Comparative effectiveness and safety of low-strength and high-strength direct oral anticoagulants compared with warfarin: a sequential cohort study

OBJECTIVES

The aim of this study was to compare effectiveness and safety of low-strength and high-strength direct oral anticoagulants (DOACs) with warfarin in the Australian Veteran population.

DESIGN

Sequential cohort study using inverse probability of treatment weighting (IPTW) and propensity score matching. Initiators of high-strength (apixaban 5 mg, dabigatran 150 mg, rivaroxaban 20 mg) and low-strength DOACS (apixaban 2.5 mg, dabigatran 110 mg, rivaroxaban 15 mg) were compared with warfarin initiators.

SETTING

Australian Government Department of Veterans' Affairs claims database.

PARTICIPANTS

4836 patients who initiated oral anticoagulants (45.8%, 26.0% and 28.2% on low-strength, high-strength DOACs and warfarin, respectively) between August 2013 and March 2015. Mean age was 85, 75 and 83 years for low-strength, high-strength DOACs and warfarin initiators, respectively.

MAIN OUTCOME MEASURES

One-year risk of hospitalisation for ischaemic stroke, any bleeding event or haemorrhagic stroke. Secondary outcomes were 1-year risk of hospitalisation for myocardial infarction and death.

RESULTS

Using the IPTW method, no difference in risk of ischaemic stroke or bleeding was found with low-strength DOACs compared with warfarin. As a class, no increased risk of myocardial infarction was found for low-strength DOACs, however, risk was elevated for apixaban (HR 2.25, 95% CI 1.23 to 4.13). For high-strength DOACs, no difference was found for ischaemic stroke compared with warfarin, however, there was a significant reduction in risk of bleeding events (HR 0.63, 95% CI 0.44 to 0.89) and death (HR 0.40, 95% CI 0.28 to 0.58). Propensity score matching showed no difference in risk of ischaemic stroke or bleeding.

CONCLUSION

We found that in the practice setting both DOAC formulations were similar to warfarin with regard to effectiveness and had no increased risk of bleeding.

Propensity score methods and regression adjustment for analysis of nonrandomized studies with health-related quality of life outcomes

PURPOSE

The aim of this study was to investigate the potential added value of combining propensity score (PS) methods with multivariable linear regression (MLR) in estimating the average treatment effect on the treated (ATT) in nonrandomized studies with health-related quality of life (HRQoL) outcomes.

METHODS

We first used simulations to compare the performances of different PS-based methods, either alone or in combination with further MLR adjustment, in estimating ATT. PS methods were, respectively, optimal pair (OPM) and full (OFM) PS matching, subclassification on the PS (SBC), and the inverse probability of treatment weighting (IPTW). We simulated several scenarios, according to different sample sizes, proportions of treated vs untreated subjects, and types of HRQoL outcomes. We also applied the same methods to a real clinical data set.

RESULTS

OPM and IPTW provided the closest Type I error to the nominal threshold α = 0.05 across all scenarios. Overall, both methods showed also lower variability in estimates than SBC and OFM. SBC performed worst, generally providing the highest levels of bias. Further MLR adjustment lessened bias for all methods, however providing higher Type I error for SBC and OFM. In the real case, all methods provided similar ATT estimates except for one outcome.

CONCLUSIONS

Our findings suggest that for sample sizes up to n = 200, OPM and IPTW are to be preferred to OFM and SBC in estimating ATT on HRQoL outcomes. Specifically, OPM performed best in sample sizes of n ≥ 80, IPTW for smaller sample sizes. Additional MLR adjustment can further improve ATT estimates.

Evaluating Monetary-Based Benefit-Sharing as a Mechanism to Improve Local Human Development and its Importance for Impact Assessment of Hydropower Plants in Brazil

Although hydropower companies and governments have promoted monetary-based Benefit-Sharing Mechanisms alone as a vector of local development for flooded municipalities, it is not possible to identify this evidence in the scientific literature. The present work investigates the quantitative influence of Financial Compensation on Human Development Indexes (HDI) in flooded municipalities over 2000–2010. The econometric analysis shows that there are no statistically significant results related to the quantities of Financial Compensation and the development variables. The findings reinforce that Financial Compensation itself could not be considered the only input to improve development processes. Management frameworks should be considered since they can provide a broader view of the affected areas, including elements such as participatory processes, adaptation management, formal and legal guidelines and stakeholder engagement. Specially in the Brazilian case, the Impact Assessment procedures and their products could provide detailed data and criteria to municipalities to manage the inflow resources.

Scope-of-practice laws and expanded health services: the case of underserved women and advanced cervical cancer diagnoses

BACKGROUND

Underserved women (rural, minority or poor) are disproportionally diagnosed with late-stage cervical cancer, indicative of inadequate access to, and use of, preventative healthcare. The Institute of Medicine (IOM) has proposed that nurse practitioners (NP) can address provider shortages among underserved populations, but to reduce shortages, scope-of-practice laws that restrict the delivery of care, must be revised. We examined the IOM recommendation of NP expanded scope-of-practice laws on reducing the disparity of underserved women diagnosed with late-stage cervical cancer.

METHODS

We examined the cohort of 10 673 women diagnosed with cervical cancer between 2010 and 2014 and reported to the Surveillance, Epidemiology and End Results cancer registry. We linked state-level laws regarding NP scope-of-practice to patients with cancer by their state of residence, diagnosis date and law enactment date. Hierarchical regression was used to explore NP full scope-of-practice law's impact on late-stage cancer diagnoses considering the moderating effect of women living in medically underserved areas. We adjusted for known confounders available in this population-based data set.

RESULTS

Medically underserved women living in states with laws that restrict NP full scope-of-practice are twofold more likely to be diagnosed with late-stage cancer; adjusted OR and 95% CI (OR 2.08, 95% CI 1.4 to 3.1). These disparities were not observed among underserved women living in areas with NP full scope-of-practice laws (OR 0.95, 95% CI 0.7 to 1.3).

CONCLUSIONS

NP full scope-of-practice laws could provide a pragmatic and cost-effective solution to healthcare provider shortages associated with late stage of cervical cancer diagnoses among underserved women.

Disparities in Breast Cancer Survival by Socioeconomic Status Despite Medicare and Medicaid Insurance

Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance.

CONTEXT

Disparities in breast cancer survival by socioeconomic status (SES) exist despite the "safety net" programs Medicare and Medicaid. What is less clear is the extent to which SES disparities affect various racial and ethnic groups and whether causes differ across populations.

METHODS

We conducted a tapered matching study comparing 1,890 low-SES (LSES) non-Hispanic white, 1,824 black, and 723 Hispanic white women to 60,307 not-low-SES (NLSES) non-Hispanic white women, all in Medicare and diagnosed with invasive breast cancer between 1992 and 2010 in 17 US Surveillance, Epidemiology, and End Results (SEER) regions. LSES Medicare patients were Medicaid dual-eligible and resided in neighborhoods with both high poverty and low education. NLSES Medicare patients had none of these factors.

MEASUREMENTS

5-year and median survival.

FINDINGS

LSES non-Hispanic white patients were diagnosed with more stage IV disease (6.6% vs 3.6%; p < 0.0001), larger tumors (24.6 mm vs 20.2 mm; p < 0.0001), and more chronic diseases such as diabetes (37.8% vs 19.0%; p < 0.0001) than NLSES non-Hispanic white patients. Disparity in 5-year survival (NLSES - LSES) was 13.7% (p < 0.0001) when matched for age, year, and SEER site (a 42-month difference in median survival). Additionally, matching 55 presentation factors, including stage, reduced the disparity to 4.9% (p = 0.0012), but further matching on treatments yielded little further change in disparity: 4.6% (p = 0.0014). Survival disparities among LSES blacks and Hispanics, also versus NLSES whites, were significantly associated with presentation factors, though black patients also displayed disparities related to initial treatment. Before being diagnosed, all LSES populations used significantly less preventive care services than matched NLSES controls.

CONCLUSIONS

In Medicare, SES disparities in breast cancer survival were large (even among non-Hispanic whites) and predominantly related to differences of presentation characteristics at diagnosis rather than differences in treatment. Preventive care was less frequent in LSES patients, which may help explain disparities at presentation.

Community-based specialist palliative care teams and health system costs at end of life: a retrospective matched cohort study

BACKGROUND

Access to community-based specialist palliative care teams has been shown to improve patients' quality of life; however, the impact on health system expenditures is unclear. This study aimed to determine whether exposure to these teams reduces health system costs compared with usual care.

METHODS

We conducted a retrospective matched cohort study in Ontario, Canada, using linked administrative data. Decedents treated by 1 of 11 community-based specialist palliative care teams in 2009/10 and 2010/11 (the exposed group) were propensity score matched (comorbidity, extent of home care, etc.) 1 to 1 to similar decedents in usual care (the unexposed group). The teams are comprised of a core group of specialized physicians, nurses and other providers; their role is to manage symptoms around the clock, provide education and coordinate care. Our primary outcome was the overall difference in health system costs (among 5 health care sectors) between all matched pairs of exposed versus unexposed patients in the last 30 days of life.

RESULTS

The total cohort of decedents included 3109 matched pairs. Among matched pairs, the mean health system cost difference was $512 (95% confidence interval [CI] -$641 to -$383) lower in the last 30 days among exposed than among unexposed patients. In the last 30 days, the mean home care costs of the exposed group were $189 higher (95% CI -$151 to $227) than those of the unexposed group, but their mean hospital costs were $733 lower (95% CI -$950 to -$516).

INTERPRETATION

Our study suggests that health system costs are lower for patients who have access to community-based specialist teams than for those who receive usual care alone, largely because of decreased hospital costs. Ensuring access to in-home palliative care support, as provided by these teams, is an efficacious strategy for reducing health care expenditures at the end of life.

Should a propensity score model be super? The utility of ensemble procedures for causal adjustment

In investigations of the effect of treatment on outcome, the propensity score is a tool to eliminate imbalance in the distribution of confounding variables between treatment groups. Recent work has suggested that Super Learner, an ensemble method, outperforms logistic regression in nonlinear settings; however, experience with real-data analyses tends to show overfitting of the propensity score model using this approach. We investigated a wide range of simulated settings of varying complexities including simulations based on real data to compare the performances of logistic regression, generalized boosted models, and Super Learner in providing balance and for estimating the average treatment effect via propensity score regression, propensity score matching, and inverse probability of treatment weighting. We found that Super Learner and logistic regression are comparable in terms of covariate balance, bias, and mean squared error (MSE); however, Super Learner is computationally very expensive thus leaving no clear advantage to the more complex approach. Propensity scores estimated by generalized boosted models were inferior to the other two estimation approaches. We also found that propensity score regression adjustment was superior to either matching or inverse weighting when the form of the dependence on the treatment on the outcome is correctly specified.

Real-world effectiveness evaluation of budesonide/formoterol Spiromax for the management of asthma and chronic obstructive pulmonary disease in the UK

OBJECTIVES

Budesonide/formoterol (BF) Spiromax ® is an inhaled corticosteroid/long-acting β2-agonist fixed-dose combination (FDC) inhaler, designed to minimise common inhaler errors and provide reliable and consistent dose delivery in asthma and chronic obstructive pulmonary disease (COPD). We evaluated non-inferiority of BF Spiromax after changing from another FDC inhaler, compared with continuing the original inhaler.

METHODS

Patients with asthma and/or COPD who switched to BF Spiromax were matched (1:3) with non-switchers. Data were obtained from the Optimum Patient Care Research Database and Clinical Practice Research Datalink in the UK. The primary end point was the proportion of patients achieving disease control (using the risk domain control (RDC) algorithm); secondary end points were: exacerbation rate, short-acting β2-agonist (SABA) use and treatment stability (achieved RDC; no maintenance treatment change). Non-inferiority was defined as having 95% CI lower bound above -10%, using conditional logistic regression and adjusted for relevant confounders.

RESULTS

Comparing 385 matched patients (asthma 253; COPD 132) who switched to BF Spiromax with 1091 (asthma 743; COPD 348) non-switchers, non-inferiority of BF Spiromax in RDC was demonstrated (adjusted difference: +6.6%; 95% CI -0.3 to 13.5). Among patients with asthma, switchers to BF Spiromax versus BF Turbuhaler® reported fewer exacerbations (adjusted rate ratio (RR) 0.76;95% CI 0.60 to 0.99; p=0.044); were less likely to use high daily doses of SABA (adjusted OR 0.71;95% CI 0.52 to 0.98; p=0.034); used fewer SABA inhalers (adjusted RR 0.92;95% CI 0.86 to 0.99; p=0.019); and were more likely to achieve treatment stability (adjusted OR 1.44;95% CI 1.02 to 2.04; p=0.037). No significant differences in these end points were seen among patients with COPD.

CONCLUSIONS

Among UK patients with asthma and COPD, real-world use of BF Spiromax was non-inferior to BF Turbuhaler in terms of disease control. Among patients with asthma, switching to BF Spiromax was associated with reduced exacerbations, reduced SABA use and improved treatment stability versus continuing on BF Turbuhaler.

A Meta-Analysis on the Effect of Agricultural Conservation Practices on Nutrient Loss

Conservation practices are widely used to reduce N and P loads from agricultural fields and minimize their impact on water quality, but research using field-scale data to model the national average impact of conservation practices for different forms of N and P is needed. Thus, we quantified the effects of conservation practices (grassed waterways, terraces, contour farming, filter strips, and riparian buffers) on total, particulate, and dissolved N and P runoff from farmlands. Specifically, we conducted a meta-analysis of the Measured Annual Nutrient loads from AGricultural Environments (MANAGE) database using propensity score matching and multilevel modeling to remove the influence of confounding factors. There is no best method for addressing this influence, so we applied two alternative methods because similar results increase confidence in our findings. Propensity score matching found that conservation practices reduced total P, particulate P, and particulate N loading by an average of 67, 83, and 67%, respectively. Multilevel modeling estimated reductions of 58, 76, and 64% for the same nutrients. Although the propensity score method only yields a mean rate of reduction, multilevel modeling further estimates the reduction for different subgroups (i.e., different crops and fertilizer application methods) when such groupings are feasible. The multilevel models indicated that conservation practices affected row crops the most (e.g., corn [ L.] and soybean [ (L.) Merr.]) and fields with injected or surface-applied fertilizers. Our analysis used field-scale data to estimate the average effectiveness of conservation practices in reducing N and P runoff, providing valuable insight for regional and national decision making.

Social Exclusion and Parental Incarceration Impacts on Adolescents' Networks and School Engagement

Although prior research links parental incarceration to deleterious outcomes for children over the life-course, few studies have examined whether such incarceration affects the social exclusion of children during adolescence. Drawing on several lines of scholarship, we examine whether adolescents with incarcerated parents have fewer or lower quality relationships, participate in more antisocial peer networks, and feel less integrated or engaged in school. The study applies propensity score matching to survey and network data from a national sample of youth. Analyses indicated that children with incarcerated parents have more antisocial peers; we found limited evidence, though, that parental incarceration adversely impacts peer networks and school integration domains. Generally, the results suggested that the impacts of parental incarceration on adolescents' social lives have less to do with isolation than with the types of peers adolescents befriend. Findings provide support for the idea that parental incarceration may adversely affect children's social exclusion.

Using compensating variation to measure the costs of child disability in the UK

The objective of disability policy is to create a society where people with disabilities and their families enjoy an equal standard of living to those without disabilities, though evidence to underpin policy is sparse. We defined the compensating variation (CV) of child disability as the amount of additional income a family with a disabled child would require to achieve the same living standards as a similar family without a disabled child. The aims of this study were to estimate the CV for child disability and to explore how this varied for different levels of disability and reference levels of living standards. Using data on 54,641 families from the Family Resources Survey (2004-2012), we matched families with (cases) and without (controls) a disabled child on family and child characteristics plus living standards and calculated the income difference inclusive of disability benefits. Our findings suggest that across families with the most disabled children, a compensating variation equal to an extra £56-£79 a week was required to achieve the same living standards as matched families without a disabled child compared with the mean level of state disability benefit £47-£71 a week in this group.

The Role of Discrimination in Care Postponement Among Trans-Feminine Individuals in the U.S. National Transgender Discrimination Survey

PURPOSE

This study examines the associations between discrimination experiences (types and locations) and care postponement among trans-feminine individuals in the United States.

METHODS

This secondary, cross-sectional study utilized a subset of the data from the National Transgender Discrimination Survey (n = 2248), specifically for trans-feminine individuals. In this analysis, we examined the relationship between discrimination and primary care postponement.

RESULTS

Twenty-six percent (26.25%) of the study sample reported delaying preventive care due to fear of discrimination; 23.98%-46.66% of respondents reported past experiences of discrimination (setting dependent). Discrimination in health and non-health settings and different types of discrimination-being denied services, verbally harassed, or physically assaulted-were all significantly associated with delaying care; respondents reporting discrimination were up to 20 times more likely to postpone care. While discrimination at a health location had the strongest association with care postponement (adjusted odds ratio = 9.65, confidence interval = 7.60-12.24), discrimination in all non-health-related locations was also important. Individuals reporting discrimination in greater numbers of locations and multiple types of discrimination were more likely to postpone care.

CONCLUSION

To promote preventive care-seeking, these results affirm the importance of interventions that promote discrimination-free environments for gender minorities.

Do Combined Pharmacist and Prescriber Efforts on Medication Reconciliation Reduce Postdischarge Patient Emergency Department Visits and Hospital Readmissions?

BACKGROUND

Although medication reconciliation (Med Rec) has demonstrated a reduction in potential adverse drug events, its effect on hospital readmissions remains inconclusive.

OBJECTIVE

To evaluate the impact of an interprofessional Med Rec bundle from admission to discharge on patient emergency department visits and hospital readmissions (hospital visits).

METHODS

The design was a retrospective, cohort study. Patients discharged from general internal medicine over a 57-month interval were identified through administrative databases. Patients who received an enhanced, Gold level, Med Rec bundle (including both admission Med Rec and interprofessional pharmacist-prescriber collaboration on discharge Med Rec) were assigned to the intervention group. Patients who received partial Med Rec services, Silver and Bronze level, comprised the control group. The primary outcome was hospital visits within 30 days of discharge.

RESULTS

Over a 57-month period, 9931 unique patient visits (n = 8678 patients) met the study criteria. The main analysis did not detect a difference in 30-day hospital visits between the intervention (Gold level bundle) and control (21.25% vs 19.26%; adjusted odds ratio, 1.06; 95% confidence interval [CI], 0.95-1.19). Propensity score adjustment also did not detect an effect (16.7% vs18.9%; relative risk of readmission, 0.88; 95% CI, 0.59-1.32).

CONCLUSION

A long-term, observational evaluation of interprofessional Med Rec did not detect a difference in 30- day postdischarge patient hospital visits between patients who received enhanced versus partial Med Rec patient care bundles. In future prospective studies, researchers could focus on evaluating high-risk populations and specific elements of Med Rec services on avoidable, medication-related hospital admissions and postdischarge adverse drug events.

Sociocultural and health system factors associated with mortality among febrile inpatients in Tanzania: a prospective social biopsy cohort study

INTRODUCTION

Communicable diseases are the leading causes of death in Tanzania despite the existence of effective treatment tools. We aimed to assess the sociocultural and health system factors associated with mortality from febrile illness in northern Tanzania.

METHODS

We interviewed febrile inpatients to determine prevalence of barriers in seeking or receiving care and grouped these barriers using the Three Delays model (delays at home, in transport and at healthcare facilities). We assessed 6-week mortality and, after matching on age, gender and severity of illness, measured the association between delays and mortality using conditional logistic regression.

RESULTS

We enrolled 475 children, of whom 18 (3.8%) died, and 260 adults, of whom 34 (13.0%) died. For children, home delays were not associated with mortality. Among adults, a delay in care-seeking due to not recognising severe symptoms was associated with mortality (OR: 3.01; 95% CI 1.24 to 7.32). For transport delays, taking >1 hour to reach a facility increased odds of death in children (OR: 3.27; 95% CI 1.11 to 9.66) and adults (OR: 3.03; 95% CI 1.32 to 6.99). For health system delays, each additional facility visited was associated with mortality for children (OR: 1.59; 95% CI 1.06 to 2.38) and adults (OR: 2.00; 95% CI 1.17 to 3.41), as was spending >4 days between the first facility visit and reaching tertiary care (OR: 4.39; 95% CI 1.49 to 12.93).

CONCLUSION

Our findings suggest that delays at home, in transport and in accessing tertiary care are risk factors for mortality from febrile illness in northern Tanzania. Interventions that may reduce mortality include community education regarding severe symptoms, expanding transportation infrastructure and streamlining referrals to tertiary care for the sickest patients.

Does insurance enrolment increase healthcare utilisation among rural-dwelling older adults? Evidence from the National Health Insurance Scheme in Ghana

INTRODUCTION

This paper examines the relationship between national health insurance enrolment and the utilisation of inpatient and outpatient healthcare for older adults in rural areas in Ghana. The Ghanaian National Health Insurance Scheme (NHIS) aims to improve affordability and increase the utilisation of healthcare. However, the system has been criticised for not being responsive to the needs of older adults. The majority of older adults in Ghana live in rural areas with poor accessibility to healthcare. With an ageing population, a specific assessment of whether the scheme has benefitted older adults, and also if the benefit is equitable, is needed.

METHODS

Using the Ghanaian Living Standards Survey from 2012 to 2013, this paper uses propensity score matching to estimate the effect of enrolment within the NHIS on the utilisation of inpatient and outpatient care among older people aged 50 and over.

RESULTS

The raw results show higher utilisation of healthcare among NHIS members, which persists after matching. NHIS members were 6% and 9% more likely to use inpatient and outpatient care, respectively, than non-members. When these increases were disaggregated for outpatient care, the non-poor and females were seen to benefit more than their poor and male counterparts. For inpatient care, the benefits of enrolment were equal by poverty status and sex. However, overall, poor older adults use health services much less than the non-poor older adults even when enrolled.

CONCLUSION

The results indicate that NHIS coverage does increase healthcare utilisation among rural older adults but that inequalities remain. The poor are still at a great disadvantage in their use of health services overall and benefit less from enrolment for outpatient care. The receipt of healthcare is significantly influenced by a set of auxiliary barriers to access to healthcare even where insurance should remove the financial burden of ad hoc out of pocket payments.

Digital Peer-Support Platform (7Cups) as an Adjunct Treatment for Women With Postpartum Depression: Feasibility, Acceptability, and Preliminary Efficacy Study

Background

Peer support is considered to be an important framework of support for mothers experiencing postpartum depression (PPD); however, some barriers exist that may limit its use including peer availability and mothers’ lack of time due to child care.

Objective

This non-randomized study was designed to examine the feasibility, acceptance, and preliminary clinical outcomes of using 7 Cups of Tea (7Cups), a digital platform that delivers self-help tools and 24/7 emotional support delivered by trained volunteers, as an adjunct treatment for mothers diagnosed with PPD.

Methods

Mothers with PPD were referred during intake to the study coach who provided guidance about 7Cups. 7Cups features included self-help tools and chats with trained volunteers who had experienced a perinatal mood disorder in their past. Acceptability was measured by examining self-reports and user engagement with the program. The primary outcome was the Edinburgh Postnatal Depression Scale (EPDS) change score between pre- and postintervention at 2 months, as collected in usual care by clinicians blinded to the study questions. Using a propensity score matching to control for potential confounders, we compared women receiving 7Cups to women receiving treatment as usual (TAU).

Results

Participants (n=19) proactively logged into 7Cups for a median of 12 times and 175 minutes. Program use was mostly through the mobile app (median of mobile use 94%) and between 18:00 and 08:00 when clinicians are unavailable (68% of total program use time). Participants chatted with volunteers for a total of 3064 minutes and have indicated in their responses 0 instances in which they felt unsafe. Intent-to-treat analysis revealed that 7Cups recipients experienced significant decreases in EPDS scores (P<.001, Cohen d=1.17). No significant difference in EPDS decrease over time was found between 7Cups and TAU, yet the effect size was medium favoring 7Cups (P=.05, Cohen d=0.58).

Conclusions

This study supports using a computerized method to train lay people, without any in-person guidance or screening, and engage them with patients diagnosed with mental illness as part of usual care. The medium effect size (d=0.58) favoring the 7Cups group relative to TAU suggests that 7Cups might enhance treatment outcomes. A fully powered trial has to be conducted to examine this effect.

Hispanic Hospice Patients' Experiences of End-Stage Restlessness

End-stage restlessness, or terminal agitation, is experienced by some patients during their final days and is characterized by physical, emotional, or spiritual distress, agitation or anxiety. End-stage restlessness negatively affects the patient's death experience and can be distressing to the family and care team. Using the 2007 National Home and Hospice Care survey, this study examined factors associated with experiencing end-stage restlessness among non-Hispanic white and Hispanic hospice patients deceased at time of discharge. Results showed that being Hispanic/Latino, experiencing dyspnea, pain, and receiving palliative sedation treatment were risk factors for experiencing end-stage restlessness. The association between pain and restlessness was stronger for Hispanics compared with non-Hispanic whites. The Hispanic population remains underrepresented and little is known about the patient-centered experiences of Hispanic hospice users. Findings indicated that dying Hispanic patients continue to experience pain and other negative symptoms, even when hospice care is in place. Thus, it is important that social workers provide education to interdisciplinary team members about culturally competent practices, and advocate for a patient-centered approach to care.

New Insights Into the Alleged Kidney Donor Profile Index Labeling Effect on Kidney Utilization

The Kidney Donor Profile Index (KDPI) became a driving factor in deceased donor kidney allocation on December 4, 2014, with the implementation of the kidney allocation system (KAS). On April 20, 2016, the annual recalibration of the Kidney Donor Risk Index into KDPI was incorrectly programmed in DonorNet, resulting in erroneously high KDPI values, by between 1 and 21 percentage points (e.g. actual KDPI of 70% was displayed as 86%). The error was corrected on May 19, 2016, <24 h after being recognized. During this 30-day period, the distribution of recipients largely resembled pre-KAS patterns. The observed discard rate of 22.9% was higher than the post-KAS average of 19.6% (odds ratio [OR]: 1.22) but far lower than the projected rate of 31.4% (OR: 1.96) based on the usual discard rate by KDPI relationship, suggesting clinicians and patients did not rely heavily on this single number (KDPI) in kidney-utilization decisions. Still, risk-adjusted analyses suggest the elevated discard rate was most likely attributable to the erroneously high KDPIs, not a shift in donor characteristics or random chance. The rise in discard rate was sharply higher for kidneys with inflated KDPI that crossed the 85% policy threshold (OR: 1.46; p = 0.049) versus those that did not (OR: 1.06; p = 0.631).

Changes in severity of psychosocial difficulties in adolescents accessing specialist mental healthcare in England (2009-2014)

In England, clinicians and professional organisations report that higher numbers of adolescents with more severe psychosocial difficulties are accessing specialist services. A lack of national data on patterns of access to specialist services means there is limited information to inform policy. We examined whether severity of psychosocial difficulties in adolescents accessing mental healthcare has changed over time. Adolescents seen in specialist child mental healthcare in 2009 vs. 2014 were matched on demographics and problem types using propensity score matching; final sample N = 2776 adolescents. We found: 1) stability over time in overall severity of difficulties, 2) an increase in severity of young women's emotional problems, and 3) a decrease in adolescents' conduct problems. The findings suggest the intriguing possibility that the criteria for accessing mental healthcare are not universally rising, but rather the patterns in access to specialist services may mirror epidemiological changes in severity of psychosocial difficulties in the population.

Mechanical Thrombectomy with the Embolus Retriever with Interlinked Cages in Acute Ischemic Stroke: ERIC, the New Boy in the Class

BACKGROUND AND PURPOSE

The Embolus Retriever with Interlinked Cages (ERIC) device is a novel stent retriever for mechanical thrombectomy. It consists of interlinked cages and could improve procedural benchmarks and clinical outcome compared with classic stent retrievers. This study compares the rates of recanalization, favorable clinical outcome, procedural adverse events, and benchmarks between the ERIC device and classic stent retrievers.

MATERIALS AND METHODS

From 545 patients treated with thrombectomy between 2012 and 2015, 316 patients were included. The mean age was 69 ±13 years, the mean baseline NIHSS score was 17 ± 5, and 174 (55%) were men. The ERIC was used as the primary thrombectomy device in 59 (19%) patients. In a propensity score matched analysis including the NIHSS score, clot location, delay to groin puncture, neurointerventionalist, and anesthetic management, 57 matched pairs were identified.

RESULTS

Patients treated with the ERIC device compared with classic stent retrievers showed equal rates of recanalization (86% versus 81%, P = .61), equal favorable 3-month clinical outcome (mRS 0-2: 46% versus 40%, P = .71), and procedural adverse events (28% versus 30%, P = 1.00). However, in patients treated with the ERIC device, thrombectomy procedures were less time-consuming (67 versus 98 minutes, P = .009) and a rescue device was needed less often (18% versus 39%, P = .02) compared with classic stent retrievers.

CONCLUSIONS

Mechanical thrombectomy with the ERIC device is effective and safe. Rates of favorable procedural and clinical outcomes are at least as good as those with classic stent retrievers. Of note, the ERIC device might be time-saving and decrease the need for rescue devices. These promising results call for replication in larger prospective clinical trials.

Clinical outcomes of levalbuterol versus racemic albuterol in pediatric patients with asthma: Propensity score matching approach in a medicaid population

OBJECTIVE

Racemic albuterol and levalbuterol are used to treat acute episodes of asthma. The main objective of this study was to compare levalbuterol therapy to albuterol therapy on incidence rates of subsequent emergency department (ED) visits and hospitalizations.

METHOD

We conducted a retrospective cohort study of asthmatic children who had pharmacy refills for levalbuterol/albuterol in the South Carolina Medicaid database in 2002-2011. Children receiving levalbuterol were matched to those receiving albuterol using propensity score matching technique. For ED visits and separately for hospitalizations, multivariable negative binomial regression was used to estimate the two group-specific incidence rates and the incidence rate ratio (IRR).

RESULTS

A total of 8,172 asthmatic patients aged 2-18 years were identified in the South Carolina Medicaid database. During the 12-month follow-up period, the levalbuterol group had fewer asthma-related ED visits and hospitalizations: 939 (11.49%) children had asthma-related ED visits (levalbuterol: 8.76%; albuterol: 14.21%), and 89 (1.09%) children had asthma-related hospitalizations (levalbuterol: 1.07%; albuterol: 1.12%). Comparing the levalbuterol group to the albuterol group, the adjusted IRR estimate was 0.57 (95% confidence interval [CI], 0.49-0.65) for of asthma-related ED visits, and 0.93 (95%CI, 0.99-1.63) for hospitalizations. Children filling levalbuterol also had a lower IRR of all-cause ED visit (0.88; 95%CI, 0.82-0.95), but similar IRR of all-cause hospitalizations (1.08; 95%CI, 0.82-1.42).

CONCLUSION

This observational study of children aged 2-18 demonstrated levalbuterol prescription fills were associated with reduced ED visits, but not hospitalizations. Additional research may be necessary to assess this association. Pediatr Pulmonol. 2017;52:516-523. © 2016 Wiley Periodicals, Inc.

Is cancer history really an exclusion criterion for clinical trial of lung cancer? Influence of gastrointestinal tract cancer history on the outcomes of lung cancer surgery

Objective

Exclusion of patients with a history of other cancer treatment except in situ situation has been considered to be inevitable for clinical trials investigating survival outcome. However, there have been few reports confirming these influences on surgical outcome of lung cancer patients ever.

Methods

Multi-institutional, individual data from patients with non–small cell lung cancer resected between 2000 and 2013 were collected. The patients were divided into two groups: those with a history of gastrointestinal tract cancer (GI group) and those without any history (non-GI group). We compared the outcomes with well-matched groups using propensity scoring to minimize bias related to the nonrandomness. The influence of gastrointestinal tract cancer stage, disease-free interval, and treatment method for gastrointestinal tract cancer on the surgical outcome of non–small cell lung cancer was examined.

Results

We analyzed 196 patients in the GI group and 3732 in the non-GI group. In unmatched cohort, multivariate analyses showed that a history of gastrointestinal tract cancer did not affect overall survival or recurrence-free survival. Independent predictors of poor prognosis included older age, male sex, high carcinoembryonic antigen levels and advanced clinical stage of non–small cell lung cancer. The two groups in the matched cohort demonstrated equivalent overall survival and recurrence-free survival, even in patients with clinical stage I. Gastrointestinal tract cancer stage, disease-free interval and treatment method for gastrointestinal tract cancer were not associated with outcomes.

Conclusions

History of early gastrointestinal tract cancer completely resected is not always necessary for exclusion criteria in clinical trial of lung cancer.

Using Propensity Score Methods To Assess Causal Effects of Mothers' Dieting Behavior on Daughters' Early Dieting Behavior

BACKGROUND

A high prevalence of dieting has been reported among preadolescent females. It is important to understand factors influencing the emergence of dieting because dieting is associated with increased likelihood of overeating, greater weight gain over time, and other chronic health problems. Previous studies suggest that mothers' own dieting behavior influences their daughters' dieting (i.e., modeling). Because it is not possible to randomly assign girls to a mother who is dieting versus not dieting, causal inference regarding the effects of mothers' modeling behaviors on daughters' dieting is not straightforward.

METHODS

In an observational study, data were collected on four occasions of measurement across a 6-year period, with 2-year intervals between assessments on 181 girls and their parents. Propensity score methods were used to estimate the causal effects of mothers' dieting on the emergence of daughters' dieting between ages 7 and 11, examining the moderating effect of weight status.

RESULTS

Girls whose mothers were currently dieting were significantly more likely to diet before age 11 than those whose mothers were not currently dieting, and this effect did not vary by girls' or mothers' weight status.

CONCLUSIONS

We conclude by discussing the implications of the effects of mothers' dieting on daughters' early dieting as well as the potential of propensity score methods in the field of obesity compared with traditional methodology such as regression analysis.

What type of clinical evidence is needed to assess medical devices?

The objective of this mini-review is to discuss the role of real-world studies as a source of clinical evidence when experimental studies, such as randomised controlled trials (RCTs), are not available. Waiting for RCT evidence when the technology is diffusing could be anti-economical, inefficient from the policy perspective and methodologically questionable.

We explain how real-world studies could provide relevant evidence to decision makers. Matching techniques are discussed as a viable solution for bias reduction.

We describe a case study concerning a cost-effectiveness analysis based on real-world data of a technology already in use: Mitraclip combined with medical therapy versus medical therapy alone in patients with moderate-to-severe mitral regurgitation. The CEA has encountered the scepticism of most reviewers, due not to the statistical methodology but to the fact that the study was observational and not experimental. Editors and reviewers converged in considering real-world economic evaluations premature in the absence of a RCT, even if in the meantime the technology had been implanted >30 000 times. We believe there is a need to acknowledge the importance of real-world studies, and engage the scientific community in the promotion and use of clinical evidence produced through observational studies.

Real-world data are a valid complement and/or alternative to RCTs to support policy decisions on medical deviceshttp://ow.ly/SHsZ300pfCB

Evaluating the Impact of an Accountable Care Organization on Population Health: The Quasi-Experimental Design of the German Gesundes Kinzigtal

A central goal of accountable care organizations (ACOs) is to improve the health of their accountable population. No evidence currently links ACO development to improved population health. A major challenge to establishing the evidence base for the impact of ACOs on population health is the absence of a theoretically grounded, robust, operationally feasible, and meaningful research design. The authors present an evaluation study design, provide an empirical example, and discuss considerations for generating the evidence base for ACO implementation. A quasi-experimental study design using propensity score matching in combination with small-scale exact matching is implemented. Outcome indicators based on claims data were constructed and analyzed. Population health is measured by using a range of mortality indicators: mortality ratio, age at time of death, years of potential life lost/gained, and survival time. The application is assessed using longitudinal data from Gesundes Kinzigtal, one of the leading population-based ACOs in Germany. The proposed matching approach resulted in a balanced control of observable differences between the intervention (ACO) and control groups. The mortality indicators used indicate positive results. For example, 635.6 fewer years of potential life lost (2005.8 vs. 2641.4; t-test: sig. P < 0.05*) in the ACO intervention group (n = 5411) attributable to the ACO, also after controlling for a potential (indirect) immortal time bias by excluding the first half year after enrollment from the outcome measurement. This empirical example of the impact of a German ACO on population health can be extended to the evaluation of ACOs and other integrated delivery models of care.

Use and Interpretation of Propensity Scores in Aging Research: A Guide for Clinical Researchers

Observational studies are an important source of evidence for evaluating treatment benefits and harms in older adults, but lack of comparability in the outcome risk factors between the treatment groups leads to confounding. Propensity score (PS) analysis is widely used in aging research to reduce confounding. Understanding the assumptions and pitfalls of common PS analysis methods is fundamental to applying and interpreting PS analysis. This review was developed based on a symposium of the American Geriatrics Society Annual Meeting on the use and interpretation of PS analysis in May 2014. PS analysis involves two steps: estimation of PS and estimation of the treatment effect using PS. Typically estimated from a logistic model, PS reflects the probability of receiving a treatment given observed characteristics of an individual. PS can be viewed as a summary score that contains information on multiple confounders and is used in matching, weighting, or stratification to achieve confounder balance between the treatment groups to estimate the treatment effect. Of these methods, matching and weighting generally reduce confounding more effectively than stratification. Although PS is often included as a covariate in the outcome regression model, this is no longer a best practice because of its sensitivity to modeling assumption. None of these methods reduce confounding by unmeasured variables. The rationale, best practices, and caveats in conducting PS analysis are explained in this review using a case study that examined the effective of angiotensin-converting enzyme inhibitors on mortality and hospitalization in older adults with heart failure.

Newly Diagnosed Anemia Increases Risk of Parkinson's disease: A Population-Based Cohort Study

Anemia and low hemoglobin have been identified to increase Parkinson’s disease (PD) risk. This population-based cohort study investigated PD risk in newly diagnosed anemic patients by using data from the Taiwan National Health Insurance Research Database. All newly diagnosed anemic patients (n = 86,334) without a history of stroke, neurodegenerative diseases, traumatic brain injury, major operations, or blood loss diseases were enrolled. A cohort of nonanemic controls, 1:1 matched with anemic patients on the basis of the demographics and pre-existing medical conditions, was also included. Competing risk analysis was used to evaluate PD risk in anemic patients compared with that in their matched controls. The adjusted hazard ratio (aHR) of PD risk in the anemic patients was 1.36 (95% confidence interval [CI]: 1.22–1.52, p < 0.001). Iron deficiency anemia (IDA) patients tended to exhibit a higher PD risk (aHR: 1.49; 95% CI: 1.24–1.79, p < 0.001). Furthermore, Iron supplement did not significantly affect the PD risk: the aHRs for PD risk were 1.32 (95% CI: 1.07–1.63, p < 0.01) and 1.86 (95% CI: 1.46–2.35, p < 0.001) in IDA patients with and without iron supplementation, respectively. The population-based cohort study indicated newly diagnosed anemia increases PD risk.

No difference between aspirin and warfarin after extracardiac Fontan in a propensity score analysis of 475 patients

OBJECTIVES

The most effective method of long-term thromboprophylaxis after the Fontan procedure is not clear. We compared the rates of thromboembolic events between patients receiving aspirin and warfarin after an extracardiac conduit Fontan procedure in a bi-national registry.

METHODS

All patients who underwent an extracardiac conduit Fontan procedure from 1997 to 2010 in Australia and New Zealand were identified. Medication status and routine follow-up and echocardiographic data were obtained from all patients. Survival analysis with propensity score matching and adjustment was performed to determine the treatment effect of warfarin compared with that of aspirin beyond the first year of follow-up, after which time patients had settled on their long-term thromboprophylaxis strategy.

RESULTS

Of 570 eligible patients, the data of 475 patients who were regularly followed up without mechanical valve replacement were available for analysis. Long-term thromboprophylaxis consisted of warfarin in 301 patients (63%), aspirin in 157 (33%) and none in 17 (4%). The 10-year rate of freedom from all thromboembolic events was 91% [95% confidence interval (CI) 88-94%]. Thromboembolic events beyond the first year of follow-up occurred in 18 patients (6 on aspirin and 12 on warfarin). After (i) propensity score adjustment and (ii) matching yielding 164 pairs, the hazard rates of thromboembolic events beyond the first year were not statistically different between the warfarin and aspirin groups [(i) hazard ratio (HR) 2.3, 95% CI 0.7-7.4, P = 0.2 and (ii) HR 1.5, 95% CI 0.5-4.7, P = 0.5, respectively].

CONCLUSIONS

No difference in the hazard rates of late thromboembolic events was observed between aspirin and warfarin beyond the first year after the extracardiac conduit Fontan procedure.

Comparison of Calipers for Matching on the Disease Risk Score

Previous studies have compared calipers for propensity score (PS) matching, but none have considered calipers for matching on the disease risk score (DRS). We used Medicare claims data to perform 3 cohort studies of medication initiators: a study of raloxifene versus alendronate in 1-year nonvertebral fracture risk, a study of cyclooxygenase 2 inhibitors versus nonselective nonsteroidal antiinflammatory medications in 6-month gastrointestinal bleeding, and a study of simvastatin + ezetimibe versus simvastatin alone in 6-month cardiovascular outcomes. The study periods for each cohort were 1998 through 2005, 1999 through 2002, and 2004 through 2005, respectively. In each cohort, we calculated 1) a DRS, 2) a prognostic PS which included the DRS as the independent variable in a PS model, and 3) the PS for each patient. We then nearest-neighbor matched on each score in a variable ratio and a fixed ratio within 8 calipers based on the standard deviation of the logit and the natural score scale. When variable ratio matching on the DRS, a caliper of 0.05 on the natural scale performed poorly when the outcome was rare. The prognostic PS did not appear to offer any consistent practical benefits over matching on the DRS directly. In general, logit-based calipers or calipers smaller than 0.05 on the natural scale performed well when DRS matching in all examples.

Clinical Utility and Lifespan Profiling of Neurological Soft Signs in Schizophrenia Spectrum Disorders

Neurological soft signs (NSSs) bear the promise for early detection of schizophrenia spectrum disorders. Nonetheless, the sensitivity and specificity of NSSs in the psychosis continuum remains a topic of controversy. It is also unknown how NSSs reveal neurodevelopmental abnormality in schizophrenia. We investigated the effect sizes of NSSs in differentiating individuals with schizophrenia spectrum disorders from individuals with other psychiatric conditions and from covariate-matched healthy subjects. We also investigated the partitioned age-related variations of NSSs in both schizophrenia and healthy individuals. NSSs were assessed by the abridged version of the Cambridge Neurological Inventory (CNI) in 3105 participants, consisting of healthy individuals (n=1577), unaffected first-degree relatives of schizophrenia patients (n= 155), individuals with schizotypal personality disorder (n= 256), schizophrenia patients (n= 738), and other psychiatric patients (n= 379). Exact matching and propensity score matching procedures were performed to control for covariates. Multiple regression was used to partition age-related variations. Individuals along the schizophrenia continuum showed elevated levels of NSSs, with moderate effect sizes, in contrast to other psychiatric patients who had minimal NSSs, as well as matched healthy controls. Furthermore, the age-and-NSS relationship in schizophrenia patients was represented by a flat but overall elevated pattern, in contrast to a U-shaped pattern in healthy individuals. In sum, NSSs capture a moderate portion of psychosis proneness with reasonable specificity. Lifespan profiling reveals an abnormal developmental trajectory of NSSs in schizophrenia patients, which supports the endophenotype hypothesis of NSSs by associating it with the neurodevelopmental model of schizophrenia.

Indirect Standardization Matching: Assessing Specific Advantage and Risk Synergy

OBJECTIVE

To develop a method to allow a hospital to compare its performance using its entire patient population to the outcomes of very similar patients treated elsewhere.

DATA SOURCES/SETTING

Medicare claims in orthopedics and common general, gynecologic, and urologic surgery from Illinois, New York, and Texas from 2004 to 2006.

STUDY DESIGN

Using two example "focal" hospitals, each hospital's patients were matched to 10 very similar patients selected from 619 other hospitals.

DATA COLLECTION/EXTRACTION METHODS

All patients were used at each focal hospital, and we found the 10 closest matched patients from control hospitals with exactly the same principal procedure as each focal patient.

PRINCIPAL FINDINGS

We achieved exact matches on all procedures and very close matches for other patient characteristics for both hospitals. There were few to no differences between each hospital's patients and their matched control patients on most patient characteristics, yet large and significant differences were observed for mortality, failure-to-rescue, and cost.

CONCLUSION

Indirect standardization matching can produce fair audits of quality and cost, allowing for a comprehensive, transparent, and relevant assessment of all patients at a focal hospital. With this approach, hospitals will be better able to benchmark their performance and determine where quality improvement is most needed.

Laparoscopic surgery for patients with colorectal cancer produces better short-term outcomes with similar survival outcomes in elderly patients compared to open surgery

The number of operations on elderly colorectal cancer (CRC) patients has increased with the aging of the population. The aim of this study was to evaluate surgical outcomes in elderly patients who underwent laparoscopic or open surgery for CRC. We analyzed the data of 280 patients aged 80 or over who underwent surgery for CRC between January 2001 and December 2010. Seventy-one pairs were selected after propensity score matching for laparoscopic or open surgery. Operative time, return to normal bowel function, length of hospital stay, postoperative complications, overall survival (OS), recurrence-free survival (RFS), and prognostic factors affecting survival were investigated. In matched cohorts, operative time in the laparoscopic group was longer than in the open group (P < 0.001). In the laparoscopic group, time to flatus passage (P < 0.001) and length of postoperative hospital stay (P = 0.037) were shorter than in the open group. The rate of operation-related morbidity was higher in the open group (P = 0.019). There was no difference in OS and RFS between two groups. This study suggests that laparoscopic surgery for CRC in elderly patients may be safe and feasible, with better short-term outcomes. OS and RFS, however, were not different in both groups.

Feasibility and safety comparison of laparoscopy-assisted versus open gastrectomy for advanced gastric carcinoma with D2 lymphadenectomy

OBJECTIVE

Laparoscopy-assisted gastrectomy for advanced gastric cancer still remains controversial. The aim of this study is to compare oncologic feasibility and technical safety of laparoscopic versus open gastrectomy for advanced gastric cancer with D2 lymphadenectomy by comparing patients' short-term postoperative outcomes.

METHODS

One hundred and one patients with laparoscopy-assisted gastrectomy and 101 patients with open gastrectomy were one-to-one matched and then compared in terms of operative outcomes and hospital courses.

RESULTS

The laparoscopic group showed significantly longer operating time (297.4 vs. 198.1 min, P < 0.001), earlier first flatus time (2.8 vs. 3.6 days, P < 0.001), earlier diet start time (3.8 vs. 4.6 days, P < 0.001), shorter hospital stay (10.5 vs. 11.9 days, P < 0.001) and less morbidity (21.8 vs. 37.6%, P = 0.019). However, retrieval lymph nodes, intraoperative blood loss, transfused patients, postoperative fever and mortality were similar in the two groups. As for complications, incision infection (1.0 vs. 8.9%, P = 0.021) was significantly more common in the open group than in the laparoscopic group. In the subgroup comparisons of outcomes of laparoscopy-assisted gastrectomy, the tumor, node, metastasis III group showed significantly increased retrieval lymph nodes (37.2 vs. 31.0, P < 0.001), increased intraoperative blood loss (147.2 vs. 120.5 ml, P = 0.010), increased length of hospital stay (11.1 vs. 9.9 days, P < 0.001) and increased morbidity (32.6 vs. 13.8%, P = 0.024) when compared with the tumor, node, metastasis II group.

CONCLUSIONS

Laparoscopy-assisted gastrectomy is feasible and safe for the treatment of advanced gastric cancer with D2 lymphadenectomy compared with open gastrectomy. Higher-level tumor stage (tumor, node, metastasis III) may increase the operative risk and should be performed with caution by surgeons with considerable experience of laparoscopic gastrectomy.

Long-term survival following open versus thoracoscopic lobectomy after preoperative chemotherapy for non-small cell lung cancer

OBJECTIVES

Video-assisted thoracoscopic (VATS) lobectomy is increasingly accepted for the management of early-stage non-small cell lung cancer (NSCLC), but its role for locally advanced cancers has not been as well characterized. We compared outcomes of patients who received induction therapy followed by lobectomy, via VATS or thoracotomy.

METHODS

Perioperative complications and long-term survival of all patients with NSCLC who received induction chemotherapy (ICT) (with or without induction radiation therapy) followed by lobectomy from 1996-2012 were assessed using Kaplan-Meier and Cox proportional hazard analysis. Propensity score-matched comparisons were used to assess the potential impact of selection bias.

RESULTS

From 1996 to 2012, 272 patients met inclusion criteria and underwent lobectomy after ICT: 69 (25%) by VATS and 203 (75%) by thoracotomy. An 'intent-to-treat' analysis was performed. Compared with thoracotomy patients, VATS patients had a higher clinical stage, were older, had greater body mass index, and were more likely to have coronary disease and chronic obstructive pulmonary disease. Induction radiation was used more commonly in thoracotomy patients [VATS 28% (n = 19) vs open 72% (n = 146), P < 0.001]. Thirty-day mortality was similar between the VATS [3% (n = 2)] and open [4% (n = 8)] groups (P = 0.69). Seven (10%) of the VATS cases were converted to thoracotomy due to difficulty in dissection from fibrotic tissue and adhesions (n = 5) or bleeding (n = 2); none of these conversions led to perioperative deaths. In univariate analysis, VATS patients had improved 3-year survival compared with thoracotomy (61% vs 43%, P = 0.010). In multivariable analysis, the VATS approach showed a trend towards improved survival, but this did not reach statistical significance (hazard ratio, 0.56; 95% confidence interval, 0.32-1.01; P = 0.053). Moreover, a propensity score-matched analysis balancing patient characteristics demonstrated that the VATS approach had similar survival to an open approach (P = 0.56).

CONCLUSIONS

VATS lobectomy in patients treated with induction therapy for locally advanced NSCLC is feasible and effective and does not appear to compromise oncologic outcomes.

Thiazolidinediones and Parkinson Disease: A Cohort Study

Thiazolidinediones, a class of medications indicated for the treatment of type 2 diabetes mellitus, reduce inflammation and have been shown to provide a therapeutic benefit in animal models of Parkinson disease. We examined the association between treatment with thiazolidinediones and the onset of Parkinson disease in older individuals. We performed a cohort study of 29,397 Medicare patients enrolled in state pharmaceutical benefits programs who initiated treatment with thiazolidinediones or sulfonylureas during the years 1997 through 2005 and had no prior diagnosis of Parkinson disease. New users of thiazolidinediones were propensity score matched to new users of sulfonylureas and followed to determine whether they were diagnosed with Parkinson disease. We used Cox proportional hazards models to compare time to diagnosis of Parkinson disease in the propensity score-matched populations. To assess the association with duration of use, we performed several analyses that required longer continuous use of medications. In the primary analysis, thiazolidinedione users had a hazard ratio for a diagnosis of Parkinson disease of 1.09 (95% confidence interval: 0.71, 1.66) when compared with sulfonylurea users. Increasing the duration-of-use requirements to 10 months did not substantially change the association; the hazard ratios ranged from 1.00 (95% confidence interval: 0.49, 2.05) to 1.17 (95% confidence interval: 0.60, 2.25). Thiazolidinedione use was not associated with a longer time to diagnosis of Parkinson disease than was sulfonylurea use, regardless of duration of exposure.

Progression to insulin therapy among patients with type 2 diabetes treated with sitagliptin or sulphonylurea plus metformin dual therapy

AIM

To assess time to insulin initiation among patients with type 2 diabetes mellitus (T2DM) treated with sitagliptin versus sulphonylurea as add-on to metformin.

METHODS

This retrospective cohort study used GE Centricity electronic medical records and included patients aged ≥18 years with continuous medical records and an initial prescription of sitagliptin or sulphonylurea (index date) with metformin for ≥90 days during 2006-2013. Sitagliptin and sulphonylurea users were matched 1 : 1 using propensity score matching, and differences in insulin initiation were assessed using Kaplan-Meier curves and Cox regression. We used conditional logistic regression to examine the likelihood of insulin use 1-6 years after the index date for each year.

RESULTS

Propensity score matching produced 3864 matched pairs. Kaplan-Meier analysis showed that sitagliptin users had a lower risk of insulin initiation compared with sulphonylurea users (p = 0.003), with 26.6% of sitagliptin users initiating insulin versus 34.1% of sulphonylurea users over 6 years. This finding remained significant after adjusting for baseline characteristics (hazard ratio 0.76, 95% confidence interval 0.65-0.90). Conditional logistic regression analyses confirmed that sitagliptin users were less likely to initiate insulin compared with sulphonylurea users [odds ratios for years 1-6: 0.77, 0.79, 0.81, 0.57, 0.29 and 0.75, respectively (p < 0.05 for years 4 and 5)].

CONCLUSIONS

In this real-world matched cohort study, patients with T2DM treated with sitagliptin had a significantly lower risk of insulin initiation compared with patients treated with sulphonylurea, both as add-on to metformin.

A Longitudinal Evaluation of the Positive Action Program in a Low-Income, Racially Diverse, Rural County: Effects on Self-Esteem, School Hassles, Aggression, and Internalizing Symptoms

Positive Action is a school-based program that aims to decrease problem behaviors (e.g., violence, substance use) and increase positive behaviors (e.g., school engagement, academic achievement). Although a number of studies have shown that Positive Action successfully achieves these goals, few studies have evaluated the program's effectiveness in rural schools. Given that rural youth are at an increased risk for risky behaviors (e.g., violence, substance use), this is a critical gap in the existing Positive Action research base. The current study assesses the impact of Positive Action on change rates of self-esteem, school hassles, aggression, and internalizing symptoms in a group (N = 1246, 52% female) of ethnically/racially diverse (27% White, 23% African American, 12% mixed race/other, 8% Latino, 30% as American Indian) middle school youth (age range 9-20) located in two violent, low-income rural counties in North Carolina. One county engaged in Positive Action over the 3-year study window while the other county did not. Following multiple imputation and propensity score analysis, 4 two-level hierarchical linear models were run using each of the outcome measures as dependent variables. The results indicate that the program generates statistically significant beneficial effects for youth from the intervention county on self-esteem scores and school hassles scores. Although the program generates beneficial effects for intervention youth on the change in aggression scores, the finding is not statistically significant. The finding on the change in internalizing scores shows a non-significant detrimental effect: the youth from the comparison county have lower internalizing scores than those from the intervention county. Implications are discussed.

Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: the prospective longitudinal trial of FFR(CT): outcome and resource impacts study

Aims

In symptomatic patients with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) improves patient selection for invasive coronary angiography (ICA) compared with functional testing. The impact of measuring fractional flow reserve by CTA (FFR_CT) is unknown.

Methods and results

At 11 sites, 584 patients with new onset chest pain were prospectively assigned to receive either usual testing (n = 287) or CTA/FFR_CT (n = 297). Test interpretation and care decisions were made by the clinical care team. The primary endpoint was the percentage of those with planned ICA in whom no significant obstructive CAD (no stenosis ≥50% by core laboratory quantitative analysis or invasive FFR < 0.80) was found at ICA within 90 days. Secondary endpoints including death, myocardial infarction, and unplanned revascularization were independently and blindly adjudicated. Subjects averaged 61 ± 11 years of age, 40% were female, and the mean pre-test probability of obstructive CAD was 49 ± 17%. Among those with intended ICA (FFR_CT-guided = 193; usual care = 187), no obstructive CAD was found at ICA in 24 (12%) in the CTA/FFR_CT arm and 137 (73%) in the usual care arm (risk difference 61%, 95% confidence interval 53–69, P< 0.0001), with similar mean cumulative radiation exposure (9.9 vs. 9.4 mSv, P = 0.20). Invasive coronary angiography was cancelled in 61% after receiving CTA/FFR_CT results. Among those with intended non-invasive testing, the rates of finding no obstructive CAD at ICA were 13% (CTA/FFR_CT) and 6% (usual care; P = 0.95). Clinical event rates within 90 days were low in usual care and CTA/FFR_CT arms.

Conclusions

Computed tomographic angiography/fractional flow reserve by CTA was a feasible and safe alternative to ICA and was associated with a significantly lower rate of invasive angiography showing no obstructive CAD.

Optimal full matching for survival outcomes: a method that merits more widespread use

Matching on the propensity score is a commonly used analytic method for estimating the effects of treatments on outcomes. Commonly used propensity score matching methods include nearest neighbor matching and nearest neighbor caliper matching. Rosenbaum (1991) proposed an optimal full matching approach, in which matched strata are formed consisting of either one treated subject and at least one control subject or one control subject and at least one treated subject. Full matching has been used rarely in the applied literature. Furthermore, its performance for use with survival outcomes has not been rigorously evaluated. We propose a method to use full matching to estimate the effect of treatment on the hazard of the occurrence of the outcome. An extensive set of Monte Carlo simulations were conducted to examine the performance of optimal full matching with survival analysis. Its performance was compared with that of nearest neighbor matching, nearest neighbor caliper matching, and inverse probability of treatment weighting using the propensity score. Full matching has superior performance compared with that of the two other matching algorithms and had comparable performance with that of inverse probability of treatment weighting using the propensity score. We illustrate the application of full matching with survival outcomes to estimate the effect of statin prescribing at hospital discharge on the hazard of post‐discharge mortality in a large cohort of patients who were discharged from hospital with a diagnosis of acute myocardial infarction. Optimal full matching merits more widespread adoption in medical and epidemiological research. © 2015 The Authors. Statistics in Medicine Published by John Wiley & Sons Ltd.

Noninferiority of Inhaled Epoprostenol to Inhaled Nitric Oxide for the Treatment of ARDS

Background: Inhaled nitric oxide and inhaled epoprostenol have been evaluated for the management of hypoxemia in acute respiratory distress syndrome, with clinical trials demonstrating comparable improvements in oxygenation. However, these trials have several limitations, making it difficult to draw definitive conclusions regarding clinical outcomes. Objective: The aim of this study was to evaluate the noninferiority and safety of inhaled epoprostenol compared with inhaled nitric oxide in mechanically ventilated acute respiratory distress syndrome (ARDS) patients with a primary outcome of ventilator-free days from day 1 to day 28. Methods: This was a retrospective, noninterventional, propensity-matched, noninferiority cohort study. Propensity score for receipt of inhaled nitric oxide was developed and patients were matched accordingly using a prespecified algorithm. Secondary objectives included evaluating day 28 intensive care unit–free days, changes in PaO2/FiO2 ratio after inhalation therapy initiation, and hospital mortality. Safety endpoints assessed included hypotension, methemoglobinemia, renal dysfunction, rebound hypoxemia, significant bleeding, and thrombocytopenia. Results: Ninety-four patients were included, with 47 patients in each group. Patients were well-matched with similar baseline characteristics, except patients in inhaled nitric oxide group had lower PaO2/FiO2 ratio. Management of ARDS was similar between groups. Mean difference in ventilator-free days between inhaled epoprostenol and inhaled nitric oxide was 2.16 days (95% confidence interval = −0.61 to 4.9), with lower limit of 95% confidence interval greater than the prespecified margin, hence satisfying noninferiority. There were no differences in any secondary or safety outcomes. Conclusions: Inhaled epoprostenol was noninferior to inhaled nitric oxide with regard to ventilator-free days from day 1 to day 28 in ARDS patients.

Mental Health Recovery in the Patient-Centered Medical Home

OBJECTIVES

We examined the impact of transitioning clients from a mental health clinic to a patient-centered medical home (PCMH) on mental health recovery.

METHODS

We drew data from a large US County Behavioral Health Services administrative data set. We used propensity score analysis and multilevel modeling to assess the impact of the PCMH on mental health recovery by comparing PCMH participants (n = 215) to clients receiving service as usual (SAU; n = 22,394) from 2011 to 2013 in San Diego County, California. We repeatedly assessed mental health recovery over time (days since baseline assessment range = 0-1639; mean = 186) with the Illness Management and Recovery (IMR) scale and Recovery Markers Questionnaire.

RESULTS

For total IMR (log-likelihood ratio χ(2)[1] = 4696.97; P < .001) and IMR Factor 2 Management scores (log-likelihood ratio χ(2)[1] = 7.9; P = .005), increases in mental health recovery over time were greater for PCMH than SAU participants. Increases on all other measures over time were similar for PCMH and SAU participants.

CONCLUSIONS

Greater increases in mental health recovery over time can be expected when patients with severe mental illness are provided treatment through the PCMH. Evaluative efforts should be taken to inform more widespread adoption of the PCMH.

A propensity score-matched case-control comparative study of laparoscopic and open liver resection for hepatocellular carcinoma

BACKGROUND

The aim of this study was to compare the perioperative and long-term oncologic outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for single hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score.

PATIENTS AND METHODS

Between January 2005 and February 2013, 292 patients underwent surgical resection for HCC. Of these, 202 patients who underwent surgical resection for initial treatment for a single mass were enrolled. These patients were divided into two groups according to the method of operation: the Lap group (patients who underwent LLR) and the Open group (patients who underwent OLR). To correct different demographic and clinical factors in the two groups, propensity score matching was used at a 1:1 ratio, and, finally, 102 patients were enrolled in this study, 51 patients in each group. Preoperative characteristics, perioperative results, and long-term results were retrospectively analyzed based on the prospectively recorded database.

RESULTS

Preoperative baseline variables were well balanced in both groups. There were no differences of extent of surgery and rate of anatomical resection between the two groups. With the exception of a shorter postoperative hospital stay in the Lap group than that of the Open group (8.2 days versus 12.3 days; P=.004), there were no significant differences in perioperative, pathological, and long-term outcomes. The 5-year overall survival rates were 80.1% in the Lap group and 85.7% in the Open group, respectively (P=.173). The 5-year disease-free survival rates were 67.8% in the Lap group and 54.8% in the Open group, respectively (P=.519).

CONCLUSIONS

LLR for HCC is safe, and long-term oncologic outcomes in selected patients were comparable to those who underwent OLR.

Importance of risk factor management in diabetic patients and reduction in Stage B heart failure

BACKGROUND

A number of studies have demonstrated the presence of a diabetic cardiomyopathy, increasing the risk of heart failure development in this population. Improvements in present-day risk factor control may have modified the risk of diabetes-associated cardiomyopathy.

AIM

We sought to determine the contemporary impact of diabetes mellitus (DM) on the prevalence of cardiomyopathy in at-risk patients with and without adjustment for risk factor control.

DESIGN

A cross-sectional study in a population at risk for heart failure.

METHODS

Those with diabetes were compared to those with other cardiovascular risk factors, unmatched, matched for age and gender and then matched for age, gender, body mass index, systolic blood pressure and low density lipoprotein cholesterol.

RESULTS

In total, 1399 patients enrolled in the St Vincent's Screening to Prevent Heart Failure (STOP-HF) cohort were included. About 543 participants had an established history of DM. In the whole sample, Stage B heart failure (asymptomatic cardiomyopathy) was not found more frequently among the diabetic cohort compared to those without diabetes [113 (20.8%) vs. 154 (18.0%), P = 0.22], even when matched for age and gender. When controlling for these risk factors and risk factor control Stage B was found to be more prevalent in those with diabetes [88 (22.2%)] compared to those without diabetes [65 (16.4%), P = 0.048].

CONCLUSION

In this cohort of patients with established risk factors for Stage B heart failure superior risk factor management among the diabetic population appears to dilute the independent diabetic insult to left ventricular structure and function, underlining the importance and benefit of effective risk factor control in this population on cardiovascular outcomes.

Comparative efficacy of switching to natalizumab in active multiple sclerosis

OBJECTIVE

To compare treatment efficacy and persistence in patients who switched to natalizumab versus those who switched between glatiramer acetate (GA) and interferon-beta (IFNβ) after an on-treatment relapse on IFNβ or GA using propensity score matched real-world datasets.

METHODS

Patients included were registered in MSBase or the TYSABRI Observational Program (TOP), had relapsed on IFNβ or GA within 12 months prior to switching to another therapy, and had initiated natalizumab or IFNβ/GA treatment ≤6 months after discontinuing prior therapy. Covariates were balanced across post switch treatment groups by propensity score matching at treatment initiation. Relapse, persistence, and disability measures were compared between matched treatment arms in the total population (n = 869/group) and in subgroups defined by prior treatment history (IFNβ only [n = 578/group], GA only [n = 165/group], or both IFNβ and GA [n = 176/group]).

RESULTS

Compared to switching between IFNβ and GA, switching to natalizumab reduced annualized relapse rate in year one by 65-75%, the risk of first relapse by 53-82% (mean follow-up 1.7-2.2 years) and treatment discontinuation events by 48-65% (all P ≤ 0.001). In the total population, switching to natalizumab reduced the risk of confirmed disability progression by 26% (P = 0.036) and decreased the total disability burden by 1.54 EDSS-years (P < 0.0001) over the first 24 months post switch.

INTERPRETATION

Using large, real-world, propensity-matched datasets we demonstrate that after a relapse on IFNβ or GA, switching to natalizumab (rather than between IFNβ and GA) led to superior outcomes for patients in all measures assessed. Results were consistent regardless of the prior treatment identity.

The association of breastfeeding initiation with sensitivity, cognitive stimulation, and efficacy among young mothers: a propensity score matching approach

OBJECTIVE

This study examined the association between breastfeeding initiation and maternal sensitivity, efficacy, and cognitive stimulation among young, low-income, African American mothers.

SUBJECTS AND METHODS

Two hundred twenty-one mothers were interviewed during pregnancy, at birth, and at 4 months postpartum regarding breastfeeding and parenting. Medical records were collected after birth, and mother-infant interactions were videotaped at 4 months. Propensity score matching was used to address selection bias by matching breastfeeding and nonbreastfeeding mothers on characteristics measured prior to breastfeeding.

RESULTS

One hundred twenty-four (56%) mothers initiated breastfeeding. After matching, mothers who initiated breastfeeding reported greater parenting efficacy (effect size, d=0.44) and were observed to be more sensitive with their 4-month-old infants (effect size, d=0.42) than nonbreastfeeding mothers. Breastfeeding was marginally associated with less maternal intrusiveness (effect size, d=0.28) but was not related to parenting attitudes or cognitive stimulation.

CONCLUSIONS

This study presents evidence supporting the claim that breastfeeding may enhance maternal efficacy and sensitivity. Providing breastfeeding support to young mothers may have effects that extend beyond maternal and child health outcomes to parenting and mother-child interactions.