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New England Journal of Medicine 12/2012; 367(26):2467-9. · 53.30 Impact Factor
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ABSTRACT: BACKGROUND: Aligning patient and surgeon expectations preoperatively may lead to better postoperative medical and rehabilitation compliance and therefore improve outcomes and increase satisfaction. QUESTIONS/PURPOSES: We (1) determined the rate of discordantly high patient expectations compared with those of their surgeon in patients undergoing TKA; and (2) evaluated the impact of the preoperative educational class, patient characteristics, and functional status on the likelihood of having discordantly high patient expectations. METHODS: We enrolled 205 patients awaiting TKA. Each patient completed a validated questionnaire that addresses expectations of postoperative pain relief, function, and well-being as part of a preoperative assessment. The surgeon completed the same expectations questionnaire preoperatively blinded to their patient's response. Patients had discordantly high expectations if their scores were ≥ 7 points higher than the surgeon on a 0 to 100 score range. Regression analysis was performed to determine the effect of class, patient characteristics, and functional status on the likelihood of having discordantly high patient expectations. RESULTS: Thirty-seven percent of the patients had expectation scores ≥ 7 points higher than those of their surgeon. Patients were less likely to have discordantly higher expectations if they were female (OR, 0.56; CI, 0.32-0.97) and if their pain level was high (OR, 0.99; CI, 0.98-0.99). Patients were more likely to have discordantly higher expectations if they filled out the expectations survey before rather than after the preoperative educational class (OR, 1.80; CI, 1.08-3.01). CONCLUSIONS: With increasing TKA use, surgeons will likely encounter more patients with discordantly high expectations. The preoperative educational class can be used to target patients more likely to have discordantly high expectations. LEVEL OF EVIDENCE: Level I, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 07/2012; · 2.53 Impact Factor
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ABSTRACT: Implantable cardioverter-defibrillators (ICDs) have diffused rapidly into clinical practice with little evaluation of their real-world effectiveness.
To determine the effect of the adoption of ICD on patient safety, particularly with respect to physician volume and early outcomes.
Retrospective cohort of all ICD implantations in New York state from 1997 to 2006, with follow-up at 90 days and 1 year. Setting New York state non-federal hospital discharges in which an ICD was implanted during the admission. Patients were followed forward for 1 year for subsequent admissions. Patients New York state residents undergoing ICD implantation.
Effects of annual and career ICD implantation volume on 90-day complication, readmission, reprogramming, mortality and revision of the ICD within 1 year.
This cohort (N = 38,992) represents a period of rapid adoption and implementation of this new technology, with frequency more than tripling between 1997 and 2006. We identified 6439 (16.5%) post-implantation complications and 1093 (2.8%) deaths within 90 days of implantation. The majority (73.4%) of physicians implanted one or fewer ICDs per year, and 11.0% of all implantations were performed by these very-low-volume operators. Patients treated by very-low-volume operators were more likely to die (RR = 1.8, 95% CI 1.3 to 2.4) or experience cardiac complications (RR = 4.7, 95% CI 3.3 to 6.8) even after the adjustment for case mix compared to operators who frequently performed ICD implantation.
These findings suggest a need for safe and effective implementation strategies for new medical technologies, which minimize patient risk due to rapid diffusion among inexperienced providers and assure that the intended benefit can be maximised rapidly.
Heart (British Cardiac Society) 07/2011; 97(20):1655-60. · 4.22 Impact Factor
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ABSTRACT: Delayed cerebral ischemia (DCI) is a devastating condition that occurs secondary to aneurysmal subarachnoid hemorrhage (A-SAH). The purpose is to compare computed tomography perfusion (CTP) and digital subtraction angiography (DSA) for determining DCI in A-SAH.
A retrospective study of A-SAH patients admitted at our institution between December 2004 and December 2008 was performed. CTP and DSA were obtained at days 6-8 after aneurysm rupture. Both qualitative and quantitative analyses of CT perfusion deficits were performed. DSA was categorized as presence or absence of vasospasm. The reference standard for determining DCI was based on clinical deterioration or infarction on CT or MRI. The test characteristics of CTP and DSA were calculated and their graphs of conditional probabilities were constructed using Bayesian analysis.
Fifty-seven patients were included; 79% (45/57) had DCI. Seventy percent (40/57) had CTP perfusion deficits; 80% (36/45) of the DCI and 33% (4/12) of no DCI patients. Sixty-three percent (36/57) had DSA demonstrating vasospasm; 73% (33/45) of the DCI and 25% (3/12) of no DCI patients. Quantitative analysis of the CTP data revealed a significant difference in cerebral blood flow values for the DCI (29.4 mL/100 g/minute) and no DCI groups (40.5 mL/100 g/minute, P = .0213). The sensitivity, specificity, and positive and negative predictive values for CTP were 0.80 (95% CI 0.68-0.92), 0.67 (95% CI 0.40-0.93), 0.90 (95% CI 0.82-0.96), 0.47 (95% CI 0.27-0.62), and for DSA were 0.73 (95% CI 0.60-0.86), 0.75 (95% CI 0.50-0.99), 0.92 (95% CI 0.82-0.98), and 0.43 (95% CI 0.26-0.53), respectively.
CTP and DSA have similar test characteristics and Bayesian analysis for determining DCI in A-SAH patients.
Academic radiology 06/2011; 18(9):1094-100. · 2.09 Impact Factor
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ABSTRACT: The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, which provided optimal medical therapy (OMT) to all patients and demonstrated no incremental advantage of percutaneous coronary intervention (PCI) on outcomes other than angina-related quality of life in stable coronary artery disease (CAD), suggests that a trial of OMT is warranted before PCI. It is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial.
To examine the use of OMT in patients with stable angina undergoing PCI before and after the publication of the COURAGE trial.
An observational study of patients with stable CAD undergoing PCI in the National Cardiovascular Data Registry between September 1, 2005, and June 30, 2009. Analysis compared use of OMT, both before PCI and at the time of discharge, before and after the publication of the COURAGE trial. Optimal medical therapy was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, β-blocker, and statin).
Rates of OMT before PCI and at discharge (following PCI) between the 2 study periods.
Among all 467,211 patients (173,416 before [37.1%] and 293,795 after [62.9%] the COURAGE trial) meeting study criteria, OMT was used in 206,569 patients (44.2%; 95% confidence interval [CI], 44.1%-44.4%) before PCI and in 303,864 patients (65.0%; 95% CI, 64.9%-65.2%) at discharge following PCI (P < .001). Before PCI, OMT was applied in 75,381 patients (43.5%; 95% CI, 43.2%-43.7%) before the COURAGE trial and in 131,188 patients (44.7%; 95% CI, 44.5%-44.8%) after the COURAGE trial (P < .001). The use of OMT at discharge following PCI before and after the COURAGE trial was 63.5% (95% CI, 63.3%-63.7%) and 66.0% (95% CI, 65.8%-66.1%), respectively (P < .001).
Among patients with stable CAD undergoing PCI, less than half were receiving OMT before PCI and approximately two-thirds were receiving OMT at discharge following PCI, with relatively little change in these practice patterns after publication of the COURAGE trial.
JAMA The Journal of the American Medical Association 05/2011; 305(18):1882-9. · 30.03 Impact Factor
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ABSTRACT: Total joint arthroplasties are recognized as being effective in the treatment of joint disease and making a significant difference in patients' quality of life. Understanding the trends and disparities in use of these procedures is important for policy decisions. However, research on these issues has been limited because of the suboptimal samples used. To study trends and racial and economic disparities associated with total hip and total knee arthroplasties, we used a large national database, Nationwide Inpatient Sample, 1996-2005, which may be best suited for elucidating trends and disparities in treatment use. Primary and revision hip and knee arthroplasties were the primary outcomes. Rates of use were computed by count per 100,000 persons in the population. Logistic regression was used to examine the associations between disparity factors and each outcome, where regressors included age, sex, race, regional income, hospital characteristics, payer, comorbidities, and obesity. Between 1996 and 2005, primary arthroplasty rates have increased, but revision rates only minimally. Racial disparities were larger than income disparities. Our study also revealed that racial disparities were not confined to the elderly or to low-income populations. This may mean that there is an unmet need for these medical procedures among racial minorities.
American journal of orthopedics (Belle Mead, N.J.) 09/2010; 39(9):E95-102.
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ABSTRACT: Multiple randomized controlled trials (RCTs) have established the efficacy of statins for the prevention of cardiovascular disease. The benefits observed are often framed in terms of percentage reductions in low-density lipoprotein (LDL) cholesterol from baseline or percentage reductions between control and treatment groups, although epidemiologic data suggest that the absolute intergroup difference in LDL cholesterol (DeltaLDL(Control-Rx)) is the more informative measure. A systematic review of large-scale trials of statins versus placebo, usual care, or active (lower dose statin) control was conducted to calculate updated summary estimates of risk reduction in coronary artery disease and all-cause mortality. Meta-regression analysis was used to ascertain the relations of different LDL cholesterol metrics to outcomes. In 20 eligible RCTs, there were significant overall reductions for coronary artery disease (odds ratio 0.72, 95% confidence interval 0.67 to 0.78) and mortality (odds ratio 0.89, 95% confidence interval 0.84 to 0.94), but with substantial variability in trial results. DeltaLDL(Control-Rx) was the strongest determinant of coronary artery disease risk reduction, particularly after excluding active-comparator studies, and was independent of baseline LDL cholesterol. In contrast, baseline LDL cholesterol edged out DeltaLDL(Control-Rx) as the strongest determinant of mortality, but neither was significant after the exclusion of active-comparator studies. The exclusion of 3 RCTs involving distinct populations, however, rendered DeltaLDL(Control-Rx) the predominant determinant of mortality reduction. In conclusion, these findings underscore the primacy of absolute reductions in LDL cholesterol in the design and interpretation of RCTs of lipid-lowering therapies and in framing treatment recommendations on the basis of the proved coronary benefits of these drugs.
The American journal of cardiology 05/2010; 105(9):1289-96. · 3.58 Impact Factor
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New England Journal of Medicine 01/2010; 362(3):e6. · 53.30 Impact Factor
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ABSTRACT: Comparative Effectiveness Research (CER) has recently emerged as a major theme in health care reform. Unfortunately, there is a widespread lack of understanding about what it will do and fear that it will do more harm than good. These concerns include threats to individual physician's autonomy and professionalism, as well as fears that care will be rationed based on such findings. In this paper, we argue that the main components of the current healthcare reform (HCR) bills, which include expanding insurance while increasing efficiencies through cost containment, should embrace CER. This type of research will provide a "safeguard" against "blind" cost-containment, so that the new financial incentives being introduced can be actualized effectively and safely. Evidence for this is provided from examples from the authors' prior and current research as well as from the literature. We also argue that the requirement for data from CER will create long-term disincentives for "me-too" drugs and devices and, therefore, become a catalyst for effective innovation.
Transactions of the American Clinical and Climatological Association 01/2010; 121:141-54; discussion 154-5.
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ABSTRACT: National guidelines disagree on who should be screened for undiagnosed diabetes. No existing diabetes risk score is highly generalizable or widely followed.
To develop a new diabetes screening score and compare it with other available screening instruments (Centers for Disease Control and Prevention, American Diabetes Association, and U.S. Preventive Services Task Force guidelines; 2 American Diabetes Association risk questionnaires; and the Rotterdam model).
Cross-sectional data.
NHANES (National Health and Nutrition Examination Survey) 1999 to 2004 for model development and 2005 to 2006, plus a combined cohort of 2 community studies, ARIC (Atherosclerosis Risk in Communities) Study and CHS (Cardiovascular Health Study), for validation.
U.S. adults aged 20 years or older.
A risk-scoring algorithm for undiagnosed diabetes, defined as fasting plasma glucose level of 7.0 mmol/L (126 mg/dL) or greater without known diabetes, was developed in the development data set. Logistic regression was used to determine which participant characteristics were independently associated with undiagnosed diabetes. The new algorithm and other methods were evaluated by standard diagnostic and feasibility measures.
Age, sex, family history of diabetes, history of hypertension, obesity, and physical activity were associated with undiagnosed diabetes. In NHANES (ARIC/CHS), the cut-point of 5 or more points selected 35% (40%) of persons for diabetes screening and yielded a sensitivity of 79% (72%), specificity of 67% (62%), positive predictive value of 10% (10%), and positive likelihood ratio of 2.39 (1.89). In contrast, the comparison scores yielded a sensitivity of 44% to 100%, specificity of 10% to 73%, positive predictive value of 5% to 8%, and positive likelihood ratio of 1.11 to 1.98.
Data during pregnancy were not available.
This easy-to-implement diabetes screening score seems to demonstrate improvements over existing methods. Studies are needed to evaluate it in diverse populations in real-world settings.
Clinical and Translational Science Center at Weill Cornell Medical College.
Annals of internal medicine 12/2009; 151(11):775-83. · 16.73 Impact Factor
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Medical Care 01/2008; 45(12):1227-32. · 3.41 Impact Factor
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ABSTRACT: Racial disparities in medical care in the United States are pervasive and persistent. Minorities, African American patients in particular, have lower utilization rates for coronary artery bypass graft surgery (CABG) and, compared with white patients, they receive care from surgeons with worse records of performance.
We sought to examine the persistence of disparities in CABG care (overall access to surgery and access to high-quality surgeons) in recent years and the potential causes for declining disparities.
We undertook a retrospective analysis of data comparing access to CABG surgery and access to high-quality cardiac surgeons for white and black patients in the late 1990s and the early 2000s. Data used included the Medicare inpatient and physician part B claims and the New York State Cardiac Surgery Reports. A total of 24,087 Medicare fee-for-service patients undergoing CABG surgery between the years 1997-1999 and 23,048 patients undergoing CABG surgery between the years of 2001-2003 in New York State were studied. We measured the number of patients undergoing surgery by race and quality of surgeons measured by the surgeons' risk-adjusted mortality rates.
Disparities have declined between the 2 periods. The decline seems to be associated with freed surgical capacity among all surgeons, although other factors may also present barriers, especially in terms of overall access to surgery. Despite the decline in disparities, gaps in care received by white and black patients remain.
Medical Care 08/2007; 45(7):664-71. · 3.41 Impact Factor
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ABSTRACT: Race and insurance status influence the likelihood of undergoing laparoscopic appendectomy (LA) versus open appendectomy for the treatment of acute appendicitis. We hypothesized that these disparities are caused by presenting hospitals' use of LA.
The analysis included 26,104 appendectomies for acute appendicitis in New York State during 2003 and 2004. Multiple logistic regression was used to determine independent predictors for undergoing LA versus open appendectomy.
Before adjustment for individual hospital use of LA, both white patients (odds ratio [OR] = 1.28, 95% confidence interval [CI] 1.21-1.36; P < .0001] and privately insured patients (OR = 1.52, 95% CI 1.44-1.61; P < .0001) were more likely to undergo LA. Controlling for differential hospitals' use of LA decreased the OR for laparoscopic surgery to 1.08 (95% CI 1.01-1.15; P = .04) for white patients and to 1.22 (95% CI 1.15-1.31; P < .0001) for privately insured patients.
Differences in presenting hospitals' use of LA maintain racial and, to a lesser extent, insurance-related disparities in the surgical management of patients with acute appendicitis.
American journal of surgery 07/2007; 194(1):57-62. · 2.36 Impact Factor
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ABSTRACT: To estimate the cost-effectiveness from a societal perspective of a hip protector (HP) program over the remaining lifetime of individuals initially living at home.
A state-transition Markov model considering outcomes of HP use in cohorts stratified by age, sex, and functional and residential status. Costs, transition probabilities, HP adherence, and efficacy were derived from published sources.
Community and nursing homes in the United States.
Hypothetical cohort of individuals aged 65 and older without a hip fracture and initially living at home.
HP program.
Fractures, life years, and dollars saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER).
HP use prevented fractures and increased life expectancy in all cohorts. HP use saved costs and improved QALYs in women initiating HP use at age 80 and in men at age 85. In women initiating HP use at age 75, the HP ICER was 19,000 dollars/QALY. In men initiating HP use at age 80, HP use saved costs but slightly decreased QALYs. In younger cohorts, HP use was neither cost saving nor QALY improving. In sensitivity analyses, if there was no QALY loss from wearing a HP, the ICER was less than 50,000 dollars/QALY for all age and sex cohorts. If HP cost was reduced 50%, HP use was cost saving for women initiating HP use at age 75. In probabilistic sensitivity analyses, the HP ICER was less than 50,000 dollars/QALY in 68% of simulations for women initiating HP use at age 75 and 61% of simulations for men initiating at age 85.
HP use saved costs and QALYs for older age cohorts of both sexes. Additional research on the quality-of-life effects and obstacles to wearing HP is warranted.
Journal of the American Geriatrics Society 12/2006; 54(11):1658-65. · 3.74 Impact Factor
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ABSTRACT: To examine the referral process to cardiac surgeons in order to explain racial disparities in access to high-quality cardiac surgeons. DATA SOURCES/STUDY SETTINGS: All white and black Medicare fee-for-service patients undergoing coronary artery bypass graft (CABG) surgery in New York State during 1997-1999.
A retrospective analysis of referral patterns for white and black patients in relation to the quality of the cardiac surgeon, measured by the surgeon's risk-adjusted mortality rate (RAMR), and in relation to characteristics of the physician providing the majority of cardiac care before the surgery. The average RAMRs of the surgeons to whom different physicians referred patients were compared using t-tests and paired t-tests. A hierarchical multivariate regression model was estimated to test hypotheses about the effect of physicians' characteristics on referrals of blacks to low-quality surgeons. DATA EXTRACTION METHOD: Variables were constructed from Medicare claims.
The differential in surgeons' quality for white and black patients is partially due to the physician providing the majority of cardiac care before the surgery. There is both across- and within-physician variation in referrals. Of the physician characteristics investigated, only the number of black patients referred to CABG and the percent of all cardiac referrals to the same hospital decrease the difference in surgeons' quality between whites and blacks.
Several different pathways lead blacks to cardiac surgeons of lower quality. Further research is needed to understand the causes and inform policies designed to minimize disparities in access to high-quality providers.
Health Services Research 09/2006; 41(4 Pt 1):1276-95. · 2.16 Impact Factor
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Journal of the American Geriatrics Society 08/2006; 54(7):1159-60. · 3.74 Impact Factor
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Jack Zwanziger,
W Jackson Hall,
Andrew W Dick,
Hongwei Zhao, Alvin I Mushlin,
Rebecca Marron Hahn,
Hongkun Wang,
Mark L Andrews,
Cathleen Mooney,
Hongyue Wang,
Arthur J Moss
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ABSTRACT: We sought to evaluate the cost implications of the implantable cardioverter-defibrillator (ICD), using utilization, cost, and survival data from the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II.
This trial showed that prophylactic implantation of a defibrillator reduces the rate of mortality in patients who experienced a previous myocardial infarction and low left ventricular ejection fraction. Given the size of the eligible population, the cost effectiveness of the ICD has substantial implications.
Our research comprises the cost-effectiveness component of the randomized controlled trial, MADIT-II, based on utilization, cost, and survival information from 1,095 U.S. patients who were assigned randomly to receive an ICD or conventional medical care. Utilization data were converted to costs using a variety of national and hospital-specific data. The incremental cost-effectiveness ratio (iCER) was calculated as the difference in discounted costs divided by the difference in discounted life expectancy within 3.5 years. Secondary analyses included projections of survival (using three alternative assumptions), corresponding cost assumptions, and the resulting cost-effectiveness ratios until 12 years after randomization.
During the 3.5-year period of the study, the average survival gain for the defibrillator arm was 0.167 years (2 months), the additional costs were 39,200 dollars, and the iCER was 235,000 dollars per year-of-life saved. In three alternative projections to 12 years, this ratio ranged from 78,600 dollars to 114,000 dollars.
The estimated cost per life-year saved by the ICD in the MADIT-II study is relatively high at 3.5 years but is projected to be substantially lower over the course of longer time horizons.
Journal of the American College of Cardiology 07/2006; 47(11):2310-8. · 14.16 Impact Factor
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ABSTRACT: More than 6 million Americans have undiagnosed diabetes. Several national organizations endorse screening for diabetes by physicians, but actual practice is poorly understood. Our objectives were to measure the rate, the predictors and the results of glucose testing in primary care, including rates of follow-up for abnormal values.
We conducted a retrospective cohort study of 301 randomly selected patients with no known diabetes who received care at a large academic general internal medicine practice in New York City. Using medical records, we collected patients' baseline characteristics in 1999 and followed patients through the end of 2002 for all glucose tests ordered. We used multivariate logistic regression to measure associations between diabetes risk factors and the odds of glucose testing.
Three-fourths of patients (78%) had at least 1 glucose test ordered. Patient age (> or = 45 vs. < 45 years), non-white ethnicity, family history of diabetes and having more primary care visits were each independently associated with having at least 1 glucose test ordered (p < 0.05), whereas hypertension and hyperlipidemia were not. Fewer than half of abnormal glucose values were followed up by the patients' physicians.
Although screening for diabetes appears to be common and informed by diabetes risk factors, abnormal values are frequently not followed up. Interventions are needed to trigger identification and further evaluation of abnormal glucose tests.
BMC Health Services Research 01/2006; 6:87. · 1.66 Impact Factor
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ABSTRACT: The recent affiliation of The Methodist Hospital (TMH) with Weill Medical College (WMC) of Cornell University and NewYork-Presbyterian Hospital is the first transcontinental primary affiliation between major, not-for-profit academic health centers (AHCs) in the United States. The authors describe the process followed, the issues involved, the initial accomplishments, and the opportunities envisioned. The key enablers of this affiliation were a rapid process, mutual trust based on existing professional relationships, and commitment to the project by Board leadership. Because of their geographic separation, the parties were not competitors in providing clinical care to their regional populations. The affiliation is nonexclusive, but is reciprocally primary in New York and Texas. Members of the TMH medical staff are eligible for faculty appointments at WMC. The principal areas of collaboration will be education, research, quality improvement, information technology, and international program development. The principal challenge has been the physical distance between the parties. Although extensive use of videoconferencing has been successful, personal contact is essential in establishing relationships. External processes impose a slower sequence and tempo of events than some might wish. This new model for AHCs creates exciting possibilities for the tripartite mission of research, education, and patient care. Realizing the potential of these opportunities will require unconstrained ideas and substantial investment of time and other critical resources. Since many consider that AHCs are in economic and cultural crisis, successful development of such possibilities could have importance beyond the collective interests of these three institutions.
Academic Medicine 12/2005; 80(11):1046-53. · 3.52 Impact Factor
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ABSTRACT: To estimate potential cost savings generated by a program of hip protectors in the nursing home from a Medicare perspective.
A state-transition Markov model considering short-term and long-term outcomes of hip protectors for a hypothetical nursing home population, stratified by age, sex, and functional status. Costs, transition probabilities between health states, and estimates of hip protectors' effectiveness were derived from published secondary data.
Nursing home facilities in the United States.
Hypothetical cohort of permanent nursing home residents aged 65 and older without a previous hip fracture.
Program of hip protectors reimbursed by Medicare.
Number of fractures, life years, and dollars saved.
Three pairs of hip protectors replaced annually would result in a weighted average lifetime absolute risk reduction for hip fracture of 8.5%, with net lifetime savings to Medicare of 223 dollars per resident. When the annual cost of hip protectors is less than 151 dollars per person, relative risk of fracture is less than or equal to 0.65 with hip protectors, or adherence is greater than 42%, hip protectors are cost saving to Medicare over a wide range of assumptions. Extrapolating these results to the estimated population of U.S. nursing home residents without a previous hip fracture, Medicare could save 136 million dollars in the first year of a hip-protector reimbursement program.
From a Medicare perspective, hip protectors are a cost-saving intervention in the nursing home setting when hip protector effectiveness is less than or equal to 0.65 over the remaining lifetime of subjects.
Journal of the American Geriatrics Society 03/2005; 53(2):190-7. · 3.74 Impact Factor
