Publications (42) View all
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Article: A prescription for improving drug formulary decision making.
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ABSTRACT: Gordon Schiff and colleagues present a new tool and checklist to help formularies make decisions about drug inclusion and to guide rational drug use.PLoS Medicine 05/2012; 9(5):1-7. · 16.27 Impact Factor -
Article: Migration of patients between five urban teaching hospitals in chicago.
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ABSTRACT: To quantify the extent of patient sharing and inpatient care fragmentation among patients discharged from a cohort of Chicago hospitals. Admission and discharge dates and patient ZIP codes from 5 hospitals over 2 years were matched with an encryption algorithm. Admission to more than one hospital was considered fragmented care. The association between fragmentation and socio-economic variables using ZIP-code data from the 2000 US Census was measured. Using validation from one hospital, patient matching using encrypted identifiers had a sensitivity of 99.3 % and specificity of 100 %. The cohort contained 228,151 unique patients and 334,828 admissions. Roughly 2 % of the patients received fragmented care, accounting for 5.8 % of admissions and 6.4 % of hospital days. In 3 of 5 hospitals, and overall, the length of stay of patients with fragmented care was longer than those without. Fragmentation varied by hospital and was associated with the proportion of non-Caucasian persons, the proportion of residents whose income fell in the lowest quartile, and the proportion of residents with more children being raised by mothers alone in the zip code of the patient. Patients receiving fragmented care accounted for 6.4 % of hospital days. This percentage is a low estimate for our region, since not all regional hospitals participated, but high enough to suggest value in creating Health Information Exchange. Fragmentation varied by hospital, per capita income, race and proportion of single mother homes. This secure methodology and fragmentation analysis may prove useful for future analyses.Journal of Medical Systems 04/2013; 37(2):9930. · 1.13 Impact Factor -
Article: Complexity of medication use in newly diagnosed chronic obstructive pulmonary disease patients.
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ABSTRACT: To better understand how medications have been used and the complexity of regimens used to treat patients, we characterized patterns of medication use and the degree to which patients used different classes of medications in combination and over time in a cohort of newly diagnosed chronic obstructive pulmonary disease (COPD) patients. The objectives of this study were to characterize patterns of medication use, including the degree to which patients used different classes of medications in combination and over time within a cohort of newly diagnosed COPD patients and to identify the proportion of patients who had gaps in filling their prescriptions. We identified a cohort of patients from the Veterans Affairs health care system with newly diagnosed COPD between 1999 and 2003. Using prescription fill information, we quantified the prevalence and incidence of exposure to short-acting β-agonists (SABAs), long-acting β-agonists (LABAs), short-acting anticholinergics (eg, ipratropium [IPRA]), and inhaled corticosteroids (ICSs) over 1 year. We additionally characterized the sequencing of medication addition and discontinuation and gaps between prescription fills. The prevalence of multiple respiratory medication use was summarized at 90, 180, and 365 days of follow-up. Of 133,737 patients with newly diagnosed COPD, the majority (80.0%) used a SABA, followed by 40.0% using IPRA, 33.2% using an ICS and 16.0% using a LABA during the 1-year follow-up. Medication changes were frequent, with 57.7% of patients having a medication addition and 48.6% discontinuing medication. The sequence of medication changes varied greatly across patients. Multiple respiratory medication use was common, with 29% of patients dispensed 3 to 4 medication classes in 1 year. Many COPD patients who are started on medication management undergo changes in prescribed pharmacotherapy and are taking multiple medications. Despite clinical practice guidelines, there is an ad hoc nature of COPD medication management, and such heterogeneity challenges the ability to estimate relationships between drug exposure and outcomes using real-world data.The American journal of geriatric pharmacotherapy. 01/2012; 10(2):110-122.e1. -
Article: Measuring hospital efficiency with Data Envelopment Analysis: nonsubstitutable vs. substitutable inputs and outputs.
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ABSTRACT: There is a conflict between Data Envelopment Analysis (DEA) theory's requirement that inputs (outputs) be substitutable, and the ubiquitous use of nonsubstitutable inputs and outputs in DEA applications to hospitals. This paper develops efficiency indicators valid for nonsubstitutable variables. Then, using a sample of 87 community hospitals, it compares the new measures' efficiency estimates with those of conventional DEA measures. DEA substantially overestimated the hospitals' efficiency on the average, and reported many inefficient hospitals to be efficient. Further, it greatly overestimated the efficiency of some hospitals but only slightly overestimated the efficiency of others, thus making any comparisons among hospitals questionable. These results suggest that conventional DEA models should not be used to estimate the efficiency of hospitals unless there is empirical evidence that the inputs (outputs) are substitutable. If inputs (outputs) are not substitutes, efficiency indicators valid for nonsubstitutability should be employed, or, before applying DEA, the nonsubstitutable variables should be combined using an appropriate weighting scheme or statistical methodology.Journal of Medical Systems 12/2011; 35(6):1393-401. · 1.13 Impact Factor -
Article: Comparison of rate control versus rhythm control for management of atrial fibrillation in patients with coexisting heart failure: a cost-effectiveness analysis.
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ABSTRACT: To compare lifetime costs and health outcomes of rate control versus rhythm control for management of atrial fibrillation in patients with coexisting heart failure from the third-party payer perspective. A Markov decision analysis model constructed from costs, utility, and transition probability inputs obtained from randomized clinical trials and publically available databases. A simulated cohort aged 65 years or older with persistent or paroxysmal atrial fibrillation and heart failure. Markov states for rhythm control were cardioversion plus amiodarone and maintenance amiodarone, and those for rate control were β-blocker, digoxin, and calcium channel blocker. Transition states included treatment success, hospitalizations for atrial fibrillation and/or heart failure, and severe adverse effects. Economic inputs included cost for drugs, cost of hospitalizations for atrial fibrillation and/or heart failure, and cost of management of severe adverse effects. Costs were measured in 2009 U.S. dollars, and clinical outcomes in quality-adjusted life-years (QALYs). One-way and multivariable sensitivity analyses were conducted. Uncertainty intervals (UIs) were obtained from probabilistic sensitivity analyses. Rate control was found to be less costly and more effective than rhythm control. Base case and probabilistic sensitivity analyses cost and effectiveness values for rate control were $7231 (95% UI $5517-9016) and 2.395 QALYs (95% UI 2.366-2.424 QALYs); whereas those for rhythm control were $16,291 (95% UI $11,033-21,434) and 2.197 QALYs (95% UI 2.155-2.237 QALYs). No critical values were found for any model parameters in the one-way sensitivity analyses. The cost-effectiveness acceptability curves showed that rate control was considered cost-effective in 100% of cases at willingness-to-pay ratios between $0 and $200,000/QALY. Rate control is less costly and more effective than rhythm control and should be the initial treatment for atrial fibrillation among patients with coexisting heart failure.Pharmacotherapy 06/2011; 31(6):552-65. · 2.90 Impact Factor
