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Kim DD, Wang L, Lauren BN, Liu J, Marklund M, Lee Y, Micha R, Mozaffarian D, Wong JB. Development and Validation of the US Diabetes, Obesity, Cardiovascular Disease Microsimulation (DOC-M) Model: Health Disparity and Economic Impact Model. Med Decis Making 2023; 43:930-948. [PMID: 37842820 PMCID: PMC10625721 DOI: 10.1177/0272989x231196916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 07/27/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Few simulation models have incorporated the interplay of diabetes, obesity, and cardiovascular disease (CVD); their upstream lifestyle and biological risk factors; and their downstream effects on health disparities and economic consequences. METHODS We developed and validated a US Diabetes, Obesity, Cardiovascular Disease Microsimulation (DOC-M) model that incorporates demographic, clinical, and lifestyle risk factors to jointly predict overall and racial-ethnic groups-specific obesity, diabetes, CVD, and cause-specific mortality for the US adult population aged 40 to 79 y at baseline. An individualized health care cost prediction model was further developed and integrated. This model incorporates nationally representative data on baseline demographics, lifestyle, health, and cause-specific mortality; dynamic changes in modifiable risk factors over time; and parameter uncertainty using probabilistic distributions. Validation analyses included assessment of 1) population-level risk calibration and 2) individual-level risk discrimination. To illustrate the application of the DOC-M model, we evaluated the long-term cost-effectiveness of a national produce prescription program. RESULTS Comparing the 15-y model-predicted population risk of primary outcomes among the 2001-2002 National Health and Nutrition Examination Survey (NHANES) cohort with the observed prevalence from age-matched cross-sectional 2003-2016 NHANES cohorts, calibration performance was strong based on observed-to-expected ratio and calibration plot analysis. In most cases, Brier scores fell below 0.0004, indicating a low overall prediction error. Using the Multi-Ethnic Study of Atherosclerosis cohorts, the c-statistics for assessing individual-level risk discrimination were 0.85 to 0.88 for diabetes, 0.93 to 0.95 for obesity, 0.74 to 0.76 for CVD history, and 0.78 to 0.81 for all-cause mortality, both overall and in three racial-ethnic groups. Open-source code for the model was posted at https://github.com/food-price/DOC-M-Model-Development-and-Validation. CONCLUSIONS The validated DOC-M model can be used to examine health, equity, and the economic impact of health policies and interventions on behavioral and clinical risk factors for obesity, diabetes, and CVD. HIGHLIGHTS We developed a novel microsimula'tion model for obesity, diabetes, and CVD, which intersect together and - critically for prevention and treatment interventions - share common lifestyle, biologic, and demographic risk factors.Validation analyses, including assessment of (1) population-level risk calibration and (2) individual-level risk discrimination, showed strong performance across the overall population and three major racial-ethnic groups for 6 outcomes (obesity, diabetes, CVD, and all-cause mortality, CVD- and DM-cause mortality)This paper provides a thorough explanation and documentation of the development and validation process of a novel microsimulation model, along with the open-source code (https://github.com/food-price/ DOCM_validation) for public use, to serve as a guide for future simulation model assessments, validation, and implementation.
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Affiliation(s)
- David D. Kim
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Lu Wang
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Brianna N. Lauren
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Junxiu Liu
- Department of Population Health Science and Policy, the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matti Marklund
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Yujin Lee
- Department of Food and Nutrition, Myongji University, Yongin, South Korea
| | - Renata Micha
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - John B. Wong
- Division of Clinical Decision Making, Tufts Medical Center, Boston, MA, USA
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Wang L, Lauren BN, Hager K, Zhang FF, Wong JB, Kim DD, Mozaffarian D. Health and Economic Impacts of Implementing Produce Prescription Programs for Diabetes in the United States: A Microsimulation Study. J Am Heart Assoc 2023; 12:e029215. [PMID: 37417296 PMCID: PMC10492976 DOI: 10.1161/jaha.122.029215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/31/2023] [Indexed: 07/08/2023]
Abstract
Background Produce prescription programs, providing free or discounted produce and nutrition education to patients with diet-related conditions within health care systems, have been shown to improve dietary quality and cardiometabolic risk factors. The potential impact of implementing produce prescription programs for patients with diabetes on long-term health gains, costs, and cost-effectiveness in the United States has not been established. Methods and Results We used a validated state-transition microsimulation model (Diabetes, Obesity, Cardiovascular Disease Microsimulation model), populated with national data of eligible individuals from the National Health and Nutrition Examination Survey 2013 to 2018, further incorporating estimated intervention effects and diet-disease effects from meta-analyses, and policy- and health-related costs from published literature. The model estimated that over a lifetime (mean=25 years), implementing produce prescriptions in 6.5 million US adults with both diabetes and food insecurity (lifetime treatment) would prevent 292 000 (95% uncertainty interval, 143 000-440 000) cardiovascular disease events, generate 260 000 (110000-411 000) quality-adjusted life-years, cost $44.3 billion in implementation costs, and save $39.6 billion ($20.5-58.6 billion) in health care costs and $4.8 billion ($1.84-$7.70 billion) in productivity costs. The program was highly cost effective from a health care perspective (incremental cost-effectiveness ratio: $18 100/quality-adjusted life-years) and cost saving from a societal perspective (net savings: $-0.05 billion). The intervention remained cost effective at shorter time horizons of 5 and 10 years. Results were similar in population subgroups by age, race or ethnicity, education, and baseline insurance status. Conclusions Our model suggests that implementing produce prescriptions among US adults with diabetes and food insecurity would generate substantial health gains and be highly cost effective.
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Affiliation(s)
- Lu Wang
- The Gerald J. and Dorothy R. Friedman School of Nutrition Science and PolicyTufts UniversityBostonMAUSA
| | - Brianna N. Lauren
- The Gerald J. and Dorothy R. Friedman School of Nutrition Science and PolicyTufts UniversityBostonMAUSA
| | - Kurt Hager
- The Gerald J. and Dorothy R. Friedman School of Nutrition Science and PolicyTufts UniversityBostonMAUSA
| | - Fang Fang Zhang
- The Gerald J. and Dorothy R. Friedman School of Nutrition Science and PolicyTufts UniversityBostonMAUSA
| | - John B. Wong
- Division of Clinical Decision MakingTufts Medical CenterBostonMAUSA
| | - David D. Kim
- Division of Hospital Medicine, Department of MedicineUniversity of ChicagoILUSA
| | - Dariush Mozaffarian
- The Gerald J. and Dorothy R. Friedman School of Nutrition Science and PolicyTufts UniversityBostonMAUSA
- Division of CardiologyTufts Medical CenterBostonMAUSA
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Woo Baidal JA, Duong N, Goldsmith J, Hur C, Lauren BN, Partida I, Rosenthal A, Hulse E, Shea S, Cheung K, Meyer D. Association of a primary care-based mobile food pantry with child body mass index: A propensity score matched cohort study. Pediatr Obes 2023; 18:e13023. [PMID: 36939408 PMCID: PMC10159907 DOI: 10.1111/ijpo.13023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/09/2023] [Accepted: 02/20/2023] [Indexed: 03/21/2023]
Abstract
OBJECTIVE To test the hypothesis that children in Food FARMacia-a six-month food insecurity intervention from May 2019 to January 2020-would have smaller age-adjusted, sex-specific body mass index (BMIz) gains than matched counterparts. METHODS In this proof-of-concept study, we performed a difference-in-differences (DiD) analysis of a propensity-score matched cohort among paediatric primary care patients aged <6 years with household food insecurity. Children with anthropometric measures prior to and after intervention started were included. The main outcome was child BMIz from standardized clinical anthropometric measurements. We examined differences in child BMIz change between Food FARMacia participants and matched non-participants. RESULTS Among 454 children with household food insecurity, 265 were included, 44 of whom were in Food FARMacia. Mean child age was 1.48 (SD 1.46) years and most reported Hispanic/Latino ethnicity (84.5%). After propensity score matching, children in Food FARMacia had smaller increases in BMIz (unadjusted DiD -0.28 [-0.52, -0.04]) compared to non-participants in the follow-up period. After adjusting for potential confounders, findings remained statistically significant [adjusted DiD, -0.31 units (95% CI: -0.54, -0.08)]. CONCLUSIONS In this proof-of-concept cohort study of children in households with food insecurity, a paediatric primary care-based mobile food pantry program was associated with improvement in child BMIz over 6 months.
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Affiliation(s)
- Jennifer A Woo Baidal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.,NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Ngoc Duong
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Jeff Goldsmith
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Chin Hur
- Department of Medicine, Columbia University, New York, New York, USA
| | - Brianna N Lauren
- Department of Medicine, Columbia University, New York, New York, USA
| | - Ivette Partida
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | | | - Emma Hulse
- Division of Community and Population Health, NewYork-Presbyterian, New York, New York, USA
| | - Steven Shea
- Department of Medicine, Columbia University, New York, New York, USA.,Department of Epidemiology, Columbia University, New York, New York, USA
| | - Ken Cheung
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Dodi Meyer
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
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O’Hearn M, Erndt-Marino J, Gerber S, Lauren BN, Economos C, Wong JB, Blumberg JB, Mozaffarian D. Validation of Food Compass with a healthy diet, cardiometabolic health, and mortality among U.S. adults, 1999-2018. Nat Commun 2022; 13:7066. [PMID: 36414619 PMCID: PMC9681774 DOI: 10.1038/s41467-022-34195-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/14/2022] [Indexed: 11/23/2022] Open
Abstract
The Food Compass is a nutrient profiling system (NPS) to characterize the healthfulness of diverse foods, beverages and meals. In a nationally representative cohort of 47,999 U.S. adults, we validated a person's individual Food Compass Score (i.FCS), ranging from 1 (least healthful) to 100 (most healthful) based on cumulative scores of items consumed, against: (a) the Healthy Eating Index (HEI) 2015; (b) clinical risk factors and health conditions; and (c) all-cause mortality. Nationally, the mean (SD) of i.FCS was 35.5 (10.9). i.FCS correlated highly with HEI-2015 (R = 0.81). After multivariable-adjustment, each one SD (10.9 point) higher i.FCS associated with more favorable BMI (-0.60 kg/m2 [-0.70,-0.51]), systolic blood pressure (-0.69 mmHg [-0.91,-0.48]), diastolic blood pressure (-0.49 mmHg [-0.66,-0.32]), LDL-C (-2.01 mg/dl [-2.63,-1.40]), HDL-C (1.65 mg/d [1.44,1.85]), HbA1c (-0.02% [-0.03,-0.01]), and fasting plasma glucose (-0.44 mg/dL [-0.74,-0.15]); lower prevalence of metabolic syndrome (OR = 0.85 [0.82,0.88]), CVD (0.92 [0.88,0.96]), cancer (0.95 [0.91,0.99]), and lung disease (0.92 [0.88,0.96]); and higher prevalence of optimal cardiometabolic health (1.24 [1.16,1.32]). i.FCS also associated with lower all-cause mortality (HR = 0.93 [0.89,0.96]). Findings were similar by age, sex, race/ethnicity, education, income, and BMI. These findings support validity of Food Compass as a tool to guide public health and private sector strategies to identify and encourage healthier eating.
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Affiliation(s)
- Meghan O’Hearn
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | | | - Suzannah Gerber
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | - Brianna N. Lauren
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | - Christina Economos
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | - John B. Wong
- grid.67033.310000 0000 8934 4045Tufts Medical Center, Tufts University School of Medicine, Boston, MA USA ,grid.67033.310000 0000 8934 4045Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, MA USA
| | - Jeffrey B. Blumberg
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA
| | - Dariush Mozaffarian
- grid.429997.80000 0004 1936 7531Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA USA ,grid.67033.310000 0000 8934 4045Tufts Medical Center, Tufts University School of Medicine, Boston, MA USA
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Hager K, Cudhea FP, Wong JB, Berkowitz SA, Downer S, Lauren BN, Mozaffarian D. Association of National Expansion of Insurance Coverage of Medically Tailored Meals With Estimated Hospitalizations and Health Care Expenditures in the US. JAMA Netw Open 2022; 5:e2236898. [PMID: 36251292 PMCID: PMC9577678 DOI: 10.1001/jamanetworkopen.2022.36898] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Medically tailored meals (MTMs) are associated with lower health care utilization among patients with complex diet-related diseases but are not a covered benefit in Medicare or Medicaid. The potential impact of extending insurance coverage for MTMs nationally remains unknown. OBJECTIVE To estimate 1- and 10-year potential changes in annual hospitalizations, potential changes in annual health care expenditures, and overall policy cost-effectiveness associated with national MTM coverage for US patients with diet-related disease and limited instrumental activities of daily living who have Medicaid, Medicare, or private insurance. DESIGN, SETTING, AND PARTICIPANTS In this economic evaluation, conducted from January 2021 to February 2022, a nationally representative sample from the 2019 Medical Expenditure Panel Survey was used to create a population-level cohort policy simulation model that estimated changes in annual hospitalizations and health care expenditures associated with coverage of MTMs. Participants were 6 309 998 US adults aged 18 years or older who had Medicare, Medicaid, or private payer insurance and at least 1 diet-sensitive condition and 1 limitation in instrumental activities of daily living. INTERVENTIONS Ten nutritionally tailored MTMs per week for a mean of 8 months in each year of intervention. MAIN OUTCOMES AND MEASURES The main outcomes were total hospitalizations, program costs, health care expenditures, and net policy costs. One thousand Monte Carlo simulations for each of 10 years (2019-2028) jointly incorporated uncertainty in model inputs for effect sizes, hospitalizations, health care expenditures, and program costs. RESULTS At the 2019 baseline, an estimated 6 309 998 US adults were eligible to receive MTMs. Mean (SD) age was 68.1 (16.6) years; most were female (63.4%), were non-Hispanic White (66.7%), and had Medicare and/or Medicaid (76.5%). The most common eligibility diagnoses were cardiovascular diseases (70.6%), diabetes (44.9%), and cancer (37.2%). If all eligible individuals received MTMs, an estimated 1 594 000 hospitalizations (95% uncertainty interval [UI], 1 297 000-1 912 000) and $38.7 billion (95% UI, $24.9 billion to $53.9 billion) in health care expenditures could potentially be averted in 1 year. Program costs were $24.8 billion (95% UI, $23.1 billion to $26.8 billion), for an associated net savings of $13.6 billion (95% UI, $0.2 billion to $28.5 billion) from a health care perspective. In 2019 dollars, 10 years of the MTM intervention was anticipated to cost $298.7 billion (95% UI, $279.7 billion to $317.4 billion) and to potentially be associated with 18 257 000 averted hospitalizations (95% UI, 14 690 000-22 109 000) and reductions in health care expenditures of $484.5 billion (95% UI, $310.2 billion to $678.4 billion), for net savings of $185.1 billion (95% UI, $12.9 billion to $377.8 billion). Findings were robust in multiple sensitivity analyses. CONCLUSIONS AND RELEVANCE The findings suggest that national implementation of MTMs for patients with diet-sensitive conditions and activity limitations could potentially be associated with approximately 1.6 million averted hospitalizations and net cost savings of $13.6 billion annually. The results may inform US state, federal, and private-payer interest in expanding insurance coverage for MTMs among patients with diet-related chronic illness.
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Affiliation(s)
- Kurt Hager
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Frederick P. Cudhea
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - John B. Wong
- Division of Clinical Decision Making, Tufts Medical Center, Boston, Massachusetts
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Seth A. Berkowitz
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Sarah Downer
- Center for Medicare & Medicaid Innovation, Baltimore, Maryland
| | - Brianna N. Lauren
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
- Tufts University School of Medicine, Division of Cardiology at Tufts Medical Center, Boston, Massachusetts
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Ingram MA, Lauren BN, Pumpalova Y, Park J, Lim F, Bates SE, Kastrinos F, Manji GA, Kong CY, Hur C. Cost-effectiveness of neoadjuvant FOLFIRINOX versus gemcitabine plus nab-paclitaxel in borderline resectable/locally advanced pancreatic cancer patients. Cancer Rep (Hoboken) 2022; 5:e1565. [PMID: 35122419 PMCID: PMC9458514 DOI: 10.1002/cnr2.1565] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/11/2021] [Accepted: 09/21/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The 2020 National Comprehensive Cancer Network guidelines recommend neoadjuvant FOLFIRINOX or neoadjuvant gemcitabine plus nab-paclitaxel (G-nP) for borderline resectable/locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC). AIM The purpose of our study was to compare treatment outcomes, toxicity profiles, costs, and quality-of-life measures between these two treatments to further inform clinical decision-making. METHODS AND RESULTS We developed a decision-analytic mathematical model to compare the total cost and health outcomes of neoadjuvant FOLFIRINOX against G-nP over 12 years. The model inputs were estimated using clinical trial data and published literature. The primary endpoint was incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay threshold of $100 000 per quality-adjusted-life-year (QALY). Secondary endpoints included overall (OS) and progression-free survival (PFS), total cost of care, QALYs, PDAC resection rate, and monthly treatment-related adverse events (TRAE) costs (USD). FOLFIRINOX was the cost-effective strategy, with an ICER of $60856.47 per QALY when compared to G-nP. G-nP had an ICER of $44639.71 per QALY when compared to natural history. For clinical outcomes, more patients underwent an "R0" resection with FOLFIRINOX compared to G-nP (84.9 vs. 81.0%), but FOLFIRINOX had higher TRAE costs than G-nP ($10905.19 vs. $4894.11). A one-way sensitivity analysis found that the ICER of FOLFIRINOX exceeded the threshold when TRAE costs were higher or PDAC recurrence rates were lower. CONCLUSION Our modeling analysis suggests that FOLFIRNOX is the cost-effective treatment compared to G-nP for BR/LA PDAC despite having a higher cost of total care due to TRAE costs. Trial data with sufficient follow-up are needed to confirm our findings.
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Affiliation(s)
- Myles A. Ingram
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Brianna N. Lauren
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Yoanna Pumpalova
- Department of Medicine, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Jiheum Park
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Francesca Lim
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Susan E. Bates
- Herbert Irving Comprehensive Cancer CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Fay Kastrinos
- Herbert Irving Comprehensive Cancer CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Division of Digestive and Liver DiseasesColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Gulam A. Manji
- Herbert Irving Comprehensive Cancer CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Chung Yin Kong
- Division of General MedicineMount Sinai School of MedicineNew YorkNew YorkUSA
| | - Chin Hur
- Division of General MedicineColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
- Herbert Irving Comprehensive Cancer CenterColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Division of Digestive and Liver DiseasesColumbia University Irving Medical Cancer and the Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
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O'Hearn M, Lauren BN, Wong JB, Kim DD, Mozaffarian D. Trends and Disparities in Cardiometabolic Health Among U.S. Adults, 1999-2018. J Am Coll Cardiol 2022; 80:138-151. [PMID: 35798448 PMCID: PMC10475326 DOI: 10.1016/j.jacc.2022.04.046] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/05/2022] [Accepted: 04/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies have assessed U.S. cardiometabolic health trends-optimal levels of multiple risk factors and absence of clinical cardiovascular disease (CVD)-or its impact on health disparities. OBJECTIVES The purpose of this study was to investigate U.S. trends in optimal cardiometabolic health from 1999 to 2018. METHODS We assessed proportions of adults with optimal cardiometabolic health, based on adiposity, blood glucose, blood lipids, blood pressure, and clinical CVD; and optimal, intermediate, and poor levels of each component among 55,081 U.S. adults in the National Health and Nutrition Examination Survey. RESULTS In 2017-2018, only 6.8% (95% CI: 5.4%-8.1%) of U.S. adults had optimal cardiometabolic health, declining from 1999-2000 (P trend = 0.02). Among components of cardiometabolic health, the largest declines were for adiposity (optimal levels: 33.8%-24.0%; poor levels: 47.7%-61.9%) and glucose (optimal levels: 59.4%-36.9%; poor levels: 8.6%-13.7%) (P trend <0.001 for each). Optimal levels of blood lipids increased from 29.9%-37.0%, whereas poor decreased from 28.3%-14.7% (P trend <0.001). Trends over time for blood pressure and CVD were smaller. Disparities by age, sex, education, and race/ethnicity were evident in all years, and generally worsened over time. By 2017-2018, prevalence of optimal cardiometabolic health was lower among Americans with lower (5.0% [95% CI: 2.8%-7.2%]) vs higher education (10.3% [95% CI: 7.6%-13.0%]); and among Mexican American (3.2% [95% CI: 1.4%-4.9%]) vs non-Hispanic White (8.4% [95% CI: 6.3%-10.4%]) adults. CONCLUSIONS Between 1999 and 2000 and 2017 and 2018, U.S. cardiometabolic health has been poor and worsening, with only 6.8% of adults having optimal cardiometabolic health, and disparities by age, sex, education, and race/ethnicity. These novel findings inform the need for nationwide clinical and public health interventions to improve cardiometabolic health and health equity.
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Affiliation(s)
- Meghan O'Hearn
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA.
| | - Brianna N Lauren
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA
| | - John B Wong
- Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA; Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - David D Kim
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts, USA; Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
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Rubenstein JH, Omidvari AH, Lauren BN, Hazelton WD, Lim F, Tan SX, Kong CY, Lee M, Ali A, Hur C, Inadomi JM, Luebeck G, Lansdorp-Vogelaar I. Endoscopic Screening Program for Control of Esophageal Adenocarcinoma in Varied Populations: A Comparative Cost-Effectiveness Analysis. Gastroenterology 2022; 163:163-173. [PMID: 35364064 DOI: 10.1053/j.gastro.2022.03.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/23/2022] [Accepted: 03/22/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Guidelines suggest endoscopic screening for esophageal adenocarcinoma (EAC) among individuals with symptoms of gastroesophageal reflux disease (GERD) and additional risk factors. We aimed to determine at what age to perform screening and whether sex and race should influence the decision. METHODS We conducted comparative cost-effectiveness analyses using 3 independent simulation models. For each combination of sex and race (White/Black, 100,000 individuals each), we considered 41 screening strategies, including one-time or repeated screening. The optimal strategy was that with the highest effectiveness and an incremental cost-effectiveness ratio <$100,000 per quality-adjusted life-year gained. RESULTS Among White men, 536 EAC deaths were projected without screening, and screening individuals with GERD twice at ages 45 and 60 years was optimal. Screening the entire White male population once at age 55 years was optimal in 26% of probabilistic sensitivity analysis runs. Black men had fewer EAC deaths without screening (n = 84), and screening those with GERD once at age 55 years was optimal. Although White women had slightly more EAC deaths (n = 103) than Black men, the optimal strategy was no screening, although screening those with GERD once at age 55 years was optimal in 29% of probabilistic sensitivity analysis runs. Black women had a very low burden of EAC deaths (n = 29), and no screening was optimal, as benefits were very small and some strategies caused net harm. CONCLUSIONS The optimal strategy for screening differs by race and sex. White men with GERD symptoms can potentially be screened more intensely than is recommended currently. Screening women is not cost-effective and may cause net harm for Black women.
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Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Epidemiology and Prevention Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Amir-Houshang Omidvari
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Brianna N Lauren
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - William D Hazelton
- Computational Biology Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Francesca Lim
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Sarah Xinhui Tan
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chung Yin Kong
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Minyi Lee
- Gastrointestinal Unit, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts; The Graduate Program in Bioinformatics, Boston University, Boston, Massachusetts
| | - Ayman Ali
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - John M Inadomi
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Georg Luebeck
- Computational Biology Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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9
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Eluri S, Paterson A, Lauren BN, O’Donovan M, Bhandari P, di Pietro M, Lee M, Haidry R, Lovat L, Ragunath K, Hur C, Fitzgerald RC, Shaheen NJ. Utility and Cost-Effectiveness of a Nonendoscopic Approach to Barrett's Esophagus Surveillance After Endoscopic Therapy. Clin Gastroenterol Hepatol 2022; 20:e51-e63. [PMID: 33581357 PMCID: PMC8352994 DOI: 10.1016/j.cgh.2021.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/28/2020] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A non-endoscopic approach to Barrett's esophagus (BE) surveillance after radiofrequency ablation (RFA) would offer a less invasive method for monitoring. We assessed the test characteristics and cost-effectiveness of the Cytosponge (Medtronic, Minneapolis, MN) in post-RFA patients. METHODS We performed a multicenter study of dysplastic BE patients after at least one round of RFA. A positive Cytosponge before endoscopy was defined as intestinal metaplasia (IM) on cytological assessment and/or TFF3 immunohistochemistry. Sensitivity, specificity, and receiver operator characteristic (ROC) curves were calculated. Multivariable regression was used to estimate the odds of a positive Cytosponge in BE. A microsimulation cost-effectiveness model was performed to assess outcomes of various surveillance strategies: endoscopy-only, Cytosponge-only, and alternating endoscopy/Cytosponge. RESULTS Of 234 patients, Cytosponge adequately sampled the distal esophagus in 175 (75%). Of the 142 with both endoscopic and histologic data, 19 (13%) had residual/recurrent BE. For detecting any residual Barrett's, Cytosponge had a sensitivity of 74%, specificity of 85%, accuracy of 84%, and ROC curve showed an area under the curve of 0.74. The adjusted odds of a positive Cytosponge in BE were 17.1 (95% CI, 5.2-55.9). Cytosponge-only surveillance dominated all the surveillance strategies, being both less costly and more effective. Cytosponge-only surveillance required <1/4th the endoscopies, resulting in only 0.69 additional EAC cases/1000 patients, and no increase in EAC deaths when compared to currently-practiced endoscopy-only surveillance. CONCLUSIONS A positive Cytosponge test was strongly associated with residual BE after ablation. While the assay needs further refinement in this context, it could serve as a cost-effective surveillance examination.
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Affiliation(s)
- Swathi Eluri
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Anna Paterson
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | - Brianna N. Lauren
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center
| | - Maria O’Donovan
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | | | - Minyi Lee
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center
| | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London Hospital, London, UK
| | - Laurence Lovat
- Division of Surgery and Interventional Science, University College London Hospital, London, UK
| | - Krish Ragunath
- Nottingham Digestive Diseases Center, NIHR Biomedical Research Centre, University of Nottingham, Queens Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Chin Hur
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center
| | | | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC,Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
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10
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Lauren BN, Lim F, Krikhely A, Taveras EM, Woo Baidal JA, Bellows BK, Hur C. Estimated Cost-effectiveness of Medical Therapy, Sleeve Gastrectomy, and Gastric Bypass in Patients With Severe Obesity and Type 2 Diabetes. JAMA Netw Open 2022; 5:e2148317. [PMID: 35157054 PMCID: PMC8845022 DOI: 10.1001/jamanetworkopen.2021.48317] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022] Open
Abstract
Importance Bariatric surgery is recommended for patients with severe obesity (body mass index ≥40) and type 2 diabetes (T2D). However, the most cost-effective treatment remains unclear and may depend on the patient's T2D severity. Objective To estimate the cost-effectiveness of medical therapy, sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB) among patients with severe obesity and T2D, stratified by T2D severity. Design, Setting, and Participants This economic evaluation used a microsimulation model to project health and cost outcomes of medical therapy, SG, and RYGB over 5 years. Time horizons varied between 10 and 30 years in sensitivity analyses. Model inputs were derived from clinical trials, large cohort studies, national databases, and published literature. Probabilistic sampling of model inputs accounted for parameter uncertainty. Estimates of US adults with severe obesity and T2D were derived from the National Health and Nutrition Examination Survey. Data analysis was performed from January 2020 to August 2021. Exposures Medical therapy, SG, and RYGB. Main Outcomes and Measures Quality-adjusted life-years (QALYs), costs (in 2020 US dollars), and incremental cost-effectiveness ratios (ICERs) were projected, with future cost and QALYs discounted 3.0% annually. A strategy was deemed cost-effective if the ICER was less than $100 000 per QALY. The preferred strategy resulted in the greatest number of QALYs gained while being cost-effective. Results The model simulated 1000 cohorts of 10 000 patients, of whom 16% had mild T2D, 56% had moderate T2D, and 28% had severe T2D at baseline. The mean age of simulated patients was 54.6 years (95% CI, 54.2-55.0 years), 61.6% (95% CI, 60.1%-63.4%) were female, and 65.1% (95% CI, 63.6%-66.7%) were non-Hispanic White. Compared with medical therapy over 5 years, RYGB was associated with the most QALYs gained in the overall population (mean, 0.44 QALY; 95% CI, 0.21-0.86 QALY) and when stratified by baseline T2D severity: mild (mean, 0.59 QALY; 95% CI, 0.35-0.98 QALY), moderate (mean, 0.50 QALY; 95% CI, 0.25-0.88 QALY), and severe (mean, 0.30 QALY; 95% CI, 0.07-0.79 QALY). RYGB was the preferred strategy in the overall population (ICER, $46 877 per QALY; 83.0% probability preferred) and when stratified by baseline T2D severity: mild (ICER, $36 479 per QALY; 73.7% probability preferred), moderate (ICER, $37 056 per QALY; 85.6% probability preferred), and severe (ICER, $98 940 per QALY; 40.2% probability preferred). The cost-effectiveness of RYGB improved over a longer time horizon. Conclusions and Relevance These findings suggest that the effectiveness and cost-effectiveness of bariatric surgery vary by baseline severity of T2D. Over a 5-year time horizon, RYGB is projected to be the preferred treatment strategy for patients with severe obesity regardless of baseline T2D severity.
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Affiliation(s)
- Brianna N. Lauren
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Abraham Krikhely
- Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Elsie M. Taveras
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston
| | | | - Brandon K. Bellows
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chin Hur
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
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11
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Simpson RB, Lauren BN, Schipper KH, McCann JC, Tarnas MC, Naumova EN. Critical Periods, Critical Time Points and Day-of-the-Week Effects in COVID-19 Surveillance Data: An Example in Middlesex County, Massachusetts, USA. IJERPH 2022; 19:ijerph19031321. [PMID: 35162344 PMCID: PMC8835321 DOI: 10.3390/ijerph19031321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 01/14/2023]
Abstract
Critical temporal changes such as weekly fluctuations in surveillance systems often reflect changes in laboratory testing capacity, access to testing or healthcare facilities, or testing preferences. Many studies have noted but few have described day-of-the-week (DoW) effects in SARS-CoV-2 surveillance over the major waves of the novel coronavirus 2019 pandemic (COVID-19). We examined DoW effects by non-pharmaceutical intervention phases adjusting for wave-specific signatures using the John Hopkins University’s (JHU’s) Center for Systems Science and Engineering (CSSE) COVID-19 data repository from 2 March 2020 through 7 November 2021 in Middlesex County, Massachusetts, USA. We cross-referenced JHU’s data with Massachusetts Department of Public Health (MDPH) COVID-19 records to reconcile inconsistent reporting. We created a calendar of statewide non-pharmaceutical intervention phases and defined the critical periods and timepoints of outbreak signatures for reported tests, cases, and deaths using Kolmogorov-Zurbenko adaptive filters. We determined that daily death counts had no DoW effects; tests were twice as likely to be reported on weekdays than weekends with decreasing effect sizes across intervention phases. Cases were also twice as likely to be reported on Tuesdays-Fridays (RR = 1.90–2.69 [95%CI: 1.38–4.08]) in the most stringent phases and half as likely to be reported on Mondays and Tuesdays (RR = 0.51–0.93 [0.44, 0.97]) in less stringent phases compared to Sundays; indicating temporal changes in laboratory testing practices and use of healthcare facilities. Understanding the DoW effects in daily surveillance records is valuable to better anticipate fluctuations in SARS-CoV-2 testing and manage appropriate workflow. We encourage health authorities to establish standardized reporting protocols.
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Rogers AM, Lauren BN, Woo Baidal JA, Ozanne EM, Hur C. Corrigendum to "Persistent effects of the COVID-19 pandemic on diet, exercise, risk for food insecurity, and quality of life: A longitudinal study among U.S. adults" [Appetite 167 (2021) 105639]. Appetite 2021; 168:105701. [PMID: 34607699 PMCID: PMC9025975 DOI: 10.1016/j.appet.2021.105701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Alexandra M Rogers
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, United States; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, United States
| | - Brianna N Lauren
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, United States; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, United States
| | - Jennifer A Woo Baidal
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Irving Medical Center, New York, NY, United States
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Chin Hur
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, United States; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, United States.
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13
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Rogers AM, Lauren BN, Woo Baidal JA, Ozanne EM, Hur C. Persistent effects of the COVID-19 pandemic on diet, exercise, risk for food insecurity, and quality of life: A longitudinal study among U.S. adults. Appetite 2021; 167:105639. [PMID: 34384807 PMCID: PMC8990782 DOI: 10.1016/j.appet.2021.105639] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/22/2021] [Accepted: 08/06/2021] [Indexed: 01/20/2023]
Abstract
COVID-19 has affected the health and well-being of almost every American. The aim of this study was to examine the sustained impacts of COVID-19 prevention measures on the diet and exercise habits, risk for food insecurity, and quality of life among adults in the U.S. We conducted a longitudinal study using a convenience sample of participants recruited via Amazon's Mechanical Turk (MTurk) platform between March 30 and April 7, 2020, and 8 months into the outbreak, from November 2 to November 21, 2020. We compared self-reported diet and exercise habits and risk for food insecurity shortly after the pandemic began, in April, to those reported in November. We also measured changes in quality-of-life using the PROMIS-29 + 2 (PROPr) scale. A total of 636 respondents completed both surveys. Compared to reports in April, respondents ate lunch and dinner out more frequently in November and consumed more take-out and fast food. Weekly frequencies of consuming frozen food and the number of daily meals were slightly lower in November than they were in April. 54% of respondents screened positively for being at risk for food insecurity in April, reducing to 41% by November. In April, survey respondents were found to have lower quality-of-life relative to U.S. population norms, but by November levels of depression and cognitive function had improved. Our findings underscore how the initial effects of the pandemic on diet, exercise, risk for food insecurity, and quality of life have evolved. As U.S. states re-open, continued efforts to encourage healthy eating and support mental health, especially to reduce feelings of anxiety and social isolation, remain important to mitigate the potential long-term effects of the pandemic.
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Affiliation(s)
- Alexandra M Rogers
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, USA; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, USA
| | - Brianna N Lauren
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, USA; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, USA
| | - Jennifer A Woo Baidal
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Columbia University Irving Medical Center, New York, NY, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Chin Hur
- Department of General Medicine, Columbia University Irving Medical Center, New York, NY, USA; Healthcare Innovations Research and Evaluation, Columbia University Irving Medical Center, New York, NY, USA.
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14
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Omidvari AH, Hazelton WD, Lauren BN, Naber SK, Lee M, Ali A, Seguin C, Kong CY, Richmond E, Rubenstein JH, Luebeck GE, Inadomi JM, Hur C, Lansdorp-Vogelaar I. The Optimal Age to Stop Endoscopic Surveillance of Patients With Barrett's Esophagus Based on Sex and Comorbidity: A Comparative Cost-Effectiveness Analysis. Gastroenterology 2021; 161:487-494.e4. [PMID: 33974935 PMCID: PMC8495224 DOI: 10.1053/j.gastro.2021.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 04/15/2021] [Accepted: 05/01/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Current guidelines recommend surveillance for patients with nondysplastic Barrett's esophagus (NDBE) but do not include a recommended age for discontinuing surveillance. This study aimed to determine the optimal age for last surveillance of NDBE patients stratified by sex and level of comorbidity. METHODS We used 3 independently developed models to simulate patients diagnosed with NDBE, varying in age, sex, and comorbidity level (no, mild, moderate, and severe). All patients had received regular surveillance until their current age. We calculated incremental costs and quality-adjusted life-years (QALYs) gained from 1 additional endoscopic surveillance at the current age versus not performing surveillance at that age. We determined the optimal age to end surveillance as the age at which incremental cost-effectiveness ratio of 1 more surveillance was just less than the willingness-to-pay threshold of $100,000/QALY. RESULTS The benefit of having 1 more surveillance endoscopy strongly depended on age, sex, and comorbidity. For men with NDBE and severe comorbidity, 1 additional surveillance at age 80 years provided 4 more QALYs per 1000 patients with BE at an additional cost of $1.2 million, whereas for women with severe comorbidity the benefit at that age was 7 QALYs at a cost of $1.3 million. For men with no, mild, moderate, and severe comorbidity, the optimal ages of last surveillance were 81, 80, 77, and 73 years, respectively. For women, these ages were younger: 75, 73, 73, and 69 years, respectively. CONCLUSIONS Our comparative modeling analysis illustrates the importance of considering comorbidity status and sex when deciding on the age to discontinue surveillance in patients with NDBE.
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Affiliation(s)
- Amir-Houshang Omidvari
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands.
| | - William D. Hazelton
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Steffie K. Naber
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - Minyi Lee
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Ayman Ali
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Claudia Seguin
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chun Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Ellen Richmond
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
| | - Joel H. Rubenstein
- Barrett’s Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan,Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Georg E. Luebeck
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John M. Inadomi
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chin Hur
- Department of Medicine, Columbia University, New York, New York
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, The Netherlands
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15
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Lauren BN, Silver ER, Faye AS, Rogers AM, Woo-Baidal JA, Ozanne EM, Hur C. Predictors of households at risk for food insecurity in the United States during the COVID-19 pandemic. Public Health Nutr 2021; 24:3929-3936. [PMID: 33500018 PMCID: PMC8207551 DOI: 10.1017/s1368980021000355] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine associations between sociodemographic and mental health characteristics with household risk for food insecurity during the COVID-19 outbreak. DESIGN Cross-sectional online survey analysed using univariable tests and a multivariable logistic regression model. SETTING The United States during the week of 30 March 2020. PARTICIPANTS A convenience sample of 1965 American adults using Amazon's Mechanical Turk platform. Participants reporting household food insecurity prior to the pandemic were excluded from analyses. RESULTS One thousand two hundred and fifty participants reported household food security before the COVID-19 outbreak. Among this subset, 41 % were identified as at risk for food insecurity after COVID-19, 55 % were women and 73 % were white. On a multivariable analysis, race, income, relationship status, living situation, anxiety and depression were significantly associated with an incident risk for food insecurity. Black, Asian and Hispanic/Latino respondents, respondents with an annual income <$100 000 and those living with children or others were significantly more likely to be newly at risk for food insecurity. Individuals at risk for food insecurity were 2·60 (95 % CI 1·91, 3·55) times more likely to screen positively for anxiety and 1·71 (95 % CI 1·21, 2·42) times more likely to screen positively for depression. CONCLUSIONS An increased risk for food insecurity during the COVID-19 pandemic is common, and certain populations are particularly vulnerable. There are strong associations between being at risk for food insecurity and anxiety/depression. Interventions to increase access to healthful foods, especially among minority and low-income individuals, and ease the socioemotional effects of the outbreak are crucial to relieving the economic stress of this pandemic.
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Affiliation(s)
- Brianna N Lauren
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, PH9E-105, New York, NY10032, USA
| | - Elisabeth R Silver
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, PH9E-105, New York, NY10032, USA
| | - Adam S Faye
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Alexandra M Rogers
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, PH9E-105, New York, NY10032, USA
| | - Jennifer A Woo-Baidal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake, UT, USA
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, 622 W 168th St, PH9E-105, New York, NY10032, USA
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
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16
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Omidvari AH, Ali A, Hazelton WD, Kroep S, Lee M, Naber SK, Lauren BN, Ostvar S, Richmond E, Kong CY, Rubenstein JH, Lansdorp-Vogelaar I, Luebeck G, Hur C, Inadomi J. Optimizing Management of Patients With Barrett's Esophagus and Low-Grade or No Dysplasia Based on Comparative Modeling. Clin Gastroenterol Hepatol 2020; 18:1961-1969. [PMID: 31816445 PMCID: PMC7447845 DOI: 10.1016/j.cgh.2019.11.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic treatment is recommended for patients with Barrett's esophagus (BE) with high-grade dysplasia, yet clinical management recommendations are inconsistent for patients with BE without dysplasia (NDBE) or with low-grade dysplasia (LGD). We used a comparative modeling analysis to identify optimal management strategies for these patients. METHODS We used 3 independent population-based models to simulate cohorts of 60-year-old individuals with BE in the United States. We followed up each cohort until death without surveillance and treatment (natural disease progression), compared with 78 different strategies of management for patients with NDBE or LGD. We determined the optimal strategy using cost-effectiveness analyses, at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY). RESULTS In the 3 models, the average cumulative incidence of esophageal adenocarcinoma was 111 cases, with costs totaling $5.7 million per 1000 men with BE. Surveillance and treatment of men with BE prevented 23% to 75% of cases of esophageal adenocarcinoma, but increased costs to $6.2 to $17.3 million per 1000 men with BE. The optimal strategy was surveillance every 3 years for men with NDBE and treatment of LGD after confirmation by repeat endoscopy (incremental cost-effectiveness ratio, $53,044/QALY). The average results for women were consistent with the results for men for LGD management, but the optimal surveillance interval for women with NDBE was 5 years (incremental cost-effectiveness ratio, $36,045/QALY). CONCLUSIONS Based on analyses from 3 population-based models, the optimal management strategy for patient with BE and LGD is endoscopic eradication, but only after LGD is confirmed by a repeat endoscopy. The optimal strategy for patients with NDBE is endoscopic surveillance, using a 3-year interval for men and a 5-year interval for women.
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Affiliation(s)
- Amir-Houshang Omidvari
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Ayman Ali
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Tulane University School of Medicine, New Orleans, Louisiana
| | - William D Hazelton
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sonja Kroep
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Minyi Lee
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Steffie K Naber
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Sassan Ostvar
- Irving Medical Center, Columbia University, New York, New York
| | - Ellen Richmond
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
| | - Chun Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Georg Luebeck
- Program in Computational Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Irving Medical Center, Columbia University, New York, New York
| | - John Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
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Ingram M, Lauren BN, Pumpalova YS, Manji GA, Bates SE, Hur C. Cost-effectiveness of neoadjuvant FOLFIRINOX versus gemcitabine plus nab-paclitaxel in locally advanced/borderline resectable pancreatic cancer patients. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e16793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16793 Background: The 2019 NCCN guidelines recommend neoadjuvant FOLFIRINOX or neoadjuvant gemcitabine plus nab-paclitaxel (G-nP) for locally advanced and borderline resectable pancreatic ductal adenocarcinoma (BR/LA PDAC). Neoadjuvant FOLFIRINOX and G-nP have yet to be directly compared in a prospective, randomized trial with BR/LA PDAC patients. The purpose of our study was to incorporate treatment outcomes, toxicity profiles, costs, and quality-of-life measures to further inform clinical decision-making. Methods: We developed a decision-analytic mathematical model to compare the total cost and health outcomes of neoadjuvant FOLFIRINOX against G-nP over twelve years. Adjuvant gemcitabine (GEM) was used as a comparator. The inputs for the model were estimated using clinical trial data and published literature. We used single-institution retrospective studies to estimate our survival data in the absence of a prospective trial. The primary endpoint was incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay (WTP) threshold of $100,000 per quality-adjusted-life-year (QALY). Secondary endpoints included overall (OS) and progression-free survival (PFS), total cost of care (USD), QALYs, patient resection rate, and monthly treatment-related adverse events (TRAE) costs (USD). Results: FOLFIRINOX was the cost-effective strategy, totaling incremental QALYs of 0.21 at a cost of $52,845.96 per QALY when compared to G-nP. G-nP was also on the efficiency frontier with an ICER of $46,430.73 compared to GEM. More patients received resection with FOLFIRINOX (82.15% vs. 72.40%), but had higher TRAE costs than G-nP ($12,051.26 vs. $4,666.97). A one-way sensitivity analysis found that the FOLFIRINOX ICER exceeds the WTP threshold when TRAE costs are higher and resection rates are lower. Conclusions: Our modeling analysis finds FOLFIRNOX is the cost-effective treatment compared to G-nP for BR/LA PDAC despite having a higher cost of total care due to TRAE costs. Trial data with sufficient follow-up are needed to confirm our findings. [Table: see text]
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Affiliation(s)
- Myles Ingram
- Columbia University Medical Center, New York, NY
| | | | | | - Gulam Abbas Manji
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Susan Elaine Bates
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Chin Hur
- Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY
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Lee M, Lauren BN, Zhan T, Choi J, Klebanoff M, Abu Dayyeh B, Taveras EM, Corey K, Kaplan L, Hur C. The cost-effectiveness of pharmacotherapy and lifestyle intervention in the treatment of obesity. Obes Sci Pract 2020; 6:162-170. [PMID: 32313674 PMCID: PMC7156872 DOI: 10.1002/osp4.390] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/29/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Food and Drug Administration has approved several pharmacotherapies for the treatment of obesity. This study assesses the cost-effectiveness of six pharmacotherapies and lifestyle intervention for people with mild obesity (body mass indices [BMIs] 30 to 35). METHODS A microsimulation model was constructed to compare seven weight loss strategies plus no treatment: intensive lifestyle intervention, orlistat, phentermine, phentermine/topiramate, lorcaserin, liraglutide, and semaglutide. Weight loss, quality-of-life scores, and costs were estimated using clinical trials and other published literature. Endpoints included costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay (WTP) threshold of $100 000/QALY. Results were analysed at 1-, 3-, and 5-year time horizons. RESULTS At each of the three follow-up periods, phentermine was the cost-effective strategy, with ICERs of $46 258/QALY, $20 157/QALY, and $17 880/QALY after 1, 3, and 5 years, respectively. Semaglutide was the most effective strategy in the 3- and 5-year time horizons, with total QALYs of 2.224 and 3.711, respectively. However, the ICERs were prohibitively high at $1 437 340/QALY after 3 years and $576 931/QALY after 5 years. Deterministic and probabilistic sensitivity analyses indicated these results were robust. CONCLUSIONS Phentermine is the cost-effective pharmacologic weight-loss strategy. Although semaglutide is the most effective, it is not cost-effective because of its high price.
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Affiliation(s)
- Minyi Lee
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Brianna N. Lauren
- Department of General MedicineColumbia University Irving Medical CenterNew YorkNew York
- Healthcare Innovation Research and EvaluationColumbia University Irving Medical CenterNew YorkNew York
| | - Tiannan Zhan
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Jin Choi
- Department of General MedicineColumbia University Irving Medical CenterNew YorkNew York
- Healthcare Innovation Research and EvaluationColumbia University Irving Medical CenterNew YorkNew York
| | - Matthew Klebanoff
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
- Yale School of MedicineNew HavenConnecticut
| | - Barham Abu Dayyeh
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesota
| | - Elsie M. Taveras
- Department of PediatricsMassachusetts General HospitalBostonMassachusetts
| | - Kathleen Corey
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Harvard Medical SchoolBostonMassachusetts
| | - Lee Kaplan
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Harvard Medical SchoolBostonMassachusetts
| | - Chin Hur
- Department of General MedicineColumbia University Irving Medical CenterNew YorkNew York
- Healthcare Innovation Research and EvaluationColumbia University Irving Medical CenterNew YorkNew York
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