Publications (116) View all
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Article: Measurement in Comparative Effectiveness Research.
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ABSTRACT: Comparative effectiveness research (CER) on preventive services can shape policy and help patients, their providers, and public health practitioners select regimens and programs for disease prevention. Patients and providers need information about the relative effectiveness of various regimens they may choose. Decision makers need information about the relative effectiveness of various programs to offer or recommend. The goal of this paper is to define and differentiate measures of relative effectiveness of regimens and programs for disease prevention. Cancer screening is used to demonstrate how these measures differ in an example of two hypothetical screening regimens and programs. Conceptually and algebraically defined measures of relative regimen and program effectiveness also are presented. The measures evaluate preventive services that range from individual tests through organized, population-wide prevention programs. Examples illustrate how effective screening regimens may not result in effective screening programs and how measures can vary across subgroups and settings. Both regimen and program relative effectiveness measures assess benefits of prevention services in real-world settings, but each addresses different scientific and policy questions. As the body of CER grows, a common lexicon for various measures of relative effectiveness becomes increasingly important to facilitate communication and shared understanding among researchers, healthcare providers, patients, and policymakers.American journal of preventive medicine 05/2013; 44(5):513-519. · 4.24 Impact Factor -
Article: Screening colonoscopy and risk for incident late-stage colorectal cancer diagnosis in average-risk adults: a nested case-control study.
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ABSTRACT: Chinese translation The effectiveness of screening colonoscopy in average-risk adults is uncertain, particularly for right colon cancer. To examine the association between screening colonoscopy and risk for incident late-stage colorectal cancer (CRC). Nested case-control study. Four U.S. health plans. 1039 average-risk adults enrolled for at least 5 years in one of the health plans. Case patients were aged 55 to 85 years on their diagnosis date (reference date) of stage IIB or higher (late-stage) CRC during 2006 to 2008. One or 2 control patients were selected for each case patient, matched on birth year, sex, health plan, and prior enrollment duration. Receipt of CRC screening 3 months to 10 years before the reference date, ascertained through medical record audits. Case patients and control patients were compared on receipt of screening colonoscopy or sigmoidoscopy by using conditional logistic regression that accounted for health history, socioeconomic status, and other screening exposures. In analyses restricted to 471 eligible case patients and their 509 matched control patients, 13 case patients (2.8%) and 46 control patients (9.0%) had undergone screening colonoscopy, which corresponded to an adjusted odds ratio (AOR) of 0.29 (95% CI, 0.15 to 0.58) for any late-stage CRC, 0.36 (CI, 0.16 to 0.80) for right colon cancer, and 0.26 (CI, 0.06 to 1.11; P = 0.069) for left colon/rectum cancer. Ninety-two case patients (19.5%) and 173 control patients (34.0%) had screening sigmoidoscopy, corresponding to an AOR of 0.50 (CI, 0.36 to 0.70) overall, 0.79 (CI, 0.51 to 1.23) for right colon late-stage cancer, and 0.26 (CI, 0.14 to 0.48) for left colon cancer. The small number of screening colonoscopies affected the precision of the estimates. Screening with colonoscopy in average-risk persons was associated with reduced risk for diagnosis of incident late-stage CRC, including right-sided colon cancer. For sigmoidoscopy, this association was seen for left CRC, but the association for right colon late-stage cancer was not statistically significant. National Cancer Institute of the National Institutes of Health.Annals of internal medicine 03/2013; 158(5 Pt 1):312-20. · 16.73 Impact Factor -
Article: Suspected Extracolonic Neoplasms Detected on CT Colonography: Literature Review and Possible Outcomes.
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ABSTRACT: RATIONALE AND OBJECTIVES: This study summarizes the literature on the detection of cancer among indeterminate extracolonic findings on computed tomographic (CT) colonography in five targeted organs. MATERIALS AND METHODS: We searched PubMed for English-language literature published between January 1, 1994, and December 31, 2010. We describe extracolonic findings in the kidney, lung, liver, pancreas, and ovary suspect for malignancy as they are associated with high mortality. For each organ, we calculated the median prevalence, positive predictive value (PPV), and false positive rate of malignancy and a pooled false-positive rate across studies. RESULTS: Of 91 publications initially identified, 24 were eligible for review. Indeterminate renal masses on CT colonography had 20.5% median PPV and low pooled false positive rate of 1.3% (95% confidence interval 0.6-2.0). In contrast, indeterminate masses of the lung, liver, pancreas, and ovary had low PPV (median values ranged from 0% to 3.8%). Indeterminate masses of the ovary resulted in the highest pooled false-positive rate of 2.2%. Results were similar in studies of both screening and nonscreening populations. We estimated the probability of false positive results through the detection of significant extracolonic findings as 46 per 1000 for men and 68 per 1000 for women. CONCLUSIONS: Indeterminate renal masses newly detected on CT colonography have an estimated one in five chance of malignancy and therefore warrant further follow-up to provide a definitive diagnosis. Conversely, indeterminate masses of the lung, liver, pancreas, and ovary are associated with high false positive rates and merit more conservative clinical follow-up.Academic radiology 03/2013; · 2.09 Impact Factor -
Article: Assessing the accuracy of profiling methods for identifying top providers: performance of mental health care providers.
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ABSTRACT: Provider profiling as a means to describe and compare the performance of health care professionals has gained momentum in the past decade. As a key component of pay-for-performance programs profiling has been increasingly used to identify top-performing providers. However, rigorous examination of the performance of statistical methods for profiling when used to classify top-performing providers is lacking. The objective of this study was to compare the classification accuracy of three methods for identifying providers exceeding performance thresholds and to analyze data on satisfaction with mental health care providers at Group Health Cooperative using these methods. Questionnaire data on patient satisfaction with mental health care providers at Group Health Cooperative was collected between April 2008 and January 2010. Simulated data were used to compare the classification accuracy of alternative statistical methods. We evaluated sensitivity, specificity, and root mean squared error of alternative statistical methods using simulated data. For Group Health providers, we compared agreement of alternative approaches to classification. We found that when between-provider variability in performance was low, all three methods exhibited poor classification accuracy. When used to evaluate mental health care provider performance, we found substantial uncertainty in the estimates and poor agreement across methods. Based on these findings, we recommend providing uncertainty estimates for provider rankings and caution against the use of any classification method when between-provider variability is low.Health Services and Outcomes Research Methodology 03/2013; 13(1):1-17. -
Article: Patient-Rated Alliance as a Measure of Therapist Performance in Two Clinical Settings.
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ABSTRACT: Objective: The ability to form a strong therapeutic alliance is considered a foundational skill across psychotherapies. Patient-rated measures of the alliance are now being used to make judgments about a therapist's tendency to build alliances with their patients. However, whether a patient-rated alliance measure provides a useful index of a therapist's tendency to have strong alliances is not clear. Method: We examined therapist differences in patient ratings of the alliance obtained from an HMO that included 2 samples-an internal HMO clinic (n = 3287, 3781 ratings, therapist n = 72) and an independent practice (IP) based sample (n = 1320, 1690 ratings, therapist n = 93). First, we estimated the amount of variability in alliance scores due to therapist, including the consistency of estimated differences across 2 samples and using a cross-validation strategy. Second, we used a multivariate multilevel model to examine the convergent and discriminant validity of therapist differences in patient alliance ratings in items theoretically related (e.g., satisfaction) and unrelated (e.g., patient ratings of scheduling staff) to the therapist and alliance. Results: Therapists accounted for between 1.74% and 6.93% of the variability in alliance ratings, with greater differences among IP therapists. Therapist differences were generally stable and unaffected by case mix. In addition, therapist differences in alliance were correlated with therapist differences in similar items but were relatively unrelated to theoretically distinct items. Conclusions: Therapist differences in the alliance were small but, with a sufficient number of ratings, may provide reliable information regarding a therapist's tendency to form strong alliances with their patients. (PsycINFO Database Record (c) 2012 APA, all rights reserved).Journal of Consulting and Clinical Psychology 12/2012; · 4.85 Impact Factor
