life-threatening arrhythmias. The elevated troponin values were the sole reason for hospitalization in 2.0% (n = 9), for cardiac monitoring in 6.1% (n = 28), for cardiac consultations in 11.1% (n = 51), and for left heart catheterization in 0.7% (n = 3) of the patients.Conclusion
Most of the elevated troponin test results were in patients without chest pain or ischemic electrocardiographic changes, had no clinical utility, and resulted in downstream testing. 相似文献16.
Objective
The aim of this study is to predict the risk of severe acute pancreatitis (SAP) associated with acute lung injury (ALI) by artificial neural networks (ANNs) model.Methods
The ANNs and logistic regression model were constructed using clinical and laboratory data of 217 SAP patients. The models were first trained on 152 randomly chosen patients, validated and tested on the 33 patients and 32 patients respectively. Statistical indices were used to evaluate the value of the forecast in two models.Results
The training set, validation set and test set were not significantly different for any of the 13 variables. After training, the back propagation network retained excellent pattern recognition ability. When the ANNs model was applied to the test set, it revealed a sensitivity of 87.5%, specificity of 83.3%. The accuracy was 84.43%. Significant differences could be found between ANNs model and logistic regression model in these parameter. When ANNs model was used to identify ALI, the area under receiver operating characteristic curve was 0.859 ± 0.048, which demonstrated the better overall properties than logistic regression modeling (AUC = 0.701 + 0.041) (95% CI: 0.664–0.857). Meanwhile, pancreatic necrosis rate, lactic dehydrogenase and oxyhemoglobin saturation were the important factors among all thirteen independent variable for ALI.Conclusion
The ANNs model was a valuable tool in dealing with the clinical risk prediction problem of ALI following to SAP. In addition, our approach can extract informative risk factors of ALI via the ANNs model. 相似文献17.
William V. Padula Shiona Heru Jonathan D. Campbell 《Journal of general internal medicine》2016,31(4):394-401
BACKGROUND
Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy.OBJECTIVE
To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services.DESIGN
Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3 % (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS).PATIENTS
U.S. transgender population starting before transitional therapy.INTERVENTIONS
No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both.MAIN MEASURES
Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost.KEY RESULTS
Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000–22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints —HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85 % of simulations.CONCLUSIONS
Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions.18.
Yongle Xu Xin Jia Jiwei Zhang Baixi Zhuang Weiguo Fu Danming Wu Feng Wang Yu Zhao Pingfan Guo Wei Bi Shenming Wang Wei Guo 《JACC: Cardiovascular Interventions》2018,11(23):2347-2353
Objectives
The authors sought to investigate the midterm efficacy and safety of drug-coated balloon (DCB) in the treatment of severe femoropopliteal artery disease (FPAD).Background
The midterm outcome of DCB versus uncoated balloon percutaneous transluminal angioplasty (PTA) for FPAD are still debated.Methods
A total of 200 Chinese patients with FPAD were prospectively randomized into treatment with DCB or with PTA. The primary efficacy endpoints were primary patency of the target lesion, freedom from clinically driven target lesion revascularization, improved ankle-brachial index, and improved Rutherford class at 24 months. The primary safety endpoint was the rate of major adverse events.Results
The DCB group and PTA group were comparable in demographic characteristics and clinical severity at baseline. At 24-month follow-up, primary patency was better in the DCB group versus PTA group (64.6% vs. 31.4%; p < 0.001). The DCB group had a higher rate of freedom from clinically driven target lesion revascularization than the PTA group (86.5% vs. 58.9%; p < 0.001). Rutherford class and ankle-brachial index also confirmed more improvements in the DCB group (p < 0.01 and p < 0.05, respectively). There was no significant difference in major adverse events.Conclusions
The superiority of DCB versus PTA in the efficacy of FPAD treatment persists at 24-month follow-up and the safety of DCB is equivalent to that of PTA. 相似文献19.
Disparities in Total Knee Replacement: Population Losses in Quality‐Adjusted Life‐Years Due to Differential Offer,Acceptance, and Complication Rates for African Americans 下载免费PDF全文
下载免费PDF全文 Hannah M. Kerman Savannah R. Smith Karen C. Smith Jamie E. Collins Lisa G. Suter Jeffrey N. Katz Elena Losina 《Arthritis care & research》2018,70(9):1326-1334
Objective
Total knee replacement (TKR) is an effective treatment for end‐stage knee osteoarthritis (OA). American racial minorities undergo fewer TKRs than whites. We estimated quality‐adjusted life‐years (QALYs) lost for African American knee OA patients due to differences in TKR offer, acceptance, and complication rates.Methods
We used the Osteoarthritis Policy Model, a computer simulation of knee OA, to predict QALY outcomes for African American and white knee OA patients with and without TKR. We estimated per‐person QALYs gained from TKR as the difference between QALYs with current TKR use and QALYs when no TKR was performed. We estimated average, per‐person QALY losses in African Americans as the difference between QALYs gained with white rates of TKR and QALYs gained with African American rates of TKR. We calculated population‐level QALY losses by multiplying per‐person QALY losses by the number of persons with advanced knee OA. Finally, we estimated QALYs lost specifically due to lower TKR offer and acceptance rates and higher rates of complications among African American knee OA patients.Results
African American men and women gain 64,100 QALYs from current TKR use. With white offer and complications rates, they would gain an additional 72,000 QALYs. Because these additional gains are unrealized, we call this a loss of 72,000 QALYs. African Americans lose 67,500 QALYs because of lower offer rates, 15,800 QALYs because of lower acceptance rates, and 2,600 QALYs because of higher complication rates.Conclusion
African Americans lose 72,000 QALYs due to disparities in TKR offer and complication rates. Programs to decrease disparities in TKR use are urgently needed.20.
A.B. Câmara-de-Souza M.T.K. Toyoshima M.L. Giannella D.S. Freire C.P. Camacho D.M. Lourenço M.S. Rocha T. Bacchella R. Jureidini M.C.C. Machado M.Q. Almeida M.A.A. Pereira 《Pancreatology》2018,18(3):298-303