Extending Treatment Networks in Health Technology Assessment: How Far Should We Go?

BackgroundNetwork meta-analysis may require substantially more resources than does a standard systematic review. One frequently asked question is “how far should I extend the network and which treatments should I include?”ObjectiveTo explore the increase in precision from including additional evidence.MethodsWe assessed the benefit of extending treatment networks in terms of precision of effect estimates and examined how this depends on network structure and relative strength of additional evidence. We introduced a “star”-shaped network. Network complexity is increased by adding more evidence connecting treatments under five evidence scenarios. We also examined the impact of heterogeneity and absence of evidence facilitating a “first-order” indirect comparison.ResultsIn all scenarios, extending the network increased the precision of the A versus B treatment effect. Under a fixed-effect model, the increase in precision was modest when the existing direct A versus B evidence was already strong and was substantial when the direct evidence was weak. Under a random-effects model, the gain in precision was lower when heterogeneity was high. When evidence is available for all “first-order” indirect comparisons, including second-order evidence has limited benefit for the precision of the A versus B estimate. This is interpreted as a “ceiling effect.”ConclusionsIncluding additional evidence increases the precision of a “focal” treatment comparison of interest. Once the comparison of interest is connected to all others via “first-order” indirect evidence, there is no additional benefit in including higher order comparisons. This conclusion is generalizable to any number of treatment comparisons, which would then all be considered “focal.” The increase in precision is modest when direct evidence is already strong, or there is a high degree of heterogeneity.     

Patient Loyalty in a Mature IDS Market: Is Population Health Management Worth It?

ObjectiveTo understand patient loyalty to providers over time, informing effective population health management.ConclusionsPopulation health management can be beneficial to the care system making this investment, particularly for patients exhibiting prior continuity in care system choice. The results suggest that co-located primary and specialty services are important in maintaining primary care loyalty.     

Should We End Military Recruiting in High Schools as a Matter of Child Protection and Public Health?

Recruiters for the various US armed forces have free access to our nation's high schools, as mandated by the No Child Left Behind Act. Military recruiter behaviors are disturbingly similar to predatory grooming. Adults in the active military service are reported to experience increased mental health risks, including stress, substance abuse, and suicide, and the youngest soldiers consistently show the worst health effects, suggesting military service is associated with disproportionately poor health for this population. We describe the actions of a high school parent teacher student association in Seattle, Washington, which sought to limit the aggressive recruitment of children younger than 18 years into the military.     

The De-Scent of Sexuality: Should We Smell a Rat?

Archives of Sexual Behavior -     

Declining Accuracy in Disease Classification on Health Insurance Claims: Should We Reconsider Classification by Principal Diagnosis?

Background

An ideal classification should have maximum intercategory variance and minimal intracategory variance. Health insurance claims typically include multiple diagnoses and are classified into different disease categories by choosing principal diagnoses. The accuracy of classification based on principal diagnoses was evaluated by comparing intercategory and intracategory variance of per-claim costs and the trend in accuracy was reviewed.

Methods

Means and standard deviations of log-transformed per-claim costs were estimated from outpatient claims data from the National Health Insurance Medical Benefit Surveys of 1995 to 2007, a period during which only the ICD10 classification was applied. Intercategory and intracategory variances were calculated for each of 38 mutually exclusive disease categories and the percentage of intercategory variance to overall variance was calculated to assess the trend in accuracy of classification.

Results

A declining trend in the percentage of intercategory variance was observed: from 19.5% in 1995 to 10% in 2007. This suggests that there was a decline in the accuracy of disease classification in discriminating per-claim costs for different disease categories. The declining trend temporarily reversed in 2002, when hospitals and clinics were directed to assign the principal diagnosis. However, this reversal was only temporary and the declining trend appears to be consistent.

Conclusions

Classification of health insurance claims based on principal diagnoses is becoming progressively less accurate in discriminating per-claim costs. Researchers who estimate disease-specific health care costs using health insurance claims must therefore proceed with caution.Key words: health insurance claims, ICD10, intracategory variance, intercategory variance, log-normal distribution     

Sodium Intake and Health: What Should We Recommend Based on the Current Evidence?

Several health organizations recommend low sodium intake (below 2.3 g/day, 5.8 g/day of salt) for entire populations, on the premise that lowering of sodium intake, irrespective of its level of intake, will lower blood pressure and, in turn, will result in a lower incidence of cardiovascular disease. These guidelines were developed without effective interventions to achieve long term sodium intakes at low levels in free-living individuals and without high-quality evidence that low sodium intake reduces cardiovascular events (compared with average levels of intake). In this review, we examine whether advice to consume low amounts of sodium is supported by robust evidence. We contend that current evidence indicates that most people around the world consume a moderate range of dietary sodium (3 to 5 g/day), that this level of intake is associated with the lowest risk of cardiovascular disease and mortality, and that the risk of adverse health outcomes increases when sodium intakes exceeds 5 g/day or is below 3 g/day. While the current evidence has limitations, it is reasonable, based upon prospective cohort studies, to suggest a mean target of below 5 g/day in populations, while awaiting the results of large randomized controlled trials of sodium reduction on cardiovascular disease and death.     

Litigation-Generated Science: Why Should We Care?

BACKGROUND: In a 1994 Ninth Circuit decision on the remand of Daubert v. Merrell Dow Pharmaceuticals, Inc., Judge Alex Kosinski wrote that science done for the purpose of litigation should be subject to more stringent standards of admissibility than other science. OBJECTIVES: We analyze this proposition by considering litigation-generated science as a subset of science involving conflict of interest. DISCUSSION: Judge Kosinski's formulation suggests there may be reasons to treat science involving conflict of interest differently but raises questions about whether litigation-generated science should be singled out. In particular we discuss the similar problems raised by strategically motivated science done in anticipation of possible future litigation or otherwise designed to benefit the sponsor and ask what special treatment, if any, should be given to science undertaken to support existing or potential future litigation. CONCLUSION: The problems with litigation-generated science are not special. On the contrary, they are very general and apply to much or most science that is relevant and reliable in the courtroom setting.