Methodological aspects in the assessment of treatment effects in observational health outcomes studies

No Benefit with Preservation of Midline Structures in Decompression for Lumbar Spinal Stenosis: Results From the National Swedish Spine Registry 2-Year Post-Op

STUDY DESIGN

Observational cohort study.

OBJECTIVE

The aim of this study was to investigate whether preservation of the midline structures is associated with a better clinical outcome compared to classic central decompression for lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

The classic surgical procedure for LSS is a central, facet joint sparing decompressive laminectomy (LE). Alternative approaches have been developed to preserve the midline structures. The effect of the alternative techniques compared to LE remains unclear.

METHODS

All patients >50 years of age who underwent decompression surgery for LSS without concomitant fusion in the National Swedish Spine Registry (Swespine) from December 31, 2015 until October 6, 2017 were included in this study based on surgeon-reported data and patient questionnaires before and 2 years postoperatively. Propensity score matching was used to compare decompression with preservation of midline structures with patients who underwent LE. The primary outcome was the Oswestry Disability Index (ODI) and secondary outcomes were the Numeric Rating Scale (NRS) for leg and back pain, EuroQol-5 Dimensions (EQ-5D), Global Assessment (GA), patient satisfaction and rate of subsequent surgery.

RESULTS

Some 3339 patients completed a 2-year follow-up. Of these, 2974 (89%) had decompression with LE and 365 underwent midline preserving surgery. Baseline scores were comparable between the groups. Mean ODI improvement at follow-up was 16.6 (SD = 20.0) in the LE group and 16.9 (SD = 20.2) in the midline preserving surgery group. In the propensity score-matched analysis the difference in improved ODI was 0.53 (95% confidence interval, CI -1.71 to 2.76; P = 0.64). The proportion of patients who showed a decreased ODI score of at least our defined minimal clinically important difference (=8) was 68.3% after LE and 67.0% after preserving the midline structures (P = 0.73). No significant differences were found in the improvement of NRS for leg and back pain, EQ-5D, GA or patient satisfaction. The rate of subsequent surgery was 5.5% after LE and 4.9% after midline preserving surgery without a significant difference in the propensity score-matched analysis (hazard ratio, HR 0.87; 95% CI 0.49-1.54; P = 0.64).

CONCLUSION

In this study on decompression techniques for LSS, there was no benefit in preserving the midline structures compared to LE 2 years after decompression. The conclusion is that the surgeon is free to choose the surgical method that is thought most suitable for the patient and the condition with which the patient presents.Level of Evidence: 3.

Factors influencing depression endpoints research (FINDER): Study design and population characteristics

Factors influencing outcomes of depression in clinical practice, especially health-related quality of life (HRQoL), are poorly understood. The Factors Influencing Depression Endpoints Research (FINDER) study is a European prospective, observational study designed to estimate the HRQoL of adults with a clinically diagnosed depressive episode at baseline, and 3 and 6 months after commencing antidepressant medication. We report here the study design and baseline patient characteristics.

HRQoL was assessed by the 36-item Short-Form Health Survey (SF-36) and European Quality of Life-5 Dimensions (EQ-5D). Patient ratings on Hospital Anxiety and Depression Scale (HADS) and pain Visual Analogue Scale (VAS) were also obtained. Results (n = 3468) showed that SF-36 mental component summary (mean 22.2) was more than two SDs below general population norms (mean 50.0) and one SD below clinical depression norms (mean 34.8); the physical component summary (mean 46.1) was similar to general population (mean 50.0) and clinical depression norms (mean 45.0). Mean EQ-5D scores were also lower than general population norms. Mean HADS-Depression and -Anxiety subscores were 12.3 and 13.0, respectively. Fifty-six percent of patients reported an overall pain VAS score of at least 30 mm and 70% of these patients had no physical explanation for their pain.

Further investigation into factors associated with HRQoL in depression after treatment initiation is warranted.

How is disease severity associated with quality of life in psoriasis patients? Evidence from a longitudinal population-based study in Sweden

BACKGROUND

Assessing the impact of disease severity on generic quality of life (QOL) is a critical step in outcomes research and in the development of decision-analytic models structured around health states defined by clinical measures. While data from routine clinical practice found in healthcare registers are increasingly used for research, more attention should be paid to understanding the relationship between clinical measures of disease severity and QOL. The purpose of this work was therefore to investigate this relationship in psoriasis using a population-based dataset.

METHODS

Severity was measured by the Psoriasis Area and Severity Index (PASI), which combines severity of erythema, induration, and desquamation into a single value ranging from 0 to 72. The generic EQ-5D-3L utility instrument, under the UK tariff, was used to measure QOL. The association between PASI and EQ-5D-3L was estimated using a population-based dataset of 2674 patients with moderate to severe psoriasis enrolled over ten years in the Swedish psoriasis register (PsoReg). Given the repeated measurement of patients in the register data, a longitudinal fixed-effects model was employed to control for unobserved patient-level heterogeneity.

RESULTS

Marginal changes in PASI are associated with a non-linear response in EQ-5D-3L: Moving from PASI 10 to 9 (1 to 0) is associated with an increase of 0.0135 (0.0174) in EQ-5D-3L. Furthermore, unobserved patient-level heterogeneity appears to be an important source of confounding when estimating the relationship between QOL and PASI.

CONCLUSIONS

Using register data to estimate the impact of disease severity on QOL while controlling for unobserved patient-level heterogeneity shows that PASI appears to have a larger impact on QOL than previously estimated. Routine collection of generic QOL data in registers should be encouraged to enable similar applications in other disease areas.

TRIAL REGISTRATION

Not applicable.

Differences in Neural Mechanosensitivity Between Patients with Chronic Nonspecific Neck Pain With and Without Neuropathic Features. A Descriptive Cross-Sectional Study

OBJECTIVE

To assess differences in neural mechanosensitivity between patients with chronic nonspecific neck pain with and without neuropathic features (NF and No-NF, respectively).

DESIGN

Descriptive, cross-sectional study.

SETTING

A primary care center, a hospital physiotherapy outpatient department, and a university campus.

SUBJECTS

Chronic nonspecific neck pain patients classified by the self-completed leeds assessment of neuropathic symptoms and signs pain scale (S-LANSS; 49 patients with NF [S-LANSS ≥ 12] and 50 patients with No-NF [S-LANSS < 12]) and a healthy control group (n = 48).

METHODS

The primary measurements were the mechanosensitivity of the median nerve and cervical region, specifically the assessment of the onset of symptoms and submaximal pain intensity according to the upper limb neural test 1 (ULNT1) for the median nerve and the modified passive neck flexion test (MPNFT) for the cervical region; secondary measurements included pain intensity, neck disability, kinesiophobia, and pain catastrophizing.

RESULTS

Statistically significant differences between the NF and No-NF groups were found with respect to the onset of symptoms of ULNT1 (-15.11 [-23.19 to -7.03]) and MPNFT (-6.58 [-11.54 to -1.62]), as well as the outcomes of the visual analogue scale (Mean difference [95% Confidence Interval]; 7.12 [1.81-12.42]) and neck disability index (3.72 [1.72-5.71]). Both chronic nonspecific neck pain groups showed statistically significant differences compared with the control group for all outcomes assessed (P < 0.01) except for the onset of symptoms of ULNT1 in the No-NF group.

CONCLUSIONS

The findings of this study suggest that chronic nonspecific neck pain patients with NF have greater neural mechanosensitivity, pain intensity, and neck disability than those with No-NF.

A review of the economic tools for assessing new medical devices

Whereas the economic evaluation of pharmaceuticals is an established practice within international health technology assessment (HTA) and is often produced with the support of comprehensive methodological guidance, the equivalent procedure for medical devices is less developed. Medical devices, including diagnostic products, are a rapidly growing market in healthcare, with over 10,000 medical technology patent applications filed in Europe in 2012-nearly double the number filed for pharmaceuticals. This increase in the market place, in combination with the limited, or constricting, budgets that healthcare decision makers face, has led to a greater level of examination with respect to the economic evaluation of medical devices. However, methodological questions that arise due to the unique characteristics of medical devices have yet to be addressed fully. This review of journal publications and HTA guidance identified these characteristics and the challenges they may subsequently pose from an economic evaluation perspective. These unique features of devices can be grouped into four categories: (1) data quality issues; (2) learning curve; (3) measuring long-term outcomes from diagnostic devices; and (4) wider impact from organisational change. We review the current evaluation toolbox available to researchers and explore potential future approaches to improve the economic evaluation of medical devices.

Long-term effects of pregnancy and motherhood on disease outcomes of women with cystic fibrosis

RATIONALE

Studies of pregnancy in cystic fibrosis (CF) have shown no short-term harmful effects, but there are no long-term studies on the impact of motherhood.

OBJECTIVES

This study sought to evaluate longer-term physiologic and functional outcomes in women with CF reporting a pregnancy, with the intent of assessing how the demands of parenting impacted on disease course.

METHODS

Using 1994 to 2005 Epidemiologic Study of Cystic Fibrosis data, we developed a propensity score to match women reporting a pregnancy at a 1:10 ratio with never-pregnant control subjects and compared clinical outcomes, health-related quality of life, and health care use.

MEASUREMENTS AND MAIN RESULTS

One hundred nineteen pregnant women presumed to have become mothers were matched with 1,190 control subjects, a median of 6.0 years (range 1.8-11.1 yr) from the pregnancy. No differences were found in annualized change from baseline FEV1 and body mass index, in respiratory signs and symptoms, or in prescribed chronic therapies. Women who had been pregnant were treated for more pulmonary exacerbations and had more illness-related clinic visits but showed no increase in prescribed chronic therapies. They also reported lower health-related quality-of-life scores for Respiratory Symptoms, Physical Functioning, Vitality, and Health Perceptions.

CONCLUSIONS

Pregnancy and motherhood do not appear to accelerate disease progression but lead to more illness-related visits, pulmonary exacerbations, and a decrease in some domains of quality of life. These differences presumably reflect the impact of the physical and emotional challenges of early motherhood on disease self-management.

Changes in adherence and treatment costs following initiation of oral or depot typical antipsychotics among previously non-adherent patients with schizophrenia

OBJECTIVE

This study assessed the impact of depot formulations on adherence and treating costs in the naturalistic treatment of previously non-adherent outpatients with schizophrenia.

METHODS

Data were taken from the European Schizophrenia Outpatient Health Outcomes (SOHO) study. Medication adherence and treating costs during an 18-month follow-up were assessed and compared for non-adherent patients initiated on depot typical (n = 262) or oral typical antipsychotics (n = 169) as monotherapy at the index visit. Multivariate analyses were employed to adjust for differences between the two groups at the index visit.

RESULTS

Of the previously non-adherent patients, more than half of patients initiated on depot typicals (55%) remained adherent to medication during follow-up, whereas the equivalent was 39% for patients initiated on oral typicals. Logistic regression also showed higher odds of being adherent among the former group (Odds ratio = 1.84; 95% CI = 1.19-2.85). In addition, total costs incurred by this group during 18 months were only half those incurred by patients initiated on oral typicals (£3645 vs £7817, p < 0.05) CONCLUSIONS: Depot formulations of typical antipsychotics appeared to improve medication adherence and reduce treatment costs, compared with oral formulations, in the treatment of non-adherent patients.

LIMITATION

adherence was assessed by the treating psychiatrist using a single-item.

Clinical consequences of switching from olanzapine to risperidone and vice versa in outpatients with schizophrenia: 36-month results from the Worldwide Schizophrenia Outpatients Health Outcomes (W-SOHO) study

BACKGROUND

With many atypical antipsychotics now available in the market, it has become a common clinical practice to switch between atypical agents as a means of achieving the best clinical outcomes. This study aimed to examine the impact of switching from olanzapine to risperidone and vice versa on clinical status and tolerability outcomes in outpatients with schizophrenia in a naturalistic setting.

METHODS

W-SOHO was a 3-year observational study that involved over 17,000 outpatients with schizophrenia from 37 countries worldwide. The present post hoc study focused on the subgroup of patients who started taking olanzapine at baseline and subsequently made the first switch to risperidone (n=162) and vice versa (n=136). Clinical status was assessed at the visit when the first switch was made (i.e. before switching) and after switching. Logistic regression models examined the impact of medication switch on tolerability outcomes, and linear regression models assessed the association between medication switch and change in the Clinical Global Impression-Schizophrenia (CGI-SCH) overall score or change in weight. In addition, Kaplan-Meier survival curves and Cox-proportional hazards models were used to analyze the time to medication switch as well as time to relapse (symptom worsening as assessed by the CGI-SCH scale or hospitalization).

RESULTS

48% and 39% of patients switching to olanzapine and risperidone, respectively, remained on the medication without further switches (p=0.019). Patients switching to olanzapine were significantly less likely to experience relapse (hazard ratio: 3.43, 95% CI: 1.43, 8.26), extrapyramidal symptoms (odds ratio [OR]: 4.02, 95% CI: 1.49, 10.89) and amenorrhea/galactorrhea (OR: 8.99, 95% CI: 2.30, 35.13). No significant difference in weight change was, however, found between the two groups. While the CGI-SCH overall score improved in both groups after switching, there was a significantly greater change in those who switched to olanzapine (difference of 0.29 points, p=0.013).

CONCLUSION

Our study showed that patients who switched from risperidone to olanzapine were likely to experience a more favorable treatment course than those who switched from olanzapine to risperidone. Given the nature of observational study design and small sample size, additional studies are warranted.

Research design considerations for clinical studies of abuse-deterrent opioid analgesics: IMMPACT recommendations

Opioids are essential to the management of pain in many patients, but they also are associated with potential risks for abuse, overdose, and diversion. A number of efforts have been devoted to the development of abuse-deterrent formulations of opioids to reduce these risks. This article summarizes a consensus meeting that was organized to propose recommendations for the types of clinical studies that can be used to assess the abuse deterrence of different opioid formulations. Because of the many types of individuals who may be exposed to opioids, an opioid formulation will need to be studied in several populations using various study designs to determine its abuse-deterrent capabilities. It is recommended that the research conducted to evaluate abuse deterrence should include studies assessing: (1) abuse liability, (2) the likelihood that opioid abusers will find methods to circumvent the deterrent properties of the formulation, (3) measures of misuse and abuse in randomized clinical trials involving pain patients with both low risk and high risk of abuse, and (4) postmarketing epidemiological studies.

Schizophrenia Outpatient Health Outcomes study: twelve-month findings

BACKGROUND

The purpose of this study was to assess the 12-month outcomes associated with naturalistic antipsychotic treatment of patients participating in the Schizophrenia Outpatient Health Outcomes (SOHO) study.

METHODS

SOHO is a 3-year, prospective, observational study of the health outcomes associated with antipsychotic treatment in 10 European countries. The study included over 10,000 outpatients who were initiating or changing their antipsychotic medication. Medication use pattern, change in symptom severity, social functioning, and health-related quality of life were assessed, as well as rates of response, remission, treatment discontinuation, adverse events, and hospitalization.

RESULTS

Clinical Global Impression-Severity for Schizophrenia (CGI-SCH) and quality of life scores improved in all treatment cohorts. There were greater improvements in the CGI-SCH overall symptom score and in the CGI-SCH positive, negative, cognitive, and depressive symptom scores in the olanzapine and clozapine cohorts compared with other treatment cohorts. Changes were associated with an improvement in quality of life. Patients treated with olanzapine, quetiapine, and clozapine had better tolerability per extrapyramidal symptoms and sexual-related dysfunction measures compared with patients receiving risperidone, amisulpride, or typicals. Patients treated with olanzapine had greater weight gain than patients in all other treatment cohorts.

CONCLUSION

Patients initiated on olanzapine and clozapine tend to have better outcomes at 12 months than patients initiated on other antipsychotics in routine outpatient clinical practice. Results should be interpreted conservatively due to the nonrandomized study design.

Key points for designing and reporting Helicobacter pylori therapeutic trials: a personal view

BACKGROUND & OBJECTIVES

The aim of this document is to provide a methodological framework and to review key aspects for adequately designing trials to evaluate new treatments for Helicobacter pylori infection.

METHODS

Non-systematic literature review.

RESULTS & CONCLUSIONS

Regarding the design of the article, we suggest selecting for future trials drugs to which H. pylori has no significant primary resistances and evaluating therapies with pilot studies before engaging in randomized trials. The manuscript defines how the number and type of H. pylori diagnostic tests necessary before and after the trial depend on the setting and reliability of the tests. It recommends the best methods and timing for H. pylori testing before and after therapy. Other recommendations are using current standard treatments as comparators of new therapies, determining antibiotic sensitivity - whenever useful and possible - using adequate randomization and allocation concealment but not necessarily blinding, and performing an intention-to-treat and a per-protocol analysis. In addition, we give basic tips for reporting and discussing study results.

Suicidal attempts in bipolar disorder: results from an observational study (EMBLEM)

OBJECTIVES

To compare patients with and without a history of suicidal attempts in a large cohort of patients with bipolar disorder and to identify variables that are associated with suicidal behavior.

METHODS

European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) is a two-year, prospective, observational study that enrolled 3,684 adult patients with bipolar disorder and initiated or changed oral treatment for an acute manic/mixed episode. Of those, 2,416 patients were eligible for the two-year follow-up. Only baseline characteristics were studied in the present study, included sociodemographic data, psychiatric history and comorbidities, history of suicide attempts, history of substance use problems, compliance with treatment, inpatient admissions, and functional status. Symptom severity was assessed using the Clinical Global Impression-Bipolar Disorder (CGI-BP) scale, the Young Mania Rating Scale (YMRS), and the 5-item Hamilton Depression Rating Scale (HAMD-5). A logistic regression model identified baseline variables independently associated with a history of suicidal behavior.

RESULTS

Of the 2,219 patients who provided data on their lifetime history of suicide attempts, 663 (29.9%) had a history of suicidal behavior (at least one attempt). Baseline factors associated with a history of suicidal behavior included female gender, a history of alcohol abuse, a history of substance abuse, young age at first treatment for a mood episode, longer disease duration, greater depressive symptom severity (HAMD-5 total score), current benzodiazepine use, higher overall symptom severity (CGI-BP: mania and overall score), and poor compliance.

CONCLUSIONS

These factors may be considered as potential characteristics to identify subjects at risk for suicidal behavior throughout the course of bipolar disorder.

Costs and quality of hospitals in different health care systems: a multi-level approach with propensity score matching

Cross-country comparisons of costs and quality between hospitals are often made at the macro level. The goal of this study was to explore methods to compare micro-level data from hospitals in different health care systems. To do so, we developed a multi-level framework in combination with a propensity score matching technique using similarly structured data for patients receiving treatment for acute myocardial infarction in German and US Veterans Health Administration hospitals. Our case study shows important differences in results between multi-level regressions based on matched and unmatched samples. We conclude that propensity score matching techniques are an appropriate way to deal with the usual baseline imbalances across the samples from different countries. Multi-level models are recommendable to consider the clustered structure of the data when patient-level data from different hospitals and health care systems are compared. The results provide an important justification for exploring new ways in performing health system comparisons.

Health-related quality of life (HRQL) and continuous antipsychotic treatment: 3-year results from the Schizophrenia Health Outcomes (SOHO) study

OBJECTIVES

We investigated the association between continuous antipsychotic use and health-related quality of life (HRQL) 3-year change in the European Schizophrenia Outpatients Health Outcomes (EU-SOHO) study.

METHODS

EU-SOHO is an observational study of outcomes associated with antipsychotic treatment for schizophrenia in an outpatient setting. HRQL was assessed at study entry and at 6, 12, 18, 24, 30, and 36 months using the EuroQol-5D (EQ-5D). UK population time trade-off (TTO) tariffs were applied to the self-rated EQ-5D health states to calculate HRQL ratings (0 = death, 1 = best). An epoch analysis approach was used as a conceptual framework to analyze the longitudinal data. Follow-up was divided into epochs or periods of continuous treatment. When a patient changed antipsychotic treatment, he or she was considered to have a new observation. Multilevel models were employed to evaluate the association of HRQL with medication and other clinical and sociodemographic variables for each epoch. A total of 9340 patients were analyzed (42.1% women; mean age 40 years).

RESULTS

Mean EQ-5D scores increased over time; the largest improvement occurred in the first 6 months (mean increase of 0.19). Longer duration of illness and older age at first treatment were associated with worse baseline EQ-5D scores. Improvements in EQ-5D scores were greater for more socially active patients or those in paid employment. Few significant differences were found between antipsychotic medications. Olanzapine and clozapine were associated with higher HRQL increases.

CONCLUSIONS

Continuous antipsychotic treatment is associated with important HRQL benefits at 3 years, most of which occurs during the first 6 months. Although some medications are associated with better HRQL outcomes, differences are small.

Methodological issues in assessing changes in costs pre- and post-medication switch: a schizophrenia study example

Background

Schizophrenia is a severe, chronic, and costly illness that adversely impacts patients' lives and health care payer budgets. Cost comparisons of treatment regimens are, therefore, important to health care payers and researchers. Pre-Post analyses ("mirror-image"), where outcomes prior to a medication switch are compared to outcomes post-switch, are commonly used in such research. However, medication changes often occur during a costly crisis event. Patients may relapse, be hospitalized, have a medication change, and then spend a period of time with intense use of costly resources (post-medication switch). While many advantages and disadvantages of Pre-Post methodology have been discussed, issues regarding the attributability of costs incurred around the time of medication switching have not been fully investigated.

Methods

Medical resource use data, including medications and acute-care services (hospitalizations, partial hospitalizations, emergency department) were collected for patients with schizophrenia who switched antipsychotics (n = 105) during a 1-year randomized, naturalistic, antipsychotic cost-effectiveness schizophrenia trial. Within-patient changes in total costs per day were computed during the pre- and post-medication change periods. In addition to the standard Pre-Post analysis comparing costs pre- and post-medication change, we investigated the sensitivity of results to varying assumptions regarding the attributability of acute care service costs occurring just after a medication switch that were likely due to initial medication failure.

Results

Fifty-six percent of all costs incurred during the first week on the newly initiated antipsychotic were likely due to treatment failure with the previous antipsychotic. Standard analyses suggested an average increase in cost-per-day for each patient of $2.40 after switching medications. However, sensitivity analyses removing costs incurred post-switch that were potentially due to the failure of the initial medication suggested decreases in costs in the range of $4.77 to $9.69 per day post-switch.

Conclusion

Pre-Post cost analyses are sensitive to the approach used to handle acute-service costs occurring just after a medication change. Given the importance of quality economic research on the cost of switching treatments, thorough sensitivity analyses should be performed to identify the impact of crisis events around the time of medication change.

Early outcomes of thymoglobulin and basiliximab induction in kidney transplantation: application of statistical approaches to reduce bias in observational comparisons

BACKGROUND

Retrospective comparison of treatment-related kidney transplant outcomes may be facilitated by multivariable statistical adjustments and case-matching.

METHODS

We studied Organ Procurement and Transplantation Network registry data for kidney transplants in 2001 to 2005 managed with thymoglobulin, basiliximab, or no antibody induction and discharge maintenance immunosuppression regimens of tacrolimus and mycophenolate mofetil. The primary outcome was the 6 month, Food and Drug Administration-approved composite endpoint of rejection, graft failure, or death. Outcomes according to induction exposure were compared using logistic regression analysis, exposure likelihood matching, and outcome risk score matching.

RESULTS

All statistical approaches demonstrated lower rates of the 6-month triple endpoint with thymoglobulin compared with basiliximab when steroids were present, with approximately 22% adjusted, relative reduction by logistic regression analysis and 3% absolute reductions by matching approaches. When steroids were absent, risk reduction among thymoglobulin versus basiliximab-treated patients was of larger magnitude but borderline statistical significance. Triple endpoint incidence was lower with both induction regimens compared with no induction across methods. Estimated sample sizes necessary to detect the observed differences between induction types in the presence of steroids in a prospective trial ranged from 1600 to nearly 7000 patients.

CONCLUSIONS

Consistency across statistical approaches suggests superiority of thymoglobulin compared with basiliximab or no antibody induction therapy for 6-month kidney transplant outcomes in the modern immunosuppression era. As the sample sizes necessary to power a prospective superiority trial are likely prohibitive, studies such as these provide clinically relevant information that may not be otherwise attainable.

Active management of risk in nulliparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes

OBJECTIVE

The objective of the study was to determine whether exposure of nulliparous women to a high rate of preventive labor induction was associated with improvement in birth health.

STUDY DESIGN

A risk-scoring system was used to guide the frequent use of preventive labor induction in 100 nulliparous women. The birth outcomes of this group were compared with those of 352 nulliparous women who received usual care. Cesarean delivery was the primary study outcome. The Adverse Outcome Index and the rate of uncomplicated vaginal delivery were used to measure overall birth health.

RESULTS

The exposed group experienced a higher labor induction rate (48% vs 23.6%; P < .001), a lower cesarean rate (9% vs 25.8%; adjusted odds ratio, 0.36; P = .02), and better composite birth outcomes.

CONCLUSION

Exposure of nulliparous women to a high preventive induction rate was significantly associated with improvement in birth health. Prospective randomized trials are needed to further explore the utility of risk-guided preventive labor induction.

The active management of risk in multiparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes

OBJECTIVE

To determine whether exposure of multiparous women to a high rate of preventive labor induction was associated with a significantly lower cesarean delivery rate.

STUDY DESIGN

Retrospective cohort study involving 123 multiparous women, who were exposed to the frequent use of preventive labor induction, and 304 multiparous women, who received standard management. Rates of cesarean delivery and other adverse birth outcomes were compared in the 2 groups. Logistic regression controlled for confounding covariates.

RESULTS

The exposed group had a lower cesarean delivery rate (adjusted odds ratio, 0.09; 0.8% vs 9.9%; P = .02) and a higher uncomplicated vaginal delivery rate (odds ratio, 0.53; 78.9% vs 66.4%; P = .01). Exposure was not associated with higher rates of other adverse birth outcomes.

CONCLUSION

Exposure of multiparous women to a high rate of preventive labor induction was significantly associated with improved birth outcomes, including a very low cesarean delivery rate. A prospective randomized trial is needed to determine causality.

Recovery in the outpatient setting: 36-month results from the Schizophrenia Outpatients Health Outcomes (SOHO) study

Recovery is an important outcome of schizophrenia that has not been well defined or researched. Using a stringent definition of recovery that included long-lasting symptomatic and functional remission as well as an adequate quality of life for a minimum of 24 months and until the 36-month visit, we determined the frequency and predictors of recovery in patients with schizophrenia during 3 years of antipsychotic treatment in the prospective, observational Schizophrenia Outpatients Health Outcomes (SOHO) study. Of the 6642 patients analysed, 33% achieved long-lasting symptomatic remission, 13% long-lasting functional remission, 27% long-lasting adequate quality of life, and 4% achieved recovery during the 3 year follow-up period. Logistic regression analysis revealed that social functioning at study entry (having good occupational/vocational status, living independently and being socially active) and adherence with medication were factors significantly associated with achieving recovery. Higher negative symptom severity, higher BMI and lack of effectiveness as the reason for change of medication at baseline were baseline factors associated with a lower likelihood of achieving recovery. Treatment with olanzapine was also associated with a higher frequency of recovery compared with risperidone, quetiapine, typical antipsychotics (oral, depot) and patients taking two or more antipsychotic medications. There were no differences among the patients taking olanzapine, clozapine and amisulpride. Predictors of long-lasting symptomatic remission, functional remission and adequate quality of life were also independently analysed. Although the results should be interpreted conservatively due to the observational, non-randomised study design, they indicate that only a small proportion of patients with schizophrenia achieve recovery and suggest that social functioning, medication adherence and type of antipsychotic are important predictors of recovery.

Antipsychotic treatment discontinuation in previously untreated patients with schizophrenia: 36-month results from the SOHO study

Data from the 3-year, prospective, observational SOHO study were used to compare the effectiveness (in terms of treatment discontinuation) and the tolerability of olanzapine, risperidone, other atypicals and typical antipsychotics in 1009 previously untreated outpatients with schizophrenia who started monotherapy at baseline. Kaplan-Meier survival analysis estimated the time to treatment discontinuation by the treatment group, Cox proportional hazards regression models identified the variables associated with treatment discontinuation (adjusted for baseline differences between treatment groups), and logistic regression models compared the tolerability profiles of the different treatment groups. Of the 931 patients analyzed, 31.9% discontinued the medication initiated at baseline during the 3-year follow-up. Olanzapine had the lowest rate of discontinuation (28.9%), followed by other atypical (34.0%), risperidone (36.2%) and typical antipsychotics (44.5%). Compared to olanzapine, risk of treatment discontinuation was higher with typical antipsychotics (hazard ratio [HR] 1.75; 95% confidence interval [CI] 1.11, 2.78) or risperidone (HR 1.36; 95% CI 1.02, 1.82). A higher baseline Clinical Global Impression (CGI) positive score was associated with a higher risk of treatment discontinuation (HR 1.18; 95% CI 1.06, 1.30). Olanzapine was associated with a lower frequency of extrapyramidal symptoms than other antipsychotics, fewer prolactin-related adverse events than risperidone and other atypical antipsychotics, but greater weight gain than typicals and risperidone. For all analyses, comparison with the other atypical group is limited due to its small sample size (n=50). In conclusion, treatment effectiveness and tolerability varied among antipsychotic medications in previously untreated patients with schizophrenia. The results should be interpreted conservatively given the observational study design.

The impact of hospital-acquired infection on outcome in acute pancreatitis

BACKGROUND & AIMS

Little is known regarding the impact of hospital-acquired infection (HAI) in acute pancreatitis (AP). We conducted a population-based assessment of the impact of HAI on outcome in AP.

METHODS

Patient data were obtained from the Cardinal Health Clinical Outcomes Research Database, a large population-based data set. Cases with principal diagnosis by International Classification of Diseases, ninth revision, clinical modification 577.0 (AP) between January 2004 and January 2005 were identified. These cases were linked with recently reported HAI data collected by the Pennsylvania Health Care Cost Containment Council. Identification of HAI was based on definitions set forth by the National Nosocomial Infection Surveillance System. We conducted a 5:1 multivariate propensity-matched cohort study to determine the independent contribution of HAI to in-hospital mortality, length of stay (LOS), and hospital charges.

RESULTS

From 177 participating hospitals, there were 11,046 AP cases identified. Eighty-two (0.7%) patients developed an HAI. Mortality in the overall AP population was 1.2% vs 11.4% among 405 matched non-HAI controls vs 28.4% among patients who developed HAI (chi(2) test, P < .0001). Fifteen percent of all deaths was associated with an HAI. Both average LOS and hospital charges were significantly increased among patients with HAI compared with matched non-HAI controls.

CONCLUSIONS

We determined that HAI had a major impact on mortality in AP. Patients who developed HAI also had significantly increased LOS and hospital charges. These differences were not explained by increased disease severity alone. Reducing HAI is an important step to improving outcome in AP.

Analysis of Treatment Effectiveness in Longitudinal Observational Data

Assessing treatment effectiveness in longitudinal observational data is complicated as patients may change medications at any time. To illustrate, three general statistical strategies were utilized to assess treatment effectiveness in an observational schizophrenia study: ignoring, eliminating, and modeling the switching. Differential switching rates produced dramatic differences in estimates of treatment effectiveness across the strategies, with p-values ranging from nearly 0 to almost 1. Ignoring the treatment switching by utilizing intent-to-treat approaches resulted in treatment effect estimates of near zero. Various methods of eliminating the switching, such as epoch analyses and on-drug subset analyses, along with use of marginal structural models generated reasonably consistent non-zero treatment effect estimates. When analyzing longitudinal observational data, researchers must understand the options, key concepts and assumptions behind the various statistical methods available. Marginal structural models are a promising approach to estimation of causal treatment effects in such data.

Empathy and the failure to treat pain

We set out to discuss the psychological barriers that exist in the treatment of pain. Specifically, we argue that clinicians have several innate mechanisms at play that can hinder their judgment and lead to erroneous assumptions about their patients. Issues are discussed from social psychological and psychodynamic perspectives. A focus is placed on the issue of empathy and how this, too, can act as a barrier to rational judgment when evaluating patients. In the face of growing scrutiny on pain management in the United States, it is important to understand the barriers to providing care that already exist on an intrinsic level. Through the exploration of these barriers, clinicians might be better able to reflect on their own practice. Ultimately, we hope to push forward an agenda of rational therapy in pain management that utilizes safeguards against abuse and addiction while also preserving treatment modalities for patients in need of services.

Symptomatic remission in previously untreated patients with schizophrenia: 2-year results from the SOHO study

RATIONALE

Symptomatic remission is an achievable goal of treatment in patients with schizophrenia.

OBJECTIVES

The aim of this study was to determine the frequency of symptomatic remission and baseline factors associated with symptomatic remission in previously untreated patients with schizophrenia during 2 years of antipsychotic treatment.

MATERIALS AND METHODS

The Schizophrenia Health Outcomes (SOHO) study is a 3-year, prospective, observational study of the treatment of schizophrenia in the outpatient setting in ten European countries. Symptomatic remission was defined as a score of < or =3 on the clinical global impression (CGI) overall severity score, CGI positive symptoms score, CGI negative symptoms score and CGI cognitive symptoms score, maintained for at least 6 months and without hospitalisation.

RESULTS

Of the patients enrolled at baseline, 1,009 patients were never-treated and prescribed only one antipsychotic; 701 patients (69%) were included in the follow-up analysis at 24 months. Of this sample, 70% achieved symptomatic remission during 24 months of treatment. Baseline factors associated with higher symptomatic remission were: lower negative CGI, lower cognitive CGI, lower overall CGI, having hostile behaviour, lower body mass index, taking olanzapine instead of typical antipsychotics or atypical antipsychotics (except risperidone) and being employed.

CONCLUSIONS

A high proportion of patients with schizophrenia who start antipsychotic treatment achieve remission after 2 years of treatment. Type of medication, symptom severity and previous functioning are important predictors of outcome.

Three-year antipsychotic effectiveness in the outpatient care of schizophrenia: observational versus randomized studies results

Antipsychotic discontinuation rates are a powerful indicator of medication effectiveness in schizophrenia. We examined antipsychotic discontinuation in the Schizophrenia Outpatient Health Outcomes (SOHO) study, a 3-year prospective, observational study in outpatients with schizophrenia in 10 European countries. Patients (n=7728) who started antipsychotic monotherapy were analyzed. Medication discontinuation for any cause ranged from 34% and 36% for clozapine and olanzapine, respectively, to 66% for quetiapine. Compared to olanzapine, the risk of treatment discontinuation before 36 months was significantly higher for quetiapine, risperidone, amisulpride, and typical antipsychotics (oral and depot), but similar for clozapine. Longer medication maintenance was associated with being socially active and having a longer time since first treatment contact for schizophrenia, whereas higher symptom severity, treatment with mood stabilizers, substance abuse, having hostile behaviour were associated with lower medication maintenance. Antipsychotic maintenance in SOHO was higher than the results of previous randomized studies.