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He Y, Chen W, Qin L, Ma C, Tan G, Huang Y. The Intraoperative Adherence to Multimodal Analgesia of Anesthesiologists: A Retrospective Study. Pain Ther 2022; 11:575-589. [PMID: 35275381 PMCID: PMC9098701 DOI: 10.1007/s40122-022-00367-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/10/2022] [Indexed: 12/18/2022] Open
Abstract
Introduction Multimodal analgesia (MMA) is a critical component of enhanced recovery after surgery (ERAS). However, little research revealed its intraoperative implementation by anesthesiologists, who are on the front line defending against surgical pain. Therefore, the objective of our study is to assess the adherence of anesthesiologists to MMA comprehensively. Methods A retrospective study was conducted involving patients undergoing lung resection, knee arthroplasty, and radical mastectomy from pre/post-implementation year of MMA (Jan 1, 2013, to Dec 31, 2013, vs. 2019). Intraoperative analgesia regimens (analgesic mode) and hourly rated morphine milligram equivalents (MME) were compared. In addition, patient characteristics associated with continued opioid use after surgery, surgical types, and position level of anesthesiologists (attending-junior; above attending-senior) were also analyzed. Results After MMA initiation, the rate of multimodal analgesic regimen (mode ≥ 2) was significantly increased (post- vs. pre-implementation, 31.57 vs. 21.50%, p < 0.05). However, MME did not show significant difference (post- vs. pre-implementation, 0.402 vs. 0.456, p > 0.05). Patient-level predictors of persistent opioid use after surgery were not related to increased analgesic mode. Lung resection [coefficient, − 0.538; 95% confidence interval (CI), − 0.695 to − 0.383, p < 0.001] and knee arthroplasty (coefficient, − 1.143; 95% CI, − 1.366 to − 0.925, p < 0.001) discouraged multiple analgesic mode, while senior anesthesiologists (coefficient, 0.674; 95% CI 0.548–0.800, p < 0.001) promoted it. Conclusions Although anesthesiologists used more analgesics after promoting MMA, the “opioid-sparing” principle was not followed properly. The analgesic mode was not instructed by patients’ characteristics appropriately. In addition, surgeries with cumbersome preparation/process impeded the use of multiple analgesic modes, while senior anesthesiologists preferred multiple analgesic modes.
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Affiliation(s)
- Yumiao He
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China.,Joint Laboratory of Anesthesia and Pain, Peking Union Medical College, Beijing, 100730, China
| | - Wei Chen
- Department of Gastroenterology, Beijing Friendship Hospital, National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Linan Qin
- Department of Head and Neck Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Chao Ma
- Joint Laboratory of Anesthesia and Pain, Peking Union Medical College, Beijing, 100730, China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China.
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan No.1, Dongcheng District, Beijing, 100730, China. .,Joint Laboratory of Anesthesia and Pain, Peking Union Medical College, Beijing, 100730, China.
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Farjat AE, Virdone S, Thomas LE, Kakkar AK, Pieper KS, Piccini JP. The importance of the design of observational studies in comparative effectiveness research: Lessons from the GARFIELD-AF and ORBIT-AF registries. Am Heart J 2022; 243:110-121. [PMID: 34529945 DOI: 10.1016/j.ahj.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022]
Abstract
Randomized controlled trials (RCTs) are considered the gold standard for estimating the effectiveness of a treatment. However, in many instances they are impractical to conduct because of time limitations, cost restrictions, or ethical reasons. As a consequence, non-randomized observational studies have an important role in comparative effectiveness and safety research since they can address issues that would not be possible using conventional RCT methodology. Observational studies can be strategically designed to reduce the risk of potential sources of bias by emulating the design principles of an equivalent but ideal randomized trial - the target trial - that would answer the research question of interest. In this article, we review some of the necessary components of observational studies required for valid causal inference within the framework of target trial emulation, so as to avoid common methodological pitfalls of study design. We discuss the assumptions of consistency, time-zero specification, exchangeability and positivity. To illustrate these concepts in a context where existing knowledge is well-established through clinical trials, we evaluate and compare the treatment effects of vitamin K antagonists (VKA) against no VKA (No VKA) on the treatment of atrial fibrillation from two real-world observational studies, namely the GARFIELD-AF and ORBIT-AF registries. Results are compared with those of published RCTs.
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Ramsingh D, Hu H, Yan M, Lauer R, Rabkin D, Gatling J, Floridia R, Martinez M, Dorotta I, Razzouk A. Perioperative Individualized Goal Directed Therapy for Cardiac Surgery: A Historical-Prospective, Comparative Effectiveness Study. J Clin Med 2021; 10:jcm10030400. [PMID: 33494308 PMCID: PMC7864512 DOI: 10.3390/jcm10030400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction: Cardiac surgery patients are at increased risk for post-operative complications and prolonged length of stay. Perioperative goal directed therapy (GDT) has demonstrated utility for non-cardiac surgery, however, GDT is not common for cardiac surgery. We initiated a quality improvement (QI) project focusing on the implementation of a GDT protocol, which was applied from the immediate post-bypass period into the intensive care unit (ICU). Our hypothesis was that this novel GDT protocol would decrease ICU length of stay and possibly improve postoperative outcomes. Methods: This was a historical prospective, QI study for patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). Integral to the QI project was education towards all associated providers on the concepts related to GDT. The protocol involved identifying patient specific targets for cardiac index and mean arterial pressure. These targets were maintained from the post-CPB period to the first 12 h in the ICU. Statistical comparisons were performed between the year after GDT therapy was launched to the last two years prior to protocol implementation. The primary outcome was ICU length of stay. Results: There was a significant decrease in ICU length of stay when comparing the year after the protocol initiation to years prior, from a median of 6.19 days to 4 days (2017 vs. 2019, p < 0.0001), and a median of 5.88 days to 4 days (2018 vs. 2019, p < 0.0001). Secondary outcomes demonstrated a significant reduction in total administered volumes of inotropic medication(milrinone). All other vasopressors demonstrated no differences across years. Hospital length of stay comparisons did not demonstrate a significant reduction. Conclusion: These results suggest that an individualized goal directed therapy for cardiac surgery patients can reduce ICU length of stay and decrease amount of inotropic therapy.
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Affiliation(s)
- Davinder Ramsingh
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (H.H.); (R.L.); (J.G.); (M.M.); (I.D.)
| | - Huayong Hu
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (H.H.); (R.L.); (J.G.); (M.M.); (I.D.)
| | - Manshu Yan
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (H.H.); (R.L.); (J.G.); (M.M.); (I.D.)
- Correspondence: ; Tel.: +1-909-558-4475; Fax: +1-909-558-4143
| | - Ryan Lauer
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (H.H.); (R.L.); (J.G.); (M.M.); (I.D.)
| | - David Rabkin
- Department of Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (R.F.); (A.R.)
| | - Jason Gatling
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (H.H.); (R.L.); (J.G.); (M.M.); (I.D.)
| | - Rosario Floridia
- Department of Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (R.F.); (A.R.)
| | - Mckinzey Martinez
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (H.H.); (R.L.); (J.G.); (M.M.); (I.D.)
| | - Ihab Dorotta
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (H.H.); (R.L.); (J.G.); (M.M.); (I.D.)
| | - Anees Razzouk
- Department of Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA; (D.R.); (R.F.); (A.R.)
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Chen S, Graff J, Yun S, Beal B, Ta JT, Bansal A, Carlson JJ, Veenstra DL, Basu A, Devine B. Online tools to synthesize real-world evidence of comparative effectiveness research to enhance formulary decision making. J Manag Care Spec Pharm 2020; 27:95-104. [PMID: 33377442 PMCID: PMC10391288 DOI: 10.18553/jmcp.2021.27.1.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Results of randomized controlled trials (RCTs) provide valuable comparisons of 2 or more interventions to inform health care decision making; however, many more comparisons are required than available time and resources to conduct them. Moreover, RCTs have limited generalizability. Comparative effectiveness research (CER) using real-world evidence (RWE) can increase generalizability and is important for decision making, but use of nonrandomized designs makes their evaluation challenging. Several tools are available to assist. In this study, we comparatively characterize 5 tools used to evaluate RWE studies in the context of making health care adoption decision making: (1) Good Research for Comparative Effectiveness (GRACE) Checklist, (2) IMI GetReal RWE Navigator (Navigator), (3) Center for Medical Technology Policy (CMTP) RWE Decoder, (4) CER Collaborative tool, and (5) Real World Evidence Assessments and Needs Guidance (REAdi) tool. We describe each and then compare their features along 8 domains: (1) objective/user/context, (2) development/scope, (3) platform/presentation, (4) user design, (5) study-level internal/external validity of evidence, (6) summarizing body of evidence, (7) assisting in decision making, and (8) sharing results/making improvements. Our summary suggests that the GRACE Checklist aids stakeholders in evaluation of the quality and applicability of individual CER studies. Navigator is a collection of educational resources to guide demonstration of effectiveness, a guidance tool to support development of medicines, and a directory of authoritative resources for RWE. The CMTP RWE Decoder aids in the assessment of relevance and rigor of RWE. The CER Collaborative tool aids in the assessment of credibility and relevance. The REAdi tool aids in refinement of the research question, study retrieval, quality assessment, grading the body of evidence, and prompts with questions to facilitate coverage decisions. All tools specify a framework, were designed with stakeholder input, assess internal validity, are available online, and are easy to use. They vary in their complexity and comprehensiveness. The RWE Decoder, CER Collaborative tool, and REAdi tool synthesize evidence and were specifically designed to aid formulary decision making. This study adds clarity on what the tools provide so that the user can determine which best fits a given purpose. DISCLOSURES: This work was supported by the Health Tech Fund, which was provided to the University of Washington School of Pharmacy by its Corporate Advisory Board. This consortium of pharmaceutical and biotech companies supports the research program of the University of Washington School of Pharmacy across the competitive space. The sponsors seeded the idea for the project and contributed to study design and improvement. The authors had full control of all content development, manuscript drafting, and submission for publication. The REAdi tool was developed by the authors. Chen, Bansal, Barthold, Carlson, Veenstra, Basu, Devine, Yun, Ta, and Beal were supported by a training grant from the University of Washington-Allergan Fellowship, unrelated to this work. Basu reports personal fees from Salutis Consulting, unrelated to this work. Graff is an employee of the National Pharmaceutical Council, which was a partner in the development of the CER Collaborative and funding partner for the CMTP RWE Decoder and the GRACE Checklist. A previous version of this work was presented as an invited workshop at AMCP Nexus 2018; October 22-25, 2018; Orlando, FL.
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Affiliation(s)
- Shuxian Chen
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | | | - Sophia Yun
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Brennan Beal
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Jamie T Ta
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Aasthaa Bansal
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Joshua J Carlson
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - David L Veenstra
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Anirban Basu
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Beth Devine
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
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Stier G, Ramsingh D, Raval R, Shih G, Halverson B, Austin B, Soo J, Ruckle H, Martin R. Anesthesiologists as perioperative hospitalists and outcomes in patients undergoing major urologic surgery: a historical prospective, comparative effectiveness study. Perioper Med (Lond) 2018; 7:13. [PMID: 29951203 PMCID: PMC6009851 DOI: 10.1186/s13741-018-0090-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 04/17/2018] [Indexed: 02/04/2023] Open
Abstract
Background Perioperative care has been identified as an area of wide variability in quality, with conflicting models, and involving multiple specialties. In 2014, the Loma Linda University Departments of Anesthesiology and Urology implemented a perioperative hospitalist service (PHS), consisting of anesthesiology-trained physicians, to co-manage patients for the entirety of their perioperative period. We hypothesized that implementation of this PHS model would result in an improvement in patient recovery. Methods As a quality improvement (QI) initiative, the PHS service was formed of selected anesthesiologists who received training on the core competencies for hospitalist medicine. The service was implemented following a co-management agreement to medically manage patients undergoing major urologic procedures (prostatectomy, cystectomy, and nephrectomy). Impact was assessed by comparisons to data from the year prior to PHS service implementation. Data was compared with and without propensity matching. Primary outcome marker was a reduction in length of stay. Secondary outcome markers included complication rate, return of bowel function, number of consultations, reduction in total direct patient costs, and bed days saved. Results Significant reductions in length of stay (p < 0.05) were demonstrated for all surgical procedures with propensity matching and were demonstrated for cystectomy and nephrectomy cases without. Significant reductions in complication rates and ileus were also observed for all surgical procedures post-PHS implementation. Additionally, reductions in total direct patient costs and frequency of consultations were also observed. Conclusions Anesthesiologists can safely function as perioperative hospitalists, providing appropriate medical management, and significantly improving both patient recovery and throughput. Electronic supplementary material The online version of this article (10.1186/s13741-018-0090-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gary Stier
- 1Anesthesiology, Internal Medicine and Critical Care, Loma Linda University Medical Center, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
| | - Davinder Ramsingh
- 2Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
| | - Ronak Raval
- 2Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
| | - Gary Shih
- 2Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
| | - Bryan Halverson
- 2Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
| | - Briahnna Austin
- 2Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
| | - Joseph Soo
- 2Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
| | - Herbert Ruckle
- Department of Urology, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
| | - Robert Martin
- 2Department of Anesthesiology, Loma Linda University Medical Center, 11234 Anderson Street, MC-2532-D, Loma Linda, CA 92354 USA
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Brandal D, Keller MS, Lee C, Grogan T, Fujimoto Y, Gricourt Y, Yamada T, Rahman S, Hofer I, Kazanjian K, Sack J, Mahajan A, Lin A, Cannesson M. Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. Anesth Analg 2017; 125:1784-1792. [PMID: 29049123 DOI: 10.1213/ane.0000000000002510] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The United States is in the midst of an opioid epidemic, and opioid use disorder often begins with a prescription for acute pain. The perioperative period represents an important opportunity to prevent chronic opioid use, and recently there has been a paradigm shift toward implementation of enhanced recovery after surgery (ERAS) protocols that promote opioid-free and multimodal analgesia. The objective of this study was to assess the impact of an ERAS intervention for colorectal surgery on discharge opioid prescribing practices. METHODS We conducted a historical-prospective quality improvement study of an ERAS protocol implemented for patients undergoing colorectal surgery with a focus on the opioid-free and multimodal analgesia components of the pathway. We compared patients undergoing colorectal surgery 1 year before implementation (June 15, 2015, to June 14, 2016) and 1 year after implementation (June 15, 2016, to June 14, 2017). RESULTS Before the ERAS intervention, opioids at discharge were not significantly increasing (1% per month; 95% confidence interval [CI], -1% to 3%; P = .199). Immediately after the ERAS intervention, opioid prescriptions were not significantly lower (13%; 95% CI, -30% to 3%; P = .110). After the intervention, the rate of opioid prescriptions at discharge did not decrease significantly 1% (95% CI, -3% to 1%) compared to the pre-period rate (P = .399). Subgroup analysis showed that in patients with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge, the rate of discharge opioid prescription was 72% (95% CI, 61%-83%). CONCLUSIONS This study is the first to report discharge opioid prescribing practices in an ERAS setting. Although an ERAS intervention for colorectal surgery led to an increase in opioid-free anesthesia and multimodal analgesia, we did not observe an impact on discharge opioid prescribing practices. The majority of patients were discharged with an opioid prescription, including those with a combination of low discharge pain scores, no preoperative opioid use, and low morphine milligram equivalents consumption before discharge. This observation in the setting of an ERAS pathway that promotes multimodal analgesia suggests that our findings are very likely to also be observed in non-ERAS settings and offers an opportunity to modify opioid prescribing practices on discharge after surgery. For opioid-free anesthesia and multimodal analgesia to influence the opioid epidemic, the dose and quantity of the opioids prescribed should be modified based on the information gathered by in-hospital pain scores and opioid use as well as pain history before admission.
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Affiliation(s)
- Delara Brandal
- From the *Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, California; †UCLA Fielding School of Public Health, Los Angles, California; ‡Department of Anesthesiology, Osaka City University, Osaka, Japan; §Department of Anesthesiology, Nimes University, Nimes, France; ∥Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan; and ¶Department of Surgery, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, California
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Dreyer NA, Bryant A, Velentgas P. The GRACE Checklist: A Validated Assessment Tool for High Quality Observational Studies of Comparative Effectiveness. J Manag Care Spec Pharm 2017; 22:1107-13. [PMID: 27668559 PMCID: PMC10398313 DOI: 10.18553/jmcp.2016.22.10.1107] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recognizing the growing need for robust evidence about treatment effectiveness in real-world populations, the Good Research for Comparative Effectiveness (GRACE) guidelines have been developed for noninterventional studies of comparative effectiveness to determine which studies are sufficiently rigorous to be reliable enough for use in health technology assessments. OBJECTIVE To evaluate which aspects of the GRACE Checklist contribute most strongly to recognition of quality. METHODS We assembled 28 observational comparative effectiveness articles published from 2001 to 2010 that compared treatment effectiveness and/or safety of drugs, medical devices, and medical procedures. Twenty-two volunteers from academia, pharmaceutical companies, and government agencies applied the GRACE Checklist to those articles, providing 56 assessments. Ten senior academic and industry experts provided assessments of overall article quality for the purpose of decision support. We also rated each article based on the number of annual citations and impact factor of the journal in which the article was published. To identify checklist items that were most predictive of quality, classification and regression tree (CART) analysis, a binary, recursive, partitioning methodology, was used to create 3 decision trees, which compared the 56 article assessments with 3 external quality outcomes: (1) expert assessment of overall quality, (2) citation frequency, and (3) impact factor. A fourth tree looked at the composite outcome of all 3 quality indicators. RESULTS The best predictors of quality included the following: use of concurrent comparators, limiting the study to new initiators of the study drug, equivalent measurement of outcomes in study groups, collecting data on most if not all known confounders or effect modifiers, accounting for immortal time bias in the analysis, and use of sensitivity analyses to test how much effect estimates depended on various assumptions. Only sensitivity analyses appeared consistently as a predictor of quality in all 4 trees. When a composite outcome of the 3 quality measures was used, the GRACE Checklist showed high sensitivity and specificity (71.43% and 80.95%, respectively). CONCLUSIONS The GRACE Checklist stands out from other consensus-driven and expert guidance documents because of its extensive validation efforts. This most recent work shows that the checklist has strong sensitivity and specificity, increasing its utility as a screening tool to identify high-quality observational comparative effectiveness research worthy of in-depth review and applicability for decision support. DISCLOSURES No outside funding supported this research. All authors are full-time employees of Quintiles, which provides research and consulting services to the biopharmaceutical industry. The authors have no other disclosures to report. Two of the 3 CART trees were presented at the International Society of Pharmacepidemiology in 2015 ("Article Citations per Year" and "Journal Impact Factor"). The original validation study was published in the March 2014 issue of the Journal of Managed Care & Specialty Pharmacy. The checklist questions and scoring were included using a table that was originally published by this journal in 2014. Study concept and design were primarily contributed by Dreyer and Velentgas, along with Bryant. Bryant took the lead in data collection and analysis, along with Dreyer and Velentgas, and data interpretation was performed by Dreyer, Velentgas, and Bryant. The manuscript was written and revised primarily by Dreyer, along with Bryant and Velentgas.
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Affiliation(s)
- Nancy A Dreyer
- 1 Quintiles Real-World & Late-Phase Research, Cambridge, Massachusetts
| | - Allison Bryant
- 1 Quintiles Real-World & Late-Phase Research, Cambridge, Massachusetts
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Emerging Methodology of Intraoperative Hemodynamic Monitoring Research. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0176-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cannesson M, Ramsingh D, Rinehart J, Demirjian A, Vu T, Vakharia S, Imagawa D, Yu Z, Greenfield S, Kain Z. Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study. Crit Care 2015; 19:261. [PMID: 26088649 PMCID: PMC4512146 DOI: 10.1186/s13054-015-0945-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 05/07/2015] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Perioperative goal-directed therapy (PGDT) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow. In 2012, we initiated a performance improvement (PI) project focusing on the implementation of PGDT during high-risk abdominal surgeries. The objective of the present study was to evaluate the effectiveness of this intervention. METHODS This is a historical prospective quality improvement study. The goal of this initiative was to standardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine. For fluid management, the protocol consisted in standardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT. The impact of the intervention was assessed on the length of stay in the hospital (LOS) and post-operative complications (NSQIP database). RESULTS In the 1 year pre- and post-implementation periods, 128 and 202 patients were included. The average volume of fluid administered during the case was 9.9 (7.1-13.0) ml/kg/hour in the pre-implementation period and 6.6 (4.7-9.5) ml/kg/hour in the post-implementation period (p < 0.01). LOS decreased from 10 (6-16) days to 7 (5-11) days (p = 0.0001). Based on the multiple linear regression analysis, the estimated coefficient for intervention was 0.203 (SE = 0.054, p = 0.0002) indicating that, with the other conditions being held the same, introducing intervention reduced LOS by 18% (95% confidence interval 9-27%). The incidence of NSQIP complications decreased from 39% to 25% (p = 0.04). CONCLUSION These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries. TRIAL REGISTRATION Clinicaltrials.gov NCT02057653. Registered 17 December 2013.
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Affiliation(s)
- Maxime Cannesson
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
- Health Policy Research Institute, University of California, Irvine, CA, USA.
| | - Davinder Ramsingh
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Aram Demirjian
- Department of Surgery, University of California, Irvine, CA, USA.
| | - Trung Vu
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - Shermeen Vakharia
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
| | - David Imagawa
- Department of Surgery, University of California, Irvine, CA, USA.
| | - Zhaoxia Yu
- Department of Statistics, University of California, Irvine, CA, USA.
| | - Sheldon Greenfield
- Health Policy Research Institute, University of California, Irvine, CA, USA.
| | - Zeev Kain
- Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA.
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Weissman JS, Westrich K, Hargraves JL, Pearson SD, Dubois R, Emond S, Olufajo OA. Translating comparative effectiveness research into Medicaid payment policy: views from medical and pharmacy directors. J Comp Eff Res 2015; 4:79-88. [DOI: 10.2217/cer.14.68] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: As the USA seeks to expand the conduct and dissemination of comparative effectiveness research (CER), views of key stakeholders will help guide the way. Methods: We surveyed 60 medical and pharmacy directors from 46 state Medicaid programs. Results: Over 90% felt that CER would lead to better clinical decision-making and overall value within 5 years and were willing to consider cost–effectiveness in setting medical policy. However, perceived poor quality, inconclusive research, restrictive legislative mandates, lack of budget impact and coverage recommendations, and lack of an independent body to interpret study results were major barriers cited to using CER evidence. Conclusion: Given the significant resources being invested in CER, it is critical that these barriers are overcome to maximize its usefulness for stakeholders.
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Affiliation(s)
- Joel S Weissman
- Center for Surgery & Public Health, Brigham & Women's Hospital, Harvard Medical School, 1620 Tremont Street, Boston, MA 02120, USA
- Department of Health Policy & Management, Harvard School of Public Health, Boston, MA, USA
- Department of Healthcare Policy, Harvard Medical School, Boston, MA, USA
| | | | - J Lee Hargraves
- Center for Survey Research, University of Massachusetts Boston, Boston, MA, USA
| | - Steven D Pearson
- Institute for Clinical & Economic Review (ICER), Boston, MA, USA
| | - Robert Dubois
- National Pharmaceutical Council, Washington, DC, USA
| | - Sarah Emond
- Institute for Clinical & Economic Review (ICER), Boston, MA, USA
| | - Olubode A Olufajo
- Center for Surgery & Public Health, Brigham & Women's Hospital, Harvard Medical School, 1620 Tremont Street, Boston, MA 02120, USA
- Division of Trauma, Burn & Surgical Critical Care, Brigham & Women's Hospital, Boston, MA, USA
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Dubois RW. From methods to policy: Key questions remain unanswered. J Comp Eff Res 2014; 3:9-10. [DOI: 10.2217/cer.13.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Robert W Dubois
- National Pharmaceutical Council, 1717 Pennsylvania Avenue, Northwest Suite 800, Washington, DC 20006, USA
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