Health outcomes research in medicine最新文献

Objective

To compare the incidence and time to onset of exacerbations among mild asthmatic non-controller-naive patients who began treatment with mometasone furoate via a dry powder inhaler (MF-DPI) or a beclomethasone dipropionate-hydrofluoroalkane (BDP-HFA) aerosol inhaler.

Study Design

An administrative claims database was retrospectively examined from January 1, 2005 through June 30, 2008. Patients with mild asthma aged 12-65 years who were US residents and enrolled in their health plan for ≥1 year before and after the index date for MF-DPI or BDP-HFA treatment initiation were included (n = 1273 matched patients per cohort). Primary evaluations included the incidence of and time to any asthma exacerbations and several asthma exacerbation subtypes. Multivariate generalized linear regression modeling analyses were used to compare the postindex incidence of exacerbations between cohorts. Cox regression analyses were conducted to control for the impact of input variables and evaluate the time to exacerbations.

Results

Significantly fewer MF-DPI patients experienced an exacerbation compared with BDP-HFA patients (9.7% vs 11.5%, respectively; P = .0002). At all time points examined, fewer MF-DPI patients compared with BDP-HFA patients experienced any exacerbation or an exacerbation requiring inpatient hospitalization. The difference between cohorts in the incidence of inpatient exacerbations increased over time. MF-DPI patients experienced prolonged time to any asthma exacerbation (hazard ratio = 0.77; P = .0414) or exacerbations requiring inpatient hospitalization (hazard ratio = 0.51; P = .0191) compared with BDP-HFA patients.

Conclusion

These analyses suggest that patients (previously receiving asthma-related therapy) with mild asthma receiving MF-DPI are at lower risk for asthma exacerbations compared with those receiving BDP-HFA.

Objectives

The Hamilton Depression Rating Scale (HDRS) is the most frequently used primary endpoint for antidepressant clinical trials. This study developed and evaluated the psychometric characteristics of 3 item response theory (IRT)-based short-form depression severity scales based on combinations of the HDRS and Montgomery-Asberg Depression Rating Scale (MADRS) items.

Study Design

A secondary analysis was completed using data from 1027 subjects with major depressive disorder participating in 2 antidepressant clinical trials. Data were collected using the HDRS and MADRS throughout the 6-week clinical trials. Maier, Bech, and Gibbons brief depression scales were calculated based on the HDRS.

Results

Three short-form depression severity (DS) scales were developed based on clinician recommendations and IRT analyses, (DS-1, 7 items; DS-2, 8 items; DS-3, 10 items). Internal consistency reliability of the short forms was 0.87 to 0.93. DS were more reliable across the range of the depression than the HDRS or MADRS. The DS scales were correlated 0.27 to 0.29 with HDRS, 0.55 to 0.85 with MADRS, and −0.25 to −0.34 with Quality of Enjoyment and Satisfaction Questionnaire scores at baseline. In 1 clinical trial, none of the depression outcome measures demonstrated statistically significant differences between the paroxetine and placebo groups. In the second clinical trial, there were significant between-group differences in DS-1 (P = .004; ES = 0.46), DS-2 (P <.001; ES = 0.59), DS-3 (P <.001; ES = 0.63), Bech (P = .007; ES = 0.43), Maier (P = .009; ES = 0.41), Gibbon (P = .003; ES = 0.47), HDRS (P = .007; ES = 0.43), and MADRS (P = .001; ES = 0.54) scores.

Conclusions

The IRT-based short-form depression measures were reliable, valid, and responsive in patients with major depressive disorder. Effect sizes were comparable or better to other depression severity scales.

Sleep disturbances affect practically every segment of society, permeating across all ethnic, socioeconomic, and age groups. According to the American Academy of Sleep Medicine, there are more than 90 different sleep disorders. One of the most commonly diagnosed sleep disorders is sleep apnea. There are 3 types of sleep apnea: central, mixed, and obstructive sleep apnea (OSA). Sleep-disordered breathing is extremely prevalent in the brain-injured patient population. OSA is the most common type of apnea and is easily alleviated with continuous positive airway pressure. However, if left untreated, OSA can induce and exacerbate cognitive deficits and other metabolic disorders. It has been established that OSA is a risk factor for cerebrovascular accidents and cardiovascular outcomes. Patients with brain injury have existing lesions that are exposed to episodic/intermittent hypoxia if accompanied by OSA. The ubiquitous nature of OSA poses a threat to brain-injured patients, and treatment of sleep apnea is warranted to avoid further complications that might prolong recovery and time in rehabilitation. The purpose of this article is to increase awareness among physicians in order to improve the management of patients with brain injury and OSA. We will review the current concepts, prevalence, and ramifications of sleep apnea in brain-injured patients and their cognitive function.

Purpose

Screening rates for colorectal cancer (CRC) in the United States were below the goal of 50% outlined in Healthy People 2010. Physician recommendation is an important predictor of patient compliance. We compared physician CRC screening decision processes (as depicted in decision trees) and examined how variations in decision processes affected decision outcomes. Further, we examined whether those variations could be attributed to physicians’ characteristics and guidelines’ utilization.

Methods

We conducted semi-structured interviews with primary care physicians, developed decision trees, compared trees, used trees to predict the recommendation for 8 sample patients, and used regression analysis to identify predictors of variation.

Results

Most of the physicians (77.3%) self-reported following clinical guidelines for CRC screening. Physicians considered an average of 5.9 decision criteria (range 2-12) in making their screening recommendations. Frequently cited criteria included patient age and family history. We documented variation for 3 of 8 sample patients. Regression analysis indicated that complexity of decision process, gender, age, and experience of physicians contributed to recommendations on screening. In addition, the self-report adherence to guidelines did not influence whether a physician would recommend CRC screening.

Conclusions

This study supports the notion that variation in practice is a function of decision processes. Therefore, studying decision processes may facilitate efforts to improve patient outcomes.

Objective

This analysis compared Asthma Quality-of-Life Questionnaire (AQLQ) data from across 16 countries (17 languages) to evaluate suitability to combine data in analyses.

Study Design

AQLQ data from the Gaining Optimal Asthma Control study was used for the analyses; 1832 patients had an overall AQLQ score at baseline and week 12. The original North American English version, for Canadian patients only, was the reference language (RL). AQLQ scores range from 1-7, where a high score indicates no impairment. Values within 0.5 of the RL were considered comparable.

Results

The number of patients varied from 27 (Canadian French) to 257 (Mandarin Chinese). Mean age ranged from 27.6 (Spain Spanish) to 52.9 years (Norway Norwegian). Mean overall AQLQ score (SD) at baseline in the RL was 4.59 (0.94). All but 3 languages reported scores within 0.5 of the RL. Mean change from baseline in the overall AQLQ score in the RL was 0.89 (1.06). Baseline overall AQLQ scores were all within 0.5 of the RL. Cronbach alpha ranged from 0.93 to 0.97 (RL 0.94). Correlation with baseline Asthma Control Questionnaire (ACQ) and the forced expiratory volume in 1 second (FEV₁) ranged from −0.76 to −0.58 (RL −0.69) and −0.02 to 0.41 (RL 0.08), respectively. Similarly, correlations with change from baseline for ACQ and FEV₁ ranged from −0.83 to −0.61 (RL −0.77) and −0.11 to 0.56 (RL 0.03). Effect sizes were all >0.50, ranging from 0.59 (Norway Norwegian) to 1.10 (New Zealand English) (RL 0.85).

Conclusions

The finding that internal consistency, construct validity, and responsiveness were demonstrated across languages and similar to the RL supports the combining of data for analyses.

Purpose

To examine associations between readability of survey items and missing data rates in a sample of white and African-American Medicare enrollees in managed care plans.

Methods

Consumer Assessment of Healthcare Provider and Systems (CAHPS) 2.0 health plan survey data collected from 139,284 respondents (127,524 whites and 11,760 African Americans) in 321 health plans. Product-moment correlations were computed between Flesch-Kincaid (F-K) readability estimates and the CAHPS item-missing data rates.

Results

F-K reading levels for items ranged from 4.8 to 17.7 with a mean of 8.9 across items. Missing data rates ranged from 1% to 10%, with African Americans having significantly higher missing data rates. Correlations between missing data rates and item-level readability were statistically significant for whites (r = 0.33, P = .0515) and African Americans (r = 0.37, P = .0284).

Conclusions

The significant associations between missing data rates and item-level readability estimates indicate that the completion of survey items varies by their readability. Enhancing the readability of survey items can improve the inclusion of survey data collected from different respondents.

Objective

To describe the effect of the Vermont Diabetes Information System (VDIS) on hospital and emergency department use.

Data Source

Statewide discharge database.

Study Design

Randomized controlled trial of a decision support system for 7412 adults with diabetes and their 64 primary care providers.

Data Collection/Data Extraction

Charges and dates for hospital admissions and emergency department care in Vermont during an average of 32 months of observation. Data from New York hospitals were not available.

Results

Patients randomized to VDIS were admitted to the hospital less often than control subjects (0.17 admissions vs 0.20; P = .01) and generated lower hospital charges ($3113 vs $3480; P = .019). VDIS patients also had lower emergency department utilization (0.27 visits vs 0.36; P <.0001) and charges ($304 vs $414; P <.0001). The intervention was particularly effective in men and in older subjects.

Conclusions

Despite data limitations that tended to reduce the apparent effect of the system, this randomized, controlled trial showed that VDIS reduces hospitalization and emergency department utilization and expenses.

Purpose

The purpose of this study was to compare expected utility preferences of various health outcomes of chemotherapy treatment among ovarian-cancer patients receiving chemotherapy, ovarian cancer patients who were post-treatment (eg, under surveillance), and oncologists who treat this disease.

Methods

Participants were asked to score 6 hypothetical ovarian cancer treatment-related health states using both a rating scale and the standard gamble. Scores were obtained in the range of 0.0 (death) to 1.0 (perfect health) for each hypothetical health state, with a difference of 0.10 being practically meaningful, and were analyzed by analysis of variance.

Results

Seventy-five eligible participants were included in this study (41 ovarian-cancer patients and 34 oncologists). Patients and physicians reported similar responses in the rating scale exercise (F = 0.854, P = .43). However, when the health states were presented with an element of uncertainty via the standard gamble exercise, patients who were under surveillance reported significantly different expected utilities of the health states from physicians and from patients who were receiving treatment, demonstrating greater risk aversion than the other groups (F = 4.270, P = .018).

Conclusions

This study suggests that there are significant differences in expected utility preferences among patients who are under surveillance as opposed to oncologists or patients receiving treatment, despite similarities in rating scale values. These findings suggest a need to further evaluate these differences in expected utility preferences in the context of decision in the setting of recurrent disease, where a patient under surveillance must make decisions related to re-initiation of therapy at a time when her preferences are likely to significantly differ from those of oncologists.