Publications (18) View all
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Article: Rapid diagnostic testing for seasonal influenza: an evidence-based review and comparison with unaided clinical diagnosis.
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ABSTRACT: Worldwide, seasonal influenza imposes a considerable health and economic burden. Clinical diagnosis of influenza-like illness (ILI) is complicated by non-specific symptomatology. Rapid flu tests (RFTs) impact treatment decisions and may improve patient care; yet, recommendations for RFT use are broad, and the performance of unaided clinical diagnosis relative to RFTs is unclear. To determine age-stratified, overall sensitivities and specificities of the widely studied RFT, QuickVue® (Quidel Corporation, San Diego, CA), and clinical diagnosis of ILI by meta-analysis and to seek factors associated with poorer clinical diagnostic discrimination. A systematic literature review was conducted using article selection criteria identifying studies indexed in PubMed/MEDLINE, the Cochrane Library, and other pertinent sources of studies reporting sensitivity, specificity, and effects of RFTs and clinical diagnosis on decision-making for patients with ILI. QuickVue's® diagnostic specificity exceeds that of unaided clinical diagnosis by 29-31%. False-positive results occur approximately 8.2 times more frequently by unaided clinical diagnosis than by the RFT alone. These findings were unaffected by seasonal variations in disease prevalence. RFTs reduce diagnostic testing, antibiotic use, and emergency department utilization while increasing antiviral prescription rates. No systematic relationship between the broadness of clinical diagnostic criteria for influenza and diagnostic performance was observed across studies included in this review. Use of RFTs improves seasonal influenza diagnostic specificity above that based on unaided clinical diagnosis irrespective of the broadness of clinical diagnostic criteria, and affects clinical decision-making. These results provide an improved framework upon which to diagnose influenza, design future RFT studies, and modify existing recommendations for improved ILI patient management.Journal of Emergency Medicine 03/2010; 39(4):476-490.e1. · 1.31 Impact Factor -
Article: Economic burden of ventilator-associated pneumonia based on total resource utilization.
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ABSTRACT: To characterize the current economic burden of ventilator-associated pneumonia (VAP) and to determine which services increase the cost of VAP in North American hospitals. We performed a retrospective, matched cohort analysis of mechanically ventilated patients enrolled in the North American Silver-Coated Endotracheal Tube (NASCENT) study, a prospective, randomized study conducted from 2002 to 2006 in 54 medical centers, including 45 teaching institutions (83.3%). Case patients with microbiologically confirmed VAP (n = 30)were identified from 542 study participants with claims data and were matched by use of a primary diagnostic code, and subsequently by the Acute Physiology and Chronic Health Evaluation II score, to control patients without VAP (n = 90). Costs were estimated by applying hospital-specific cost-to-charge ratios based on all-payer inpatient costs associated with VAP diagnosis-related groups. Median total charges per patient were $198,200 for case patients and $96,540 for matched control patients (P < .001); corresponding median hospital costs were $76,730 for case patients and $41,250 for control patients (P = .001). After adjusting for diagnosis-related group payments, median losses to hospitals were $32,140 for case patients and $19,360 for control patients (P = .151). The median duration of intubation was longer for case patients than for control patients (10.1 days vs 4.7 days; P < .001), as were the median duration of intensive care unit stay (18.5 days vs 8.0 days; P < .001) and the median duration of hospitalization (26.5 days vs 14.0 days; P < .001). Examples of services likely to be directly related to VAP and having higher median costs for case patients were hospital care (P < .05) and respiratory therapy (P < .05). VAP was associated with increased hospital costs, longer duration of hospital stay, and a higher number of hospital services being affected, which underscores the need for bundled measures to prevent VAP. NASCENT study ClinicalTrials.gov Identifier: NCT00148642.Infection Control and Hospital Epidemiology 03/2010; 31(5):509-15. · 3.67 Impact Factor -
Article: An evidence-based review of treatment-related determinants of patients' nonadherence to HIV medications.
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ABSTRACT: Patients' adherence to antiretroviral medications is a primary determinant of both the effectiveness of treatment and the clinical course of HIV/AIDS. This empirical review is intended to compare the relative importance of patient and treatment characteristics on nonadherence behavior and the impact of nonadherence on treatment failure. Articles cited in PubMed and published between 2006 and June 2008 (n = 200) were reviewed to select those that address patient or treatment characteristics associated with nonadherence. Twenty-two articles were selected that provided odds ratio or hazard ratio statistics that quantified predictors of patients' level of nonadherence (e.g., <80%, 80%-95% and >95%). Results were summarized using random effects meta-analytic models. Predictors of nonadherence were divided into four predictive clusters (clinical predictors, comorbid predictors, treatment competence predictors, and dosing predictors). The summary odds ratios (ORs) of nonadherence for each cluster (in order of strength) were treatment competence 2.0 (95% confidence interval [CI]: 1.6-2.6), clinical predictors 1.6 (95% CI: 1.4-1.8), comorbid predictors 1.6 (95% CI: 1.4-1.8), and dosing predictors 1.5 (95% CI: 1.3-1.7). The effect of nonadherence on treatment failure supported the findings of two prior empirical reviews (OR 2.0, 95% CI: 1.6-2.5). Within dosing predictors, a pill burden of more versus less than 10 pills per day was associated with a much higher odds of nonadherence than twice versus once daily dosing or small differences in the number of types of antiretroviral treatments in a regimen. These results provide insight into the relative importance of various determinants of patient nonadherence that may inform the design of patient educational initiatives and initiatives to simplify treatment regimens.AIDS patient care and STDs 07/2009; 23(11):903-14. · 2.68 Impact Factor -
Article: Addressing ceiling effects in health status measures: a comparison of techniques applied to measures for people with HIV disease.
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ABSTRACT: To compare different approaches to address ceiling effects when predicting EQ-5D index scores from the 10 subscales of the MOS-HIV Health Survey. Data were collected from an HIV treatment trial. Statistical methods included ordinary least squares (OLS) regression, the censored least absolute deviations (CLAD) approach, a standard two-part model (TPM), a TPM with a log-transformed EQ-5D index, and a latent class model (LCM). Predictive accuracy was evaluated using percentage of absolute error (R(1)) and squared error (R(2)) predicted by statistical methods. A TPM with a log-transformed EQ-5D index performed best on R(1); a LCM performed best on R(2). In contrast, the CLAD was worst. Performance of the OLS and a standard TPM were intermediate. Values for R(1) ranged from 0.33 (CLAD) to 0.42 (TPM-L); R(2) ranged from 0.37 (CLAD) to 0.53 (LCM). The LCM and TPM with a log-transformed dependent variable are superior to other approaches in handling data with ceiling effects.Health Services Research 03/2008; 43(1 Pt 1):327-39. · 2.16 Impact Factor -
Article: The association of consumer expectations, experiences and satisfaction with newly prescribed medications.
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ABSTRACT: To examine the association between medication expectations and subsequent experience on treatment satisfaction and intention to continue using the medication. A longitudinal study with two surveys administered to each patient. Patients prescribed a new medication were recruited in pharmacies within Michigan. Medication-related expectations were evaluated at baseline. Experiences, satisfaction and intent to continue were evaluated a month later. Analyses used included factorial ANOVA models, multiple linear regressions and structural equation modeling (SEM). Impact of satisfaction on intention to continue was evaluated using correlation analysis and SEM. A total of 344 usable responses were obtained. SEM showed that expectation scores were not associated with both experience (path coefficient = 0.10) and satisfaction (path coefficient = 0.02, NS). On the other hand, experience was strongly associated with satisfaction (path coefficient = 0.89) and satisfaction was strongly associated with intent to continue using the new medication (path coefficient = 0.81). This study empirically supports the value of the patient's experience and its contribution to satisfaction, which in turn is associated with intended continued use mainly due to greater effectiveness of the newly prescribed medication. Satisfied consumers should be more adherent, thus enhancing the probability of positive therapeutic outcomes.Quality of Life Research 10/2007; 16(7):1127-36. · 2.30 Impact Factor
