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Chhabra S, Cameron A, Thavorn K, Sikora L, Yadav K. Quality of health economic evaluations in emergency medicine journals: a systematic review. CAN J EMERG MED 2023; 25:676-688. [PMID: 37389770 DOI: 10.1007/s43678-023-00535-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 05/28/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE Health economic evaluations are used in decision-making regarding resource allocation and it is imperative that they are completed with rigor. The primary objectives were to describe the characteristics and assess the quality of economic evaluations published in emergency medicine journals. METHODS Two reviewers independently searched 19 emergency medicine-specific journals via Medline and Embase from inception until March 3, 2022. Quality assessment was completed using the Quality of Health Economic Studies (QHES) tool, and the primary outcome was the QHES score out of 100. Additionally, we identified factors that may contribute to higher-quality publications. RESULTS 7260 unique articles yielded 48 economic evaluations that met inclusion criteria. Most studies were cost-utility analyses and of high quality, with a median QHES score of 84 (interquartile range, IQR: 72, 90). Studies based on mathematical models and those primarily designed as an economic evaluation were associated with higher quality scores. The most commonly missed QHES items were: (i) providing and justifying the perspective of the analysis, (ii) providing justification for the primary outcome, and (iii) selecting an outcome that was long enough to allow for relevant events to occur. CONCLUSIONS The majority of health economic evaluations in the emergency medicine literature are cost-utility analyses and are of high quality. Decision analytic models and studies primarily designed as economic analyses were positively correlated with higher quality. To improve study quality, future EM economic evaluations should justify the choice of the perspective of the analysis and the selection of the primary outcome.
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Affiliation(s)
- Shawn Chhabra
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Austin Cameron
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Neonatal-Perinatal Medicine, IWK Health Centre, Halifax, NS, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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A systematic review on the effectiveness and impact of clinical decision support systems for breathlessness. NPJ Prim Care Respir Med 2022; 32:29. [PMID: 35987745 PMCID: PMC9392800 DOI: 10.1038/s41533-022-00291-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractBreathlessness is a common presenting symptom in practice. This systematic review aimed to evaluate the impact of CDSS on breathlessness and associated diseases in real-world clinical settings. Studies published between 1 January 2000 to 10 September 2021 were systematically obtained from 14 electronic research databases including CENTRAL, Embase, Pubmed, and clinical trial registries. Main outcomes of interest were patient health outcomes, provider use, diagnostic concordance, economic evaluation, and unintended consequences. The review protocol was prospectively registered in PROSPERO (CRD42020163141). A total of 4294 records were screened and 37 studies included of which 30 were RCTs. Twenty studies were in primary care, 13 in hospital outpatient/emergency department (ED), and the remainder mixed. Study duration ranged from 2 weeks to 5 years. Most were adults (58%). Five CDSS were focused on assessment, one on assessment and management, and the rest on disease-specific management. Most studies were disease-specific, predominantly focused on asthma (17 studies), COPD (2 studies), or asthma and COPD (3 studies). CDSS for COPD, heart failure, and asthma in adults reported clinical benefits such as reduced exacerbations, improved quality of life, improved patient-reported outcomes or reduced mortality. Studies identified low usage as the main barrier to effectiveness. Clinicians identified dissonance between CDSS recommendations and real-world practice as a major barrier. This review identified potential benefits of CDSS implementation in primary care and outpatient services for adults with heart failure, COPD, and asthma in improving diagnosis, compliance with guideline recommendations, promotion of non-pharmacological interventions, and improved clinical outcomes including mortality.
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Brothers TE, Todoran TM. Permanent inferior vena cava filters offer greater expected patient utility at lower predicted cost. J Vasc Surg Venous Lymphat Disord 2020; 8:583-592.e5. [PMID: 32335332 DOI: 10.1016/j.jvsv.2020.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/09/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Retrievable inferior vena cava (IVC) filters were first approved for use in the United States in 2003 to address the long-term complications of migration, thrombosis, fracture, and perforation observed with permanent IVC filter implantation. Although Food and Drug Administration approval of retrievable IVC filters includes permanent implantation, the incidence of complications from long-term implantation appears to be greater than that reported with existing permanent IVC filters. Also, only a small fraction of such retrievable IVC filters are ever retrieved. The purpose of the present study was to determine the threshold retrieval rate at which the use of retrievable IVC filters could be justified. METHODS A Markov decision tree was constructed comparing retrievable and permanent IVC filters regarding their effectiveness and cost. A review of the reported data provided outcome probabilities, and the Tufts Medical Center Cost-Effectiveness Analysis Registry was the source of the utility values for the various potential outcomes. Medicare reimbursement rates served as a proxy for costs. A sensitivity analysis was performed for various parameters, primarily to determine the retrieval rate threshold at which the use of retrievable IVC filters would outperform the use of permanent IVC filters. RESULTS Base case analysis demonstrated a greater predicted effectiveness for permanent compared with retrievable IVC filter implantation (5.41 quality-adjusted life-years [QALY] vs 5.33 QALY) at a lower cost ($2070 vs $4650). Monte Carlo simulation at 10,000 iterations confirmed the expected utility (5.4 ± 3.0 QALY vs 5.3 ± 3.0 QALY; P = .0002) and cost ($1900 ± $7400 vs $4800 ± 9900; P < .0001) to be statistically superior for permanent IVC filters. A sensitivity analysis for the filter retrieval rate demonstrated that the strategy of using a retrievable IVC filter was never preferable for utility or cost. The superiority of permanent IVC filter placement for effectiveness and cost persisted, regardless of anticipated patient-predicted annual mortality. A two-way sensitivity analysis for both IVC filter removal rate and annual patient mortality confirmed the superiority of permanent IVC filter placement at all levels. CONCLUSIONS The predicted effectiveness of permanent IVC filters was greater and the predicted cost lower than those for retrievable IVC filters, regardless of the IVC filter retrieval rate. This interpretation of existing reported data using Markov decision analysis modeling supports the argument that unless the long-term complication rate of retrievable IVC filters can be significantly improved, their use should be abandoned in favor of currently available permanent IVC filters.
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Affiliation(s)
- Thomas E Brothers
- Surgical Service, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC; Division of Vascular and Endovascular Surgery, Medical University of South Carolina, Charleston, SC.
| | - Thomas M Todoran
- Division of Cardiology and Vascular Medicine, Medical University of South Carolina, Charleston, SC
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Miller DG, Vakkalanka P, Moubarek ML, Lee S, Mohr NM. Reduced Computed Tomography Use in the Emergency Department Evaluation of Headache Was Not Followed by Increased Death or Missed Diagnosis. West J Emerg Med 2018; 19:319-326. [PMID: 29560060 PMCID: PMC5851505 DOI: 10.5811/westjem.2017.12.34886] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 12/15/2017] [Accepted: 12/15/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction This study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit. Methods We reviewed the electronic medical records of all patients sampled during a quality improvement effort in which the aforementioned decrease in HCT use had been observed. We reviewed notes from the ED, neurology, neurosurgery, and primary care services, as well as all brain imaging results to determine if death occurred or if an intracranial condition was discovered in the 22.5 months after each index ED visit. An independent, blinded reviewer reviewed each case where an intracranial condition was diagnosed after ED discharge to determine whether the condition was reasonably likely to have been related to the index ED visit’s presentation, thereby representing a missed diagnosis. Results Of the 582 separate index ED visits sampled, we observed a total of nine deaths and 10 missed intracranial diagnoses. There was no difference in the proportion of death (p = 0.337) or missed intracranial diagnosis (p = 0.312) observed after a 9.6% reduction in HCT use. Among patients who subsequently had visits for headache or brain imaging, we found that these patients were significantly more likely to have not had a HCT done during the index ED visit (59.2% vs. 49.6% (p = 0.031) and 37.1% vs. 26% (p = 0.006), respectively). Conclusion Our study adds to the compelling evidence that there is opportunity to safely decrease CT imaging for ED patients. To determine the cost effectiveness of such reductions further research is needed to measure what patients and their healthcare providers do after discharge from the ED when unnecessary testing is withheld.
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Affiliation(s)
- Daniel G Miller
- University of Iowa, College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - Priyanka Vakkalanka
- University of Iowa, College of Medicine, Department of Emergency Medicine, Iowa City, Iowa.,University of Iowa, College of Public Health, Department of Epidemiology, Iowa City, Iowa
| | - Mark L Moubarek
- University of Iowa, College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - Sangil Lee
- University of Iowa, College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - Nicholas M Mohr
- University of Iowa, College of Medicine, Department of Emergency Medicine, Iowa City, Iowa.,University of Iowa, College of Medicine, Iowa City, Iowa
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Kim YH, Shim WJ, Kim MA, Hong KS, Shin MS, Park SM, Cho KI, Kim M, Kim S, Kim HL, Yoon HJ, Na JO, Kim SE. Utility of Pretest Probability and Exercise Treadmill Test in Korean Women with Suspected Coronary Artery Disease. J Womens Health (Larchmt) 2016; 25:617-22. [DOI: 10.1089/jwh.2015.5242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yong-Hyun Kim
- Cardiovascular Center, Korea University Ansan Hospital, Ansan, Korea
| | - Wan-Joo Shim
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Myung-A Kim
- Cardiovascular Center, Seoul National University Boramae Hospital, Seoul, Korea
| | - Kyung-Soon Hong
- Cardiovascular Center, Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Mi-Seung Shin
- Cardiovascular Center, Gachon University Gil Hospital, Incheon, Korea
| | - Seong-Mi Park
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Kyoung Im Cho
- Cardiovascular Center, Kosin University Gospel Hospital, Busan, Korea
| | - Mina Kim
- Cardiovascular Center, Korea University Anam Hospital, Seoul, Korea
| | - Sihun Kim
- Cardiovascular Center, Gachon University Gil Hospital, Incheon, Korea
| | - Hak-Lyoung Kim
- Cardiovascular Center, Seoul National University Boramae Hospital, Seoul, Korea
| | - Hyun-Ju Yoon
- Cardiovascular Center, Chonnam University Hospital, Gwangju, Korea
| | - Jin-Oh Na
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Sung-Eun Kim
- Cardiovascular Center, Kangdong Sacred Heart Hospital, Seoul, Korea
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Finnerty NM, Rodriguez RM, Carpenter CR, Sun BC, Theyyunni N, Ohle R, Dodd KW, Schoenfeld EM, Elm KD, Kline JA, Holmes JF, Kuppermann N. Clinical Decision Rules for Diagnostic Imaging in the Emergency Department: A Research Agenda. Acad Emerg Med 2015; 22:1406-16. [PMID: 26567885 DOI: 10.1111/acem.12828] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 07/13/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging. OBJECTIVES The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED). METHODS The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference. RESULTS A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED? CONCLUSIONS The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.
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Affiliation(s)
- Nathan M. Finnerty
- Department of Emergency Medicine; The Ohio State University College of Medicine; Columbus OH
| | - Robert M. Rodriguez
- Department of Emergency Medicine; University of California San Francisco School of Medicine; San Francisco CA
| | - Christopher R. Carpenter
- Department of Emergency Medicine; Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Benjamin C. Sun
- Department of Emergency Medicine; Oregon Health & Science University; Portland OR
| | - Nik Theyyunni
- Department of Emergency Medicine; University of Michigan Medical School; Ann Arbor MI
| | - Robert Ohle
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Kenneth W. Dodd
- Department of Emergency Medicine; Hennepin County Medical Center; Minneapolis MN
- Department of Internal Medicine; Hennepin County Medical Center; Minneapolis MN
| | - Elizabeth M. Schoenfeld
- Department of Emergency Medicine; Baystate Medical Center; Tufts University School of Medicine; Springfield MA
| | - Kendra D. Elm
- Department of Emergency Medicine; University of Minnesota Medical School; Minneapolis MN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - James F. Holmes
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
| | - Nathan Kuppermann
- Department of Emergency Medicine; UC Davis School of Medicine; Sacramento CA
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Courtney DM, Mills AM, Marin JR. To test or not to test … decision analysis of decision support. Acad Emerg Med 2015; 22:594-6. [PMID: 25900106 DOI: 10.1111/acem.12663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- D. Mark Courtney
- Department of Emergency Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL
| | - Angela M. Mills
- Department of Emergency Medicine; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA
| | - Jennifer R. Marin
- Departments of Pediatrics and Emergency Medicine; University of Pittsburgh School of Medicine; Pittsburgh PA
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