Health outcomes research in medicine最新文献

Objective

Our study explored perceived patient satisfaction with either primary care or specialist physicians to identify factors accounting for the differences.

Study Design

The data were collected from an Internet-based survey, DrScore.com, for measuring patient satisfaction with physicians. Participants found their doctors through the DrScore search engine and rated their physicians with anonymity. A total satisfaction score was the sum of scores based on 9 physician rating items and then was scaled to the range of 0-100. Logistic regressions were used to analyze associations between patient satisfaction (score ≥70) and various factors.

Results

The mean satisfaction score was 79.4 for primary care (n = 11,558) and 75.5 for specialty care (n = 11,068) (P > .05). Nearly 50% of primary care patients waited for 0-2 days to get an appointment, while more than 50% of specialty care patients waited for more than 6 days. As waiting days became longer than 2 weeks, patient ratings of specialty care were lower than those of primary care. Patients (≥45 years) were 24% less likely to be satisfied with primary care (P < .01) but 40% more likely with specialty care (P < .01) than patients (<25 years).

Conclusions

Although differences in overall patient satisfaction with primary and specialty care were not observed, more specialists obtained extremely low satisfaction scores than primary care providers did. Age and factors related to waiting time for the visit or time spent with a doctor were associated with patient satisfaction with physicians.

Objectives

To elicit preferences for standardized head and neck cancer (HNC) health states describing the health-related quality of life (HRQoL) impact of cancer type or stage, progression, or treatment-related toxicities; and to measure the association between an individual’s locus of control (LOC) and mean preference values for HNC health states.

Study Design

We elicited preferences from a sample of 106 members of the Canadian general public, using the standard gamble method. Eight health states representing HNC characteristics, and 10 describing treatment-related toxicities, were developed based on literature review, data analysis, and clinician interview. All participants valuated these, anchored against full health and dead, and completed the Multidimensional Health LOC scale. A mixed-regression model was used to calculate adjusted preference decrements for all states compared with a reference state (locoregional preprogression nonlaryngeal HNC).

Results

Mean participant age was 47 years, and 48% were male. All health states were associated with substantially decreased preferences compared with full health. Mean preferences ranged from 0.62 (locoregional laryngeal HNC) to 0.33 (hospitalization for severe toxicity). After adjusting for age and sex, mean preference decrements were: −0.28 (postprogression), −0.11 (metastases), and −0.05 (recurrent disease). There was suggestive evidence that LOC was associated with preferences overall (P = .079); those with stronger beliefs in Chance rated health states lower (P = .012).

Conclusions

Health state preferences elicited here demonstrate that members of the Canadian general public rate HNC to have a large negative impact on HRQoL. The greatest impact was for postprogression and metastatic health states. These values are useful for quantifying the devastating impact of HNC on HRQoL, and for economic modeling.

Objective

Overall survival is a commonly reported end point in clinical trial publications and a key determinant of therapies’ cost-effectiveness. Patients’ survival times have skewed distributions. Outcomes are typically presented in clinical trials as the difference in median survival times; we compare median survival gain with the measure required for economic evaluation, the mean difference.

Study Design

We summarize the relationships between median and mean survival in 4 parametric survival distributions and the relationship of the differences in these measures between trial arms and parameterized treatment effects. Parametric estimates of mean survival were compared with median survival in a case study of a recent trial in metastatic melanoma.

Results

In a trial of alternative therapies in unresectable metastatic melanoma, median overall survival with ipilimumab alone was 10.1 months versus 6.4 months with gp100-alone (hazard ratio 0.66; P = 0.003). A log-normal parametric survivor function fitted the gp100 Kaplan-Meier function and a time ratio of 1.90 applied only after 90 days gave a suitable fit to the Kaplan-Meier function for ipilimumab, with mean survival difference of 7 months, compared with an estimate of 5.7 months employing a Weibull distribution, and with a 3.7-months median difference.

Conclusion

Parametric assessment of mean survival gain in clinical trials may indicate potential benefits to patients that observed medians may greatly underestimate.

Objectives

To describe the literature search strategies and results to inform development of health outcomes of interest (HOI) definitions studied within the Observational Medical Outcomes Partnership (OMOP) research program. These HOIs represent the safety and benefit endpoints that may be associated with the use of particular medications.

Methods

Two organizations implemented search strategies to identify articles that described the validation of various HOI definition algorithms and produced systematic reviews of the published literature for the OMOP HOIs; reviews of 5 HOIs were available from each organization. Search results were summarized descriptively.

Results

Based on the differences in publications identified by each organization, neither search strategy captured all the relevant literature across 5 HOIs. A composite search strategy developed by the OMOP research team failed to effectively capture all relevant publications as well. Among publications in observational databases, a large proportion did not report actual codes used to identify HOIs in administrative claims databases, nor did they provide substantive detail of any validation studies.

Conclusion

No single search strategy or literature database captured all relevant articles efficiently. The lack of specific search terms hampered identification of relevant articles. Due to limited details about positive predictive value of various HOI definitions, information culled from available literature was insufficient to identify one best definition for each HOI. Researchers seeking to capture and understand prior published work that defined relevant outcomes of interest need to be aware of the shortcomings of this approach and the lack of detail of validation studies available in published literature.

Objectives

To examine patterns of health care utilization and costs in patients with generalized anxiety disorder (GAD) who begin treatment with benzodiazepine anxiolytics as add-on therapy.

Study Design

In a large US health insurance database, we identified all patients with evidence of GAD (International Classification of Diseases, 9^th Revision, Clinical Modification diagnosis code 300.02) who received ≥90 days of therapy with a selective serotonin reuptake inhibitor or venlafaxine between January 1, 2003 and December 31, 2007. Among these patients, we selected those who initiated a course of benzodiazepine add-on therapy. Designating the date of initial receipt of a benzodiazepine as the “index date,” we examined health care utilization and costs over the 6-month period preceding this date (“pre-index”) and the 12-month period following it (“follow-up”).

Results

A total of 2131 patients met all study inclusion criteria. Patients averaged 32 days of therapy with benzodiazepines (median [interquartile range] = 20 [10-30]); 13% of patients received >90 days of therapy, however. In general, levels of health care utilization during the first 6 months of follow-up were higher than those during the pre-index period; between months 7 and 12 of follow-up, however, they were somewhat lower than pre-index levels. Mean (SD) total health care costs were $5148 ($10,658), $6325 ($15,741), and $5373 ($11,230) during pre-index, months 1-6 of follow-up, and months 7-12 of follow-up, respectively.

Conclusions

Levels of health care utilization and costs increase following initiation of add-on therapy with a benzodiazepine in patients with GAD receiving selective serotonin reuptake inhibitors or venlafaxine. Although duration of add-on therapy is typically brief, some patients are treated for >90 days, raising potential concerns about risks of dependency and sedation.

Purpose

To evaluate the association between anemia and the clinical endpoints of pressure ulcers, falls, and hospital admissions in long-term care residents.

Methods

Data were derived retrospectively from the AnalytiCare (Glenview, IL) proprietary database, containing laboratory data and detailed resident health status and condition indicators available in the Minimum Data Set (MDS) reports for 27 long-term care facilities in Colorado during January 1, 2007-September 15, 2008. Eligible residents had >90 days in the facility and a hemoglobin (Hb) value within 90 days of the earliest nonadmission (index) MDS. Anemia was defined as Hb <12 g/dL female, <13 g/dL males. Pressure ulcers were identified from the index MDS. Falls and hospital admissions were identified from all postindex MDS assessments. Logistic regression, adjusted for other covariates, was used to analyze the relationship between anemia and Hb level with the rate of pressure ulcers, falls, and hospital admissions.

Results

There were 838 residents who met inclusion criteria. Mean age was 78 years, 67% were female. Nine percent had pressure ulcers. Pressure ulcers increased from a rate of 6% for residents with Hb levels ≥13 g/dL to 21% for those with Hb <10 (P <.001). In the logistic regression model, anemia was associated with an odds ratio of 2.23 for pressure ulcers (95% confidence interval, 1.32-3.78, P = .003). Having anemia was associated with a 58% higher odds of falls (P = .012) and 134% higher odds of hospital admissions (P <.001). Risk of falling and hospital admissions centered on those having Hb levels from 10 to <12 g/dL.

Conclusion

Consistent with previous research and subject to study design limitations, anemia in the residents studied was associated with statistically significant higher odds of pressure ulcers, falls, and hospital admissions.

Background

Patients are taking a greater role in decisions about their care and treatment. Patient satisfaction is one important indicator of health outcomes and plays a key role in improving health service quality. While there is extensive public discussion of patients’ satisfaction with physicians, patient satisfaction with outpatient care has not been well characterized.

Objective

To characterize patients’ satisfaction with outpatient medical care in the US.

Methods

Data on 14,984 patients’ visits were obtained from a validated online patient satisfaction survey. Data from the National Ambulatory Medical Care Survey were used to assess how the demographics of the sample population compared with the demographics of patients seeing US physicians, and the analysis was limited to data on doctors with 10 or more ratings within 2004-2010 to help ensure representative scoring. Patients’ overall satisfaction with their physicians was scored on a 0-10 scale (where 10 is best and 0 is worst). Patients also reported their waiting times, how much time the doctor spent with them, and their satisfaction with several dimensions of the medical visit experience.

Results

The average overall patient satisfaction rating was 9.28. Of the 14,984 ratings, 10,510 (70.1%) were 10s and another 2291 (15.3%) were 9s. Less than 2% of the ratings were 0s or 1s (276 of the 14,984). Multivariate analysis revealed that waiting time, spending time with patient, and age category all were statistically significantly associated with patient satisfaction scores (all P <.05).

Conclusion

The great majority of patients reporting their satisfaction online are highly satisfied with their outpatient medical care.

Objectives

To assess health care utilization and costs among patients experiencing invasive meningococcal disease (IMD)-related sequelae compared with IMD patients without sequelae.

Study Design

A retrospective cohort analysis of an administrative claims database for years 1997-2009. Patients with IMD-related inpatient admissions and continuous health plan enrollment were selected and categorized by the presence (complicated IMD) or absence (uncomplicated IMD) of IMD-related sequelae during the 12-month follow-up period. Univariate and multivariable analyses assessed differences in health care utilization and related costs between the 2 patient groups.

Results

We identified 343 patients; 117 (34%) had a diagnosis claim for at least one IMD-related sequela during the follow-up period. Multivariable analyses showed significantly higher total health care costs for complicated IMD cases (mean: $96,826; 95% confidence interval: $88,659-$104,993) compared with uncomplicated IMD cases (mean: $32,414; 95% confidence interval: $30,825-$34,003). Risk of rehospitalization after initial IMD admission was higher for patients with complicated IMD (hazard ratio = 1.7; 95% confidence interval: 1.0-2.7; P = .034) compared with patients with uncomplicated IMD.

Conclusion(s)

Predicted health care costs among patients with complicated IMD were 3 times higher compared with patients with uncomplicated IMD. These costs should be considered when economic evaluations of meningococcal vaccination programs are made.

Health care decision-makers rarely have the appropriate evidence to evaluate the comparative clinical effectiveness of new and existing prescription drugs. In the absence of head-to-head trials comparing all available drugs, indirect comparisons of randomized trials can offer a valuable approach to investigators evaluating the comparative effect of multiple drugs. Indirect comparisons, particularly methods that allow the combination of direct and indirect evidence obtained from randomized trials, can assist in identifying which of multiple prescription drugs works better than others. In this article, we discuss the benefits and risks of using indirect evidence and make the case in favor of its wider use within the comparative effectiveness research efforts in the US. We further argue that the use of indirect comparisons should be pursued in cases where trials comparing the interventions of interest are available.