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Holloway RG, Quill TE. Treatment decisions after brain injury--tensions among quality, preference, and cost. N Engl J Med 2010; 362:1757-9. [PMID: 20463337 DOI: 10.1056/nejmp0907808] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Xian Y, Pan W, Peterson ED, Heidenreich PA, Cannon CP, Hernandez AF, Friedman B, Holloway RG, Fonarow GC. Are quality improvements associated with the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program sustained over time? A longitudinal comparison of GWTG-CAD hospitals versus non-GWTG-CAD hospitals. Am Heart J 2010; 159:207-14. [PMID: 20152218 DOI: 10.1016/j.ahj.2009.11.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Accepted: 11/06/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous reports have demonstrated that participation in GWTG-CAD, a national quality initiative of the American Heart Association, is associated with improved guideline adherence for patients hospitalized with CAD. We sought to establish whether these benefits from participation in GWTG-CAD were sustained over time. METHODS We used the Centers for Medicare and Medicaid Services Hospital Compare database to examine 6 performance measures and one composite score for 3 consecutive 12-month periods including aspirin and beta-blocker on arrival/discharge, angiotensin-converting enzyme inhibitor (ACE-I) for left ventricular systolic dysfunction (LVSD), and adult smoking cessation counseling. The differences in guideline adherence between the GWTG-CAD hospitals (n = 440, 439, 429) and non-GWTG-CAD hospitals (n = 2,438, 2,268, 2,140) were evaluated for each 12-month period. A multivariate mixed-effects model was used to estimate the independent effect of GWTG-CAD over time adjusting for hospital characteristics. RESULTS Compared with non-GWTG hospitals, the GWTG-CAD hospitals demonstrated higher guideline adherence for 6 performance measures. The largest differences existed for (1) aspirin at arrival (2.3%, 2.1%, and 1.6% for each 12-month period, respectively), (2) aspirin at discharge (3.4%, 2.2%, and 2.3%), (3) beta-blocker at arrival (3.4%, 2.9%, and 2.6%), and (4) beta-blocker at discharge (2.8%, 1.8%, and 1.5%). In multivariate analysis, the GWTG-CAD hospitals were independently associated with better adherence for 4 of the 6 measures (the exceptions were ACE-I for LVSD and smoking cessation counseling). Superior performance was also found for the composite measures. Although there was some narrowing between groups, GWTG-CAD hospitals maintained superior guideline adherence than non-GWTG-CAD hospitals for the entire 3-year period (adjusted differences 1.8%, 1.6%, and 1.4%). CONCLUSIONS Hospitals participating in GWTG-CAD had modestly superior acute cardiac care and secondary prevention measures performance relative to non-GWTG-CAD. These benefits of GWTG-CAD participation were sustained over time and independent of hospital characteristics.
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Yurcheshen ME, Guttuso T, McDermott M, Holloway RG, Perlis M. Effects of gabapentin on sleep in menopausal women with hot flashes as measured by a Pittsburgh Sleep Quality Index factor scoring model. J Womens Health (Larchmt) 2009; 18:1355-60. [PMID: 19708803 DOI: 10.1089/jwh.2008.1257] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of this research was to analyze gabapentin's effect on Pittsburgh Sleep Quality Index (PSQI) scores in menopausal women. METHODS Secondary analysis of data from a cohort of menopausal women participating in a randomized, double-blind, placebo-controlled trial of gabapentin 300 mg three times daily (TID) for hot flashes. The outcomes of interest were PSQI global and factor scores at weeks 4 and 12. RESULTS Subjects randomized to gabapentin demonstrated improvement in the sleep quality factor score, compared to placebo-treated subjects, at 4 and 12 weeks (p < 0.03). There was also gabapentin-associated improvement in the global PSQI score (p = 0.004) and the sleep efficiency factor score (p = 0.05) at 4 weeks. There was no significant effect of gabapentin on the daily disturbance factor score. CONCLUSIONS Gabapentin may improve sleep quality in menopausal women with hot flashes. These results warrant further prospective investigation, with an emphasis on measuring subjective sleep quality and maintenance.
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Kim SYH, Schrock L, Wilson RM, Frank SA, Holloway RG, Kieburtz K, de Vries RG. An approach to evaluating the therapeutic misconception. IRB 2009; 31:7-14. [PMID: 19873836 PMCID: PMC3360887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Subjects enrolled in studies testing high risk interventions for incurable or progressive brain diseases may be vulnerable to deficiencies in informed consent, such as the therapeutic misconception (TM). However, there is a continuing debate about the definition and measurement of TM, making assessments of TM controversial. In this qualitative pilot study of persons enrolled in a phase I test of gene transfer for Parkinson’s disease, we developed and tested an interview guide focusing on how the subjects made their decision to participate, with an emphasis on understanding the subject as the unit of interest, rather than focusing only on isolated statements. The results indicate that a subject’s understanding of the purpose of research is best explored in juxtaposition to the subject’s motivation for participation. Doing so reveals potential avenues for measuring and preventing TM.
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Dorsey ER, Thompson JP, Dayoub EJ, George B, Saubermann LA, Holloway RG. Selegiline shortage: Causes and costs of a generic drug shortage. Neurology 2009; 73:213-7. [PMID: 19620609 DOI: 10.1212/wnl.0b013e3181ae7b04] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In September 2007, shortages of generic selegiline occurred, forcing patients to either switch to more expensive alternatives or forego treatment. We sought to evaluate prescription trends of generic selegiline and to quantify the economic impact of any resulting drug substitution of more expensive alternatives. METHODS We analyzed proprietary data from IMS Health on monthly prescriptions in the United States for selegiline and potential substitutes from February 2002 through December 2007. Linear regression was used to predict the number of expected prescriptions after August 2007 had a shortage not occurred. The main outcome measures were the changes in prescriptions filled and the economic impact of drug substitution. RESULTS Prior to the shortage, total prescriptions filled for generic selegiline decreased 42%, and supply consolidated into one company, Apotex Inc., Toronto, Canada, whose market share increased from 41% to 83%. During the first 4 months of the shortage, Apotex Inc. filled 10,500 fewer prescriptions than projected and other selegiline manufacturers filled 7,400 more than projected for a net shortage of 3,100 prescriptions. The number of branded selegiline capsules filled during this period increased by 1,800 above projections, and 1,300 prescriptions for generic selegiline were not refilled or substituted. The societal cost of substituting generic selegiline with branded capsules was $75,000 over the first 4 months of the shortage. CONCLUSIONS Generic drug shortages carry economic and health implications. Given ongoing consolidation in the generics drug industry, these shortages may become more common and may require heightened regulatory scrutiny of the generic drug industry.
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Dorsey ER, Thompson JP, Frasier M, Sherer T, Fiske B, Nicholson S, Johnston SC, Holloway RG, Moses H. Funding of Parkinson research from industry and US federal and foundation sources. Mov Disord 2009; 24:731-7. [PMID: 19133662 DOI: 10.1002/mds.22446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Funding for biomedical and neuroscience research has increased over the last decade but without a concomitant increase in new therapies. This study's objectives were to determine the level and principal sources of recent funding for Parkinson disease (PD) research and to determine the current state of PD drug development. We determined the level and principal sources of recent funding for PD research from the following sources: US federal agencies, large PD foundations based in the United States, and global industry. We assessed the status of PD drug development through the use of a proprietary drug pipeline database. Funding for PD research from the sources examined was approximately $1.1 billion in 2003 and $1.2 billion in 2005. Industry accounted for 77% of support from 2003 to 2005. The number of drugs in development for PD increased from 67 in 2003 to 97 in 2007. Of the companies with at least one compound in development for PD in 2007, most were small (62% had annual revenue of less than $100 million), and most (53%) were based outside the United States. These companies will likely require partnerships to drive successful development of new PD therapies.
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Pogoda TK, Cramer IE, Meterko M, Lin H, Hendricks A, Holloway RG, Charns MP. Patient and organizational factors related to education and support use by Veterans with Parkinson's disease. Mov Disord 2009; 24:1916-24. [DOI: 10.1002/mds.22516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Schwamm LH, Holloway RG, Amarenco P, Audebert HJ, Bakas T, Chumbler NR, Handschu R, Jauch EC, Knight WA, Levine SR, Mayberg M, Meyer BC, Meyers PM, Skalabrin E, Wechsler LR. A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke 2009; 40:2616-34. [PMID: 19423852 DOI: 10.1161/strokeaha.109.192360] [Citation(s) in RCA: 341] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this new statement is to provide a comprehensive and evidence-based review of the scientific data evaluating the use of telemedicine for stroke care delivery and to provide consensus recommendations based on the available evidence. The evidence is organized and presented within the context of the American Heart Association's Stroke Systems of Care framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class of evidence. Evidence-based recommendations are included for the use of telemedicine in general neurological assessment and primary prevention of stroke; notification and response of emergency medical services; acute stroke treatment, including the hyperacute and emergency department phases; hospital-based subacute stroke treatment and secondary prevention; and rehabilitation.
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Kelly A, Thompson JP, Tuttle D, Benesch C, Holloway RG. Public reporting of quality data for stroke: is it measuring quality? Stroke 2008; 39:3367-71. [PMID: 18772446 PMCID: PMC2723834 DOI: 10.1161/strokeaha.108.518738] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Public reporting of quality data is becoming more common and increasingly used to improve choices of patients, providers, and payers. We reviewed the scope and content of stroke data being reported to the public and how well it captures the quality of stroke care. METHODS We performed a cross-sectional survey of all report cards within the Agency for Healthcare Research and Quality Report Card Compendium. Stroke quality data were categorized into one of 5 groups: structure, process, outcomes, utilization, and finances. We also determined the congruence of mortality ratings of New York hospitals provided by 2 different report cards. RESULTS Of 221 available report cards, 19 (9%) reported quality information regarding stroke and 17 specifically addressed the quality of hospital-based stroke care. The most frequent data reported were utilization measures (n=15 report cards) and outcome measures (n=14 report cards). Data regarding finances (n=4), structure of care (n=2), and process of care (n=1) were reported infrequently. Ratings were incongruent in 61 of the 157 hospitals (39%) with the same hospital being rated below average on one report care and average on another in 44 hospitals. CONCLUSIONS Publicly reported quality data pertaining to patients with stroke are incomplete, confusing, and inaccurate. Without further improvements and a better understanding of the needs and limitations of the many stakeholders, targeted transparency policies for stroke care may lead to worse quality and large economic losses.
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Kim SYH, Holloway RG, Frank S, Wilson R, Kieburtz K. Trust in early phase research: therapeutic optimism and protective pessimism. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2008; 11:393-401. [PMID: 18629609 DOI: 10.1007/s11019-008-9153-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/23/2008] [Indexed: 05/26/2023]
Abstract
Bioethicists have long been concerned that seriously ill patients entering early phase ('phase I') treatment trials are motivated by therapeutic benefit even though the likelihood of benefit is low. In spite of these concerns, consent forms for phase I studies involving seriously ill patients generally employ indeterminate benefit statements rather than unambiguous statements of unlikely benefit. This seeming mismatch between attitudes and actions suggests a need to better understand research ethics committee members' attitudes toward communication of potential benefits and risks of early phase studies to potential subjects. We surveyed the members of two U.S. research ethics committees using a phase I gene transfer study scenario, and compared the results to a previous survey of potential subjects' perceptions and attitudes toward benefit and risk for the same protocol. The results show that there is indeed a gap between the subjects' perceptions and the committee members' views on what is appropriate to be communicated to research subjects. This discrepancy is the product of both the commonly assumed optimism of the subjects and to a "protective pessimism" of the research ethics committee members. We discuss this discrepancy using "frameworks of trust" and demonstrate the need to incorporate these frameworks into the existing model of informed consent.
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Thompson JP, Noyes K, Dorsey ER, Schwid SR, Holloway RG. Quantitative risk-benefit analysis of natalizumab. Neurology 2008; 71:357-64. [PMID: 18663181 DOI: 10.1212/01.wnl.0000319648.65173.7a] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To model the long-term risks and benefits of natalizumab in individuals with relapsing multiple sclerosis (MS). METHODS We created a Markov model to evaluate treatment effects on reducing relapses and slowing disease progression using published natural history data and clinical trial results. Health changes, measured in quality-adjusted life-years (QALYs), were based on patient health preferences. Patient cohorts treated with no disease-modifying treatment, natalizumab, subcutaneous interferon beta-1a, and a theoretical "perfect" MS treatment were modeled. Sensitivity analysis was used to explore model uncertainty, including varying risks of developing progressive multifocal leukoencephalopathy (PML). RESULTS Treatment with natalizumab resulted in 9.50 QALYs over a 20-year time horizon, a gain of 0.80 QALYs over the untreated cohort and 0.38 QALYs over interferon beta-1a. The health loss due to PML was small (-0.06 QALYs). To offset natalizumab's incremental health gain over interferon beta-1a, the risk had to increase from 1 to 7.6 PML per 1,000 patients treated over 17.9 months. The "perfect" MS treatment accumulated 10.59 QALYs over the 20-year time horizon, 1.89 QALYs above the untreated cohort. Interferon beta-1a resulted in greater QALY gains compared with natalizumab if natalizumab's relative relapse reduction was reduced from 68% to 35% or if interferon beta-1a's relative reduction was increased from 32% to 65%. CONCLUSIONS A more than sevenfold increase in actual risk of progressive multifocal leukoencephalopathy was required to decrease natalizumab's health gain below that of interferon beta-1a, and there remains considerable room for additional gains in health (>50%) beyond those already achieved with current therapies.
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Holloway RG, Mooney CJ, Getchius TSD, Edlund WS, Miyasaki JO. Invited Article: Conflicts of interest for authors of American Academy of Neurology clinical practice guidelines. Neurology 2008; 71:57-63. [PMID: 18591506 DOI: 10.1212/01.wnl.0000316319.19159.c3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) shape clinical care worldwide but are prone to potential error and bias due to conflicts of interest (COI). OBJECTIVE To explore the extent and scope of American Academy of Neurology (AAN) guideline author reported COI and implications for management; and to review process of AAN guideline COI management to highlight challenges, establish comparative benchmarks, and identify areas to be improved. METHODS Authors of AAN clinical practice guidelines with an active membership panel completed a COI reporting form. Authors were asked to report current interests including the 1 year prior to the date of completing the form. Interests include personal income relationships (consulting, speaker's bureaus, advisory boards), equity (stocks/stock options), patent/royalties, research, clinical practice, fiduciary interest in a company, and expert testimony. Comparisons were made between the two committees that oversee CPG development at the AAN: the Quality Standards Subcommittee (QSS) and the Therapeutics and Technology Assessment (TTA) Subcommittee. RESULTS There were 50 CPG with an average of 8.5 authors per CPG. There were a total of 425 available authors, 351 of whom completed a COI reporting form (83% response rate). Forty-six of the 50 guidelines had at least one author with a COI. The most commonly reported COIs were research-related (45% of authors), clinical practice-related (42%), and personal income relationships (33%). Authors of QSS guidelines were more likely to have personal income COIs with pharmaceutical and medical device companies (39% vs 24%, p < 0.01), whereas authors of TTA guidelines were more likely to have clinical practice-related COIs (50% vs 38%, p < 0.05). A minority of authors had individual COIs exceeding >$25,000 or had multiple interests (>10) that overlapped with content of the guidelines. CONCLUSION Conflicts of interest are common for authors of American Academy of Neurology clinical practice guidelines across many domains of personal and professional interests. More research is needed to improve the methods to identify and quantify the types of conflicts and their potential biasing effects on selecting guideline topics, grading research evidence, and formulating practice recommendations.
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Frank SA, Wilson R, Holloway RG, Zimmerman C, Peterson DR, Kieburtz K, Kim SYH. Ethics of sham surgery: perspective of patients. Mov Disord 2008; 23:63-8. [PMID: 17960809 DOI: 10.1002/mds.21775] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Sham surgery is used as a control condition in neurosurgical clinical trials in Parkinson's disease (PD) but remains controversial. This study aimed to assess the perspective of patients with PD and the general public on the use of sham surgery controls. We surveyed consecutive patients from a university-based neurology outpatient clinic and a community-based general internal medicine practice. Background information was provided regarding PD and two possible methods of testing the efficacy of a novel gene transfer procedure, followed by questions that addressed participants' opinions related to the willingness to participate and permissibility of blinded and unblinded trial designs. Two hundred eighty-eight (57.6%) patients returned surveys. Patients with PD expressed less willingness to participate in the proposed gene transfer surgery trials. Unblinded studies received greater support, but a majority would still allow the use of sham surgery. Those in favor of sham surgery were more educated and more likely to use societal perspective rationales. Patients with PD are more cautious about surgical research participation than patients with non-PD. Their policy views were similar to others', with a majority supporting the use of sham controls. Future research needs to determine whether eliciting more considered judgments of laypersons would reveal different levels of support for sham surgery.
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O'Connor AB, Noyes K, Holloway RG. A cost-utility comparison of four first-line medications in painful diabetic neuropathy. PHARMACOECONOMICS 2008; 26:1045-1064. [PMID: 19014205 DOI: 10.2165/0019053-200826120-00007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Painful diabetic neuropathy is common and adversely affects patients' quality of life and function. Several treatment options exist, but their relative efficacy and value are unknown. OBJECTIVE To determine the relative efficacy, costs and cost effectiveness of the first-line treatment options for painful diabetic neuropathy. METHODS Published and unpublished clinical trial and cross-sectional data were incorporated into a decision analytic model to estimate the net health and cost consequences of treatment for painful diabetic peripheral neuropathy over 3-month (base case), 1-month and 6-month timeframes. Efficacy was measured in QALYs, and costs were measured in $US, year 2006 values, using a US third-party payer perspective. The patients included in the model were outpatients with moderate to severe pain associated with diabetic peripheral neuropathy and no contraindications to treatment with tricyclic antidepressants. Four medications were compared: desipramine 100 mg/day, gabapentin 2400 mg/day, pregabalin 300 mg/day and duloxetine 60 mg/day. RESULTS Desipramine and duloxetine were both more effective and less expensive than gabapentin and pregabalin in the base-case analysis and through a wide range of sensitivity analyses. Duloxetine offered borderline value compared with desipramine in the base case ($US47,700 per QALY), but not when incorporating baseline-observation-carried-forward analyses of the clinical trial data ($US867,000 per QALY). The results were also sensitive to the probability of obtaining pain relief with duloxetine. CONCLUSIONS Desipramine (100 mg/day) and duloxetine (60 mg/day) appear to be more cost effective than gabapentin or pregabalin for treating painful diabetic neuropathy. The estimated value of duloxetine relative to desipramine depends on the assumptions made in the statistical analyses of clinical trial data.
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Dorsey ER, Holloway RG. Quality of life in epilepsy, multiple sclerosis, and beyond. Ann Neurol 2007; 62:307-8. [PMID: 17868099 DOI: 10.1002/ana.21231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Biglan KM, Holloway RG, McDermott MP, Richard IH. Risk factors for somnolence, edema, and hallucinations in early Parkinson disease. Neurology 2007; 69:187-95. [PMID: 17620552 DOI: 10.1212/01.wnl.0000265593.34438.00] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The CALM-PD trial evaluated the development of motor complications in subjects with early Parkinson disease (PD) randomized to initial treatment with either pramipexole or levodopa. A secondary finding of the trial was a higher than anticipated development or worsening of somnolence and edema and development of hallucinations. OBJECTIVES To investigate risk factors for somnolence, edema, and hallucinations in patients with early PD initiating dopaminergic therapy. METHODS This was a secondary analysis of data from the CALM-PD trial. Baseline patient characteristics were evaluated for their associations with the development or worsening of somnolence and edema and the development of hallucinations using Cox proportional hazards regression models. RESULTS Kaplan-Meier estimates of the 4-year incidence of the development or worsening of somnolence and edema and the development of hallucinations were 35%, 45%, and 17%. Initial pramipexole treatment (hazard ratio [HR] 2.22, 95% CI 1.41, 3.50, p < 0.001), male gender (HR 1.79, 95% CI 1.09, 2.93, p = 0.02), and >5 systems with a comorbid illness (HR 1.62, 95% CI 1.04, 2.51, p = 0.03) were associated with somnolence. Initial pramipexole treatment (HR 3.18, 95% CI 1.95, 5.18, p < 0.0001), female gender (HR 1.46, 95% CI 0.94, 2.27, p = 0.09), and comorbid cardiac disease (HR 1.59, 95% CI 1.02, 2.47, p = 0.04) were associated with edema. Age > or =65 (HR 2.06, 95% CI 0.98, 4.32, p = 0.06), Mini-Mental State Examination score >28 (HR 0.42, 95% CI 0.19, 0.91, p = 0.03), and >5 systems with a comorbid illness (HR 3.42, 95% CI 1.59, 7.38, p = 0.002) were associated with hallucinations. CONCLUSIONS Comorbid illnesses are important and overlooked risk factors for the development of somnolence, edema, and hallucinations. When initiating therapy with pramipexole, patients should be counseled about and monitored for somnolence and edema. Slight decrements in cognitive function and older age are associated with an increased risk of hallucinations.
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O'Connor AB, Noyes K, Holloway RG. A Cost-Effectiveness Comparison of Desipramine, Gabapentin, and Pregabalin for Treating Postherpetic Neuralgia. J Am Geriatr Soc 2007; 55:1176-84. [PMID: 17661955 DOI: 10.1111/j.1532-5415.2007.01246.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare the net health effects and costs resulting from treatment with different first-line postherpetic neuralgia (PHN) medications. DESIGN Cost-utility analysis using published literature. PARTICIPANTS Hypothetical cohort of patients aged 60 to 80 with PHN. INTERVENTIONS Desipramine 100 mg/d, gabapentin 1,800 mg/d, and pregabalin 450 mg/d. MEASUREMENTS A decision model was designed to describe possible treatment outcomes, including different combinations of analgesia and side effects, during the first 3 months of therapy for moderate to severe PHN. The main outcome was cost per quality-adjusted life-year (QALY) gained. Costs were estimated using the perspective of a third-party payer. Multivariate, univariate, and probabilistic sensitivity analyses were performed, and the time frame of the model was varied to 1-month and 6-month horizons. RESULTS Desipramine was more effective and less expensive than gabapentin or pregabalin (dominant) under all conditions tested. Gabapentin was more effective than pregabalin but at an incremental cost of $216,000/QALY. Below $140/month, gabapentin became more cost-effective than pregabalin at a threshold of $50,000/QALY, and below $115/month gabapentin dominated pregabalin. CONCLUSION Desipramine appears to be more effective and less expensive than gabapentin or pregabalin for the treatment of older patients with PHN in whom it is not contraindicated. After its price falls, generic gabapentin will likely be more cost-effective than pregabalin.
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Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007; 35:1530-5. [PMID: 17452930 DOI: 10.1097/01.ccm.0000266533.06543.0c] [Citation(s) in RCA: 280] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). DESIGN A prospective pre/post nonequivalent control group design was used for this performance improvement study. SETTING Seventeen-bed adult MICU. PATIENTS Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. INTERVENTIONS Palliative care consultations. MEASUREMENTS AND MAIN RESULTS Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. CONCLUSIONS Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.
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Dorsey ER, Thompson JP, Noyes K, Dick AW, Holloway RG, Schwid SR. Quantifying the risks and benefits of natalizumab in relapsing multiple sclerosis. Neurology 2007; 68:1524-8. [PMID: 17470756 DOI: 10.1212/01.wnl.0000260699.09720.ad] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Using published data, we quantified the risk and benefits of natalizumab in relapsing multiple sclerosis using quality-adjusted life years (QALYs) as a metric. Over the first 2 years of therapy, the negative health effects from progressive multifocal leukoencephalopathy were small (loss of 0.001 QALYs) relative to the positive effects on relapses and disability resulting in 0.033 QALYs (12 quality-adjusted days) gained. For context, we performed an analogous calculation for interferon beta-1a, which also had a net health benefit of 0.033 QALYs (12 quality-adjusted days).
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Noyes K, Dick AW, Holloway RG. The implications of using US-specific EQ-5D preference weights for cost-effectiveness evaluation. Med Decis Making 2007; 27:327-34. [PMID: 17502449 DOI: 10.1177/0272989x07301822] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study is to examine the effect of country-specific EQ-5D preference weights on the cost-effectiveness (CE) of initial pramipexole versus levodopa strategy in patients with Parkinson disease (PD). METHODS A total of 301 subjects with PD were randomized to initial pramipexole or levodopa and followed every 3 months over a 4-year period. Subjects' health-related quality of life (HRQOL) was measured using EQ-5D, and their health preferences were calculated using both the UK and US sets of weights. The effectiveness of pramipexole was defined as the additional quality-adjusted life-years (QALY) gained compared to levodopa and was estimated as the area between the treatment-specific HRQOL profiles adjusted for baseline difference. RESULTS Using the original UK weights, the incremental effectiveness was 0.155 QALYs, which resulted in the incremental CE ratio (ICER) of $42,989/QALY and a probability that pramipexole was cost-effective relative to levodopa of 0.57, 0.77, and 0.82 when a QALY was valued at $50,000, $100,000, and $150,000, respectively. Using the US-specific weights resulted in lower incremental effectiveness (0.062 QALYs), higher ICER ($108,498/QALY), and a lower probability that pramipexole was cost-effective compared to levodopa at any valuation of QALY (0.23 for $50,000, 0.48 for $100,000, and 0.58 for $150,000). CONCLUSIONS Country-specific preference weights in clinical-economic trials might have important effects on estimates of incremental cost-effectiveness. Using US preference weights rather than UK preference weights reduced the probability that pramipexole was cost-effective compared to levodopa.
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Langfitt JT, Holloway RG, McDermott MP, Messing S, Sarosky K, Berg AT, Spencer SS, Vickrey BG, Sperling MR, Bazil CW, Shinnar S. Health care costs decline after successful epilepsy surgery. Neurology 2007; 68:1290-8. [PMID: 17438219 DOI: 10.1212/01.wnl.0000259550.87773.3d] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Surgery is an effective, high-cost procedure used increasingly to treat refractory epilepsy. For surgery to be cost-effective, long-term cost savings from reduced health care use should provide some offset to the initial costs of evaluation and surgery. There is little information about how health care costs are affected by evaluation and surgery. OBJECTIVE To determine whether health care costs change when seizures become controlled after surgery. METHODS Health care costs for the 2 years prior to surgical evaluation and for 2 years afterward were calculated from medical records of 68 subjects with temporal lobe epilepsy (TLE) participating in a multicenter observational study. Costs were compared among patients who did not have surgery, patients who had persisting seizures after surgery, and patients who were seizure free after surgery. RESULTS Antiepileptic drugs (AEDs) accounted for more than half of the costs of care in the pre-evaluation period. Total costs for seizure-free patients had declined 32% by 2 years following surgery due to less use of AEDs and inpatient care. Costs did not change in patients with persisting seizures, whether they had surgery or not. In the 18 to 24 months following evaluation, epilepsy-related costs were $2,068 to $2,094 in patients with persisting seizures vs $582 in seizure-free patients. CONCLUSIONS Costs remain stable over 2 years post-evaluation in patients with temporal lobe epilepsy whose seizures persist, but patients who become seizure free after surgery use substantially less health care than before surgery. Further cost reductions in seizure-free patients can be expected as antiepileptic drugs are successfully eliminated.
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Dorsey ER, Vitticore P, De Roulet J, Thompson JP, Carrasco M, Johnston SC, Holloway RG, Moses H. Financial anatomy of neuroscience research. Ann Neurol 2007; 60:652-9. [PMID: 17192926 DOI: 10.1002/ana.21047] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To estimate the level of funding for neuroscience research from federal and industry sources and to examine the therapeutic advances in the neurosciences over the past decade. METHODS We examined financing for neuroscience research over the past decade from the following principal sponsors of biomedical research: the National Institutes of Health, the pharmaceutical industry, large biotechnology firms, and large medical device firms. We also examined US Food and Drug Administration approvals for new molecular entities and medical devices for indications within the neurosciences. Neuroscience was defined to include funding and approvals for neurological and psychiatric conditions. RESULTS Total (nominal) industry and government funding for neuroscience research increased from $4.8 billion in 1995 to $14.1 billion in 2005 and doubled after adjusting for inflation. In 2005, the pharmaceutical industry and the largest biotechnology and medical device firms accounted for 58% of total funding. The US Food and Drug Administration approved 40 new molecular entities for indications within the neurosciences from 1995 to 2005, with the annual number of approvals remaining relatively stagnant during this period. From 1995 to 2005, the US Food and Drug Administration also approved 1,679 medical devices in the neurosciences for use. INTERPRETATION Financing for neuroscience research has increased significantly over the past decade, but new approvals for drugs in the neurosciences have not kept pace with the rapid increase in funding. This lag may represent a natural delay in realizing the return in the investment in scientific research or a decline in the productivity of neuroscience research.
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Abstract
OBJECTIVES To analyze medical errors and adverse events occurring in stroke patients and to provide insights into system or stroke-specific processes that can be modified to reduce the likelihood of error and patient harm. METHODS We analyzed spontaneously reported errors and adverse events reported within a voluntary and mandatory event reporting system in stroke patients admitted to a 750-bed academic medical center over a 3.5-year period between July 1, 2001, and December 31, 2004. We determined the frequency of near misses and preventable adverse events by event type (medication, adverse clinical, and falls). We performed a central event analysis to determine the most likely cause of preventable adverse events. RESULTS Of the 1,440 stroke patients admitted during the study period, 173 patients (12.0%) experienced an adverse event that was reported within an event-reporting system. Of the 176 events in 148 patients reported in the voluntary event reporting system, 72 were falls, 62 were medication events, and 42 were adverse clinical events. Of the 28 events in 25 patients reported in the mandatory event-reporting system, all were adverse clinical events and involved patient harm. Of the total 201 unique events (3 events were reported in both systems), 18 were near misses and 183 were adverse events. Of the 183 adverse events, 86 were preventable, 37 were not preventable, and 60 were indeterminate. Preventable adverse events involved drugs and situations commonly seen in the stroke population and occurred in all aspects of care delivery from thrombolytic management to end-of-life care. Of the 86 preventable adverse events, 37% (32/86) were transcription/documentation errors, 23% (20/86) were failure to perform a clinical task, 10% (9/86) were communication/handoff errors between providers, and 10% (9/86) were failed independent checks/calculations. CONCLUSIONS Adverse events and errors occur frequently in stroke patients. A disease-specific approach to analyzing spontaneously reported events may help close the feedback loop on patient safety and improve the quality of care.
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