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Staal J, Katarya K, Speelman M, Brand R, Alsma J, Sloane J, Van den Broek WW, Zwaan L. Impact of performance and information feedback on medical interns' confidence-accuracy calibration. Adv Health Sci Educ Theory Pract 2024; 29:129-145. [PMID: 37329493 DOI: 10.1007/s10459-023-10252-9] [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] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/04/2023] [Indexed: 06/19/2023]
Abstract
Diagnostic errors are a major, largely preventable, patient safety concern. Error interventions cannot feasibly be implemented for every patient that is seen. To identify cases at high risk of error, clinicians should have a good calibration between their perceived and actual accuracy. This experiment studied the impact of feedback on medical interns' calibration and diagnostic process. In a two-phase experiment, 125 medical interns from Dutch University Medical Centers were randomized to receive no feedback (control), feedback on their accuracy (performance feedback), or feedback with additional information on why a certain diagnosis was correct (information feedback) on 20 chest X-rays they diagnosed in a feedback phase. A test phase immediately followed this phase and had all interns diagnose an additional 10 X-rays without feedback. Outcome measures were confidence-accuracy calibration, diagnostic accuracy, confidence, and time to diagnose. Both feedback types improved overall confidence-accuracy calibration (R2No Feedback = 0.05, R2Performance Feedback = 0.12, R2Information Feedback = 0.19), in line with the individual improvements in diagnostic accuracy and confidence. We also report secondary analyses to examine how case difficulty affected calibration. Time to diagnose did not differ between conditions. Feedback improved interns' calibration. However, it is unclear whether this improvement reflects better confidence estimates or an improvement in accuracy. Future research should examine more experienced participants and non-visual specialties. Our results suggest that feedback is an effective intervention that could be beneficial as a tool to improve calibration, especially in cases that are not too difficult for learners.
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Affiliation(s)
- J Staal
- Institute of Medical Education Research, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - K Katarya
- Institute of Medical Education Research, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Faculty of Medical Sciences, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M Speelman
- Department of Internal Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - R Brand
- Intensive Care Unit, Haaglanden Medical Center Den Haag, The Hague, The Netherlands
| | - J Alsma
- Department of Internal Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J Sloane
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - W W Van den Broek
- Institute of Medical Education Research, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - L Zwaan
- Institute of Medical Education Research, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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2
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Staal J, Speelman M, Brand R, Alsma J, Zwaan L. Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study. BMC Med Educ 2022; 22:256. [PMID: 35395938 PMCID: PMC8991944 DOI: 10.1186/s12909-022-03325-7] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/29/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Diagnostic errors are a major cause of preventable patient harm. Studies suggest that presenting inaccurate diagnostic suggestions can cause errors in physicians' diagnostic reasoning processes. It is common practice for general practitioners (GPs) to suggest a diagnosis when referring a patient to secondary care. However, it remains unclear via which underlying processes this practice can impact diagnostic performance. This study therefore examined the effect of a diagnostic suggestion in a GP's referral letter to the emergency department on the diagnostic performance of medical interns. METHODS Medical interns diagnosed six clinical cases formatted as GP referral letters in a randomized within-subjects experiment. They diagnosed two referral letters stating a main complaint without a diagnostic suggestion (control), two stating a correct suggestion, and two stating an incorrect suggestion. The referral question and case order were randomized. We analysed the effect of the referral question on interns' diagnostic accuracy, number of differential diagnoses, confidence, and time taken to diagnose. RESULTS Forty-four medical interns participated. Interns considered more diagnoses in their differential without a suggested diagnosis (M = 1.85, SD = 1.09) than with a suggested diagnosis, independent of whether this suggestion was correct (M = 1.52, SD = 0.96, d = 0.32) or incorrect ((M = 1.42, SD = 0.97, d = 0.41), χ2(2) =7.6, p = 0.022). The diagnostic suggestion did not influence diagnostic accuracy (χ2(2) = 1.446, p = 0.486), confidence, (χ2(2) = 0.058, p = 0.971) or time to diagnose (χ2(2) = 3.128, p = 0.209). CONCLUSIONS A diagnostic suggestion in a GPs referral letter did not influence subsequent diagnostic accuracy, confidence, or time to diagnose for medical interns. However, a correct or incorrect suggestion reduced the number of diagnoses considered. It is important for healthcare providers and teachers to be aware of this phenomenon, as fostering a broad differential could support learning. Future research is necessary to examine whether these findings generalize to other healthcare workers, such as more experienced specialists or triage nurses, whose decisions might affect the diagnostic process later on. TRIAL REGISTRATION The study protocol was preregistered and is available online at Open Science Framework ( https://osf.io/7de5g ).
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Affiliation(s)
- J Staal
- Erasmus University Medical Center Rotterdam, Institute of Medical Education Research, Rotterdam, the Netherlands.
| | - M Speelman
- Erasmus University Medical Center Rotterdam, Institute of Medical Education Research, Rotterdam, the Netherlands
- Faculty of Medical Sciences, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - R Brand
- Intensive Care Unit, Haaglanden Medical Center Den Haag, The Hague, the Netherlands
| | - J Alsma
- Department of Internal Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - L Zwaan
- Erasmus University Medical Center Rotterdam, Institute of Medical Education Research, Rotterdam, the Netherlands
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3
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Reed M, Huang J, Brand R, Graetz I, Jaffe MG, Ballard D, Neugebauer R, Fireman B, Hsu J. Inpatient-outpatient shared electronic health records: telemedicine and laboratory follow-up after hospital discharge. Am J Manag Care 2020; 26:e327-e332. [PMID: 33094945 DOI: 10.37765/ajmc.2020.88506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Continuity of patient information across settings can improve transitions after hospital discharge, but outpatient clinicians often have limited access to complete information from recent hospitalizations. We examined whether providers' timely access to clinical information through shared inpatient-outpatient electronic health records (EHRs) was associated with follow-up visits, return emergency department (ED) visits, or readmissions after hospital discharge in patients with diabetes. STUDY DESIGN Stepped-wedge observational study. METHODS As an integrated delivery system staggered implementation of a shared inpatient-outpatient EHR, we studied 241,510 hospital discharges in patients with diabetes (2005-2011), examining rates of outpatient follow-up office visits, telemedicine (phone visits and asynchronous secure messages), laboratory tests, and return ED visits or readmissions (as adverse events). We used multivariate logistic regression adjusting for time trends, patient characteristics, and medical center and accounting for patient clustering to calculate adjusted follow-up rates. RESULTS For patients with diabetes, provider use of a shared inpatient-outpatient EHR was associated with a statistically significant shift toward follow-up delivered through a combination of telemedicine and outpatient laboratory tests, without a traditional in-person visit (from 22.9% with an outpatient-only EHR to 27.0% with a shared inpatient-outpatient EHR; P < .05). We found no statistically significant differences in 30-day return ED visits (odds ratio, 1.02; 95% CI, 0.96-1.09) or readmissions (odds ratio, 0.98; 95% CI, 0.91-1.06) with the shared EHR compared with the outpatient-only EHR. CONCLUSIONS Real-time clinical information availability during transitions between health care settings, along with robust telemedicine access, may shift the method of care delivery without adversely affecting patient health outcomes. Efforts to expand interoperability and information exchange may support follow-up care efficiency.
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Affiliation(s)
- Mary Reed
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612.
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4
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Graetz I, Huang J, Brand R, Hsu J, Reed ME. Mobile-accessible personal health records increase the frequency and timeliness of PHR use for patients with diabetes. J Am Med Inform Assoc 2019; 26:50-54. [PMID: 30358866 DOI: 10.1093/jamia/ocy129] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/12/2018] [Indexed: 11/13/2022] Open
Abstract
Personal health records (PHRs) offer patients a portal to view lab results, communicate with their doctors, and refill medications. Expanding PHR access to mobile devices could increase patients' engagement with their PHRs. We examined whether access to a mobile-optimized PHR changed the frequency and timeliness of PHR use among adult patients with diabetes in an integrated delivery system. Among patients originally using the PHR only by computer, PHR use frequency increased with mobile access. Non-White patients were more likely to view their lab results within 7 days if they had computer and mobile access compared with computer only; however, there were no statistically significant differences among White patients. More frequent and timely mobile access to PHR data and tools may lead to convenient and effective PHR engagement to support patient self-management. Future studies should evaluate whether PHR use with a mobile device is associated with changes in self-management and outcomes.
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Affiliation(s)
- Ilana Graetz
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Richard Brand
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California, USA
| | - John Hsu
- Mongan Institute and Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, California, USA
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5
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Hsu J, Price M, Vogeli C, Brand R, Chernew ME, Chaguturu SK, Weil E, Ferris TG. Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO. Health Aff (Millwood) 2018; 36:876-884. [PMID: 28461355 DOI: 10.1377/hlthaff.2016.0922] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accountable care organizations (ACOs) appear to lower medical spending, but there is little information on how they do so. We examined the impact of patient participation in a Pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations and on Medicare spending. We used data for the period 2009-14, exploiting naturally staggered program entry to create concurrent controls to help isolate the program effects. The care management program (the ACO's primary intervention) targeted beneficiaries with elevated but modifiable risks for future spending. ACO participation had a modest effect on spending, in line with previous estimates. Participation in the care management program was associated with substantial reductions in rates for hospitalizations and both all and nonemergency ED visits, as well as Medicare spending, when compared to preparticipation levels and to rates and spending for a concurrent sample of beneficiaries who were eligible for but had not yet started the program. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent. Targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanisms for altering spending within ACOs.
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Affiliation(s)
- John Hsu
- John Hsu is director of the Clinical Economics and Policy Analysis Program at the Mongan Institute for Health Policy, Massachusetts General Hospital (MGH), which is part of the Partners HealthCare system, and an associate professor in the Department of Medicine and the Department of Health Care Policy at Harvard Medical School, all in Boston, Massachusetts
| | - Mary Price
- Mary Price is a senior consulting data analyst at the Mongan Institute, MGH
| | - Christine Vogeli
- Christine Vogeli is an assistant professor of medicine at MGH and Harvard Medical School and director of evaluation and research at Partners HealthCare's Center for Population Health
| | - Richard Brand
- Richard Brand is a professor emeritus in the Department of Epidemiology and Biostatistics at the University of California, San Francisco
| | - Michael E Chernew
- Michael E. Chernew is a professor in the Department of Health Care Policy at Harvard Medical School
| | - Sreekanth K Chaguturu
- Sreekanth K. Chaguturu is vice president for population health at Partners HealthCare, a staff physician at MGH, and an instructor in medicine at Harvard Medical School
| | - Eric Weil
- Eric Weil is senior medical director for population health, Partners HealthCare; associate medical director of the Massachusetts General Physicians Organization; and associate chief of clinical affairs, Division of General Internal Medicine, MGH
| | - Timothy G Ferris
- Timothy G. Ferris is senior vice president for population health at Partners HealthCare and MGH and an associate professor of medicine at MGH and Harvard Medical School
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6
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van Hemel OJS, Elferink-Stinkens PM, Verloove-Vanhorick SP, Brand R. Comparing Mortality and Morbidity in Hospitals: Theory and Practice of Quality Assessment in Peer Review. Methods Inf Med 2018. [DOI: 10.1055/s-0038-1635006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Abstract:The incidence of mortality in a specific hospital depends on many risk factors. These risk factors may be divided roughly into two categories. The intake category, consists of those risk factors for which the hospital has hardly any influence upon their incidence; and the care category being those for which the incidence depends partly or completely on the treatment policy of the hospital. A hospital with a high incidence of risk factors in the intake category will have a higher mortality rate than a hospital with a low incidence, even if their care is exactly the same (i. e., if they treat their infants equally well). Therefore, a fair comparison between one hospital and a reference cohort, or among several hospitals (using a national registry) should adjust e. g. correct for those risk factors belonging to the intake category. A practical method is proposed, based on logistic regression, to effectuate such a “fair” judgment. The regression technique enables to compare “observed” and “expected” rates in a specific hospital and to test whether a difference between these rates is statistically significant. Both clinical and statistical aspects of the method are discussed, as well as the actual implementation of an automated annual reporting system. The method has been implemented in the Netherlands as an annual peer review and quality assessment system in obstetric care.
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Abstract
This survey study examines the use of patient portals to enhance the ability of family members to participate in communication with health care professionals.
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Affiliation(s)
- Mary E Reed
- Kaiser Permanente Division of Research, Oakland, California
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, California
| | - Richard Brand
- Kaiser Permanente Division of Research, Oakland, California
| | - Dustin Ballard
- Kaiser Permanente San Rafael Medical Group, San Rafael, California
| | - Cyrus Yamin
- Kaiser Permanente Division of Research, Oakland, California.,Kaiser Permanente Oakland Medical Group, Oakland, California
| | - John Hsu
- Mongan Institute for Health Policy, Department of Health Care Policy, Massachusetts General Hospital, Boston.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Richard Grant
- Kaiser Permanente Division of Research, Oakland, California
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8
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Hsu J, Vogeli C, Price M, Brand R, Chernew ME, Mohta N, Chaguturu SK, Weil E, Ferris TG. Substantial Physician Turnover And Beneficiary 'Churn' In A Large Medicare Pioneer ACO. Health Aff (Millwood) 2017; 36:640-648. [PMID: 28373329 DOI: 10.1377/hlthaff.2016.1107] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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] [Indexed: 11/05/2022]
Abstract
Alternative payment models, such as accountable care organizations (ACOs), attempt to stimulate improvements in care delivery by better alignment of payer and provider incentives. However, limited attention has been paid to the physicians who actually deliver the care. In a large Medicare Pioneer ACO, we found that the number of beneficiaries per physician was low (median of seventy beneficiaries per physician, or less than 5 percent of a typical panel). We also found substantial physician turnover: More than half of physicians either joined (41 percent) or left (18 percent) the ACO during the 2012-14 contract period studied. When physicians left the ACO, most of their attributed beneficiaries also left the ACO. Conversely, about half of the growth in the beneficiary population was because of new physicians affiliating with the ACO; the remainder joined after switching physicians. These findings may help explain the muted financial impact ACOs have had overall, and they raise the possibility of future gaming on the part of ACOs to artificially control spending. Policy refinements include coordinated and standardized risk-sharing parameters across payers to prevent any dilution of the payment incentives or confusion from a cacophony of incentives across payers.
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Affiliation(s)
- John Hsu
- John Hsu is director of the Clinical Economics and Policy Analysis Program at the Mongan Institute, Massachusetts General Hospital (MGH), which is a part of the Partners Healthcare system, and an associate professor in the Department of Medicine and in the Department of Health Care Policy at Harvard Medical School, both in Boston
| | | | - Mary Price
- Mary Price is an analyst at the Mongan Institute, MGH
| | - Richard Brand
- Richard Brand is a professor emeritus in the Department of Epidemiology and Biostatistics at the University of California, San Francisco
| | - Michael E Chernew
- Michael E. Chernew is a professor in the Department of Health Care Policy at Harvard Medical School
| | - Namita Mohta
- Namita Mohta is a faculty member at the Center for Healthcare Delivery Sciences and a hospitalist at Brigham and Women's Hospital, which is part of the Partners Healthcare system, both in Boston
| | - Sreekanth K Chaguturu
- Sreekanth K. Chaguturu is vice president for population health at Partners HealthCare; a staff physician at MGH; and an instructor in medicine at Harvard Medical School, all in Boston
| | - Eric Weil
- Eric Weil is senior medical director for population health, Partners HealthCare; associate medical director of the Massachusetts General Physicians Organization; and associate chief of clinical affairs, Division of General Internal Medicine, MGH, all in Boston
| | - Timothy G Ferris
- Timothy G. Ferris is the senior vice president for population health at Partners HealthCare and MGH and an associate professor of Medicine at MGH and Harvard Medical School, all in Boston
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9
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Hsu J, Price M, Spirt J, Vogeli C, Brand R, Chernew ME, Chaguturu SK, Mohta N, Weil E, Ferris T. Patient Population Loss At A Large Pioneer Accountable Care Organization And Implications For Refining The Program. Health Aff (Millwood) 2017; 35:422-30. [PMID: 26953296 DOI: 10.1377/hlthaff.2015.0805] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is an ongoing move toward payment models that hold providers increasingly accountable for the care of their patients. The success of these new models depends in part on the stability of patient populations. We investigated the amount of population turnover in a large Medicare Pioneer accountable care organization (ACO) in the period 2012-14. We found that substantial numbers of beneficiaries became part of or left the ACO population during that period. For example, nearly one-third of beneficiaries who entered in 2012 left before 2014. Some of this turnover reflected that of ACO physicians-that is, beneficiaries whose physicians left the ACO were more likely to leave than those whose physicians remained. Some of the turnover also reflected changes in care delivery. For example, beneficiaries who were active in a care management program were less likely to leave the ACO than similar beneficiaries who had not yet started such a program. We recommend policy changes to increase the stability of ACO beneficiary populations, such as permitting lower cost sharing for care received within an ACO and requiring all beneficiaries to identify their primary care physician before being linked to an ACO.
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Affiliation(s)
- John Hsu
- John Hsu is director of the Clinical Economics and Policy Analysis Program, Mongan Institute, at Massachusetts General Hospital (MGH) and an associate professor in the Department of Medicine and in the Department of Health Care Policy at Harvard Medical School, both in Boston
| | - Mary Price
- Mary Price is an analyst in the Mongan Institute, MGH
| | - Jenna Spirt
- Jenna Spirt is an analyst in the Mongan Institute, MGH
| | - Christine Vogeli
- Christine Vogeli is an assistant professor in the Mongan Institute, MGH
| | - Richard Brand
- Richard Brand is a professor emeritus of biostatistics at the University of California, San Francisco
| | - Michael E Chernew
- Michael E. Chernew is a professor in the Department of Health Care Policy at Harvard Medical School
| | - Sreekanth K Chaguturu
- Sreekanth K. Chaguturu is vice president for Population Health at Partners HealthCare, in Boston; a staff physician at MGH; and an instructor in medicine at Harvard Medical School
| | - Namita Mohta
- Namita Mohta is a faculty member at the Center for Healthcare Delivery Sciences and a hospitalist at Brigham and Women's Hospital, in Boston
| | - Eric Weil
- Eric Weil is the senior medical director for population health, Partners Healthcare; associate medical director of the Massachusetts General Physicians Organization, in Boston; and associate chief of clinical affairs, Division of General Internal Medicine, MGH
| | - Timothy Ferris
- Timothy Ferris is the senior vice president, Population Health, at Partners Healthcare and MGH and an associate professor of Medicine at MGH and Harvard Medical School
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10
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Vogeli C, Spirt J, Brand R, Hsu J, Mohta N, Hong C, Weil E, Ferris TG. Implementing a hybrid approach to select patients for care management: variations across practices. Am J Manag Care 2016; 22:358-365. [PMID: 27266437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Appropriate selection of patients is key to the success of care management programs (CMPs). Hybrid patient selection approaches, in which large data assets are culled to develop a list of patients for more targeted clinical review, are increasingly common. We sought to describe the patient and practice characteristics associated with high-risk patient identification and selection for a CMP during clinical review, and to explore variation across primary care practices. STUDY DESIGN Retrospective cohort study. METHODS Standardized estimates of Medicare beneficiaries identified as high risk for poor outcomes and high medical expense, and appropriate for a CMP within a large Pioneer Accountable Care Organization, were developed using mixed effects logistic models. Study subjects were 2685 Medicare beneficiaries aged over 18 (includes individuals eligible for Medicare due to a disability) aligned to 35 primary care practices in 2013. RESULTS Independent predictors of patient identification as high risk include older age; higher risk score; recent increases in medical conditions; higher numbers of medical hospitalizations, skilled nursing facility days, and primary care physician visits; and shorter relationships with the primary care physician. Older age, and lower income, but no prior hospice use were independently associated with patient selection for a CMP among the subset of patients identified as being high risk. Adjusted predicted percents of high-risk patients varied significantly across practices overall and for 5 of the 6 patient characteristics that were independently associated with identification as high risk. CONCLUSIONS Inconsistency in high-risk patient identification and selection for a CMP may reflect differences in practice resources, but also highlight the need for continual training and feedback in order to protect against unintentional biases.
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Affiliation(s)
- Christine Vogeli
- Mongan Institute for Health Policy, Massachusetts General Hospital, 50 Staniford St, 9th Fl, Boston, MA 02114. E-mail:
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11
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Graetz I, Huang J, Brand R, Shortell SM, Rundall TG, Bellows J, Hsu J, Jaffe M, Reed ME. The impact of electronic health records and teamwork on diabetes care quality. Am J Manag Care 2015; 21:878-884. [PMID: 26671699 PMCID: PMC5130313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Evidence of the impact electronic health records (EHRs) have on clinical outcomes remains mixed. The impact of EHRs likely depends on the organizational context in which they are used. This study focuses on one aspect of the organizational context: cohesion of primary care teams. We examined whether team cohesion among primary care team members changed the association between EHR use and changes in clinical outcomes for patients with diabetes. STUDY DESIGN Retrospective longitudinal study. METHODS We combined provider-reported primary care team cohesion with lab values for patients with diabetes collected during the staggered EHR implementation (2005-2009). We used multivariate regression models with patient-level fixed effects to assess whether team cohesion levels changed the association between outpatient EHR use and clinical outcomes for patients with diabetes. Subjects were comprised of 80,611 patients with diabetes, in whom we measured changes in glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C). RESULTS For A1C, EHR use was associated with an average decrease of 0.11% for patients with higher-cohesion primary care teams compared with a decrease of 0.08% for patients with lower-cohesion teams (difference = 0.02% in A1C; 95% CI, 0.01%-0.03%). For LDL-C, EHR use was associated with a decrease of 2.15 mg/dL for patients with higher-cohesion primary care teams compared with a decrease of 1.42 mg/dL for patients with lower-cohesion teams (difference = 0.73 mg/dL; 95% CI, 0.41-1.11 mg/dL). CONCLUSIONS Patients cared for by higher cohesion primary care teams experienced modest but statistically significantly greater EHR-related health outcome improvements, compared with patients cared for by providers practicing in lower cohesion teams.
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Affiliation(s)
- Ilana Graetz
- University of Tennessee Health Science Center, 66 N Pauline St, Ste 633, Memphis, TN 38163. E-mail:
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12
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Brand R, Erdos G, Epperly M, Dixon T, Franicola D, Falo L, Wipf P, Greenberger J. Effective Topical Delivery of Radiomitigator GS-Nitroxide (JP4-039) by Microneedle Arrays. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.1934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Mertens BJ, Datta S, Brand R, Peul W. Causal effect estimation strategies in a longitudinal study with complex time-varying confounders: A tutorial. Stat Methods Med Res 2014; 26:337-355. [PMID: 25147227 DOI: 10.1177/0962280214545529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Dutch Sciatica Trial represents a longitudinal study with complex time-varying confounders as patients with poorer health conditions (e.g. more severe pain) are more likely to opt for surgery, which, in turn, may affect future outcomes (pain severity). A straightforward classical as-treated comparison at the end point would lead to biased estimation of the surgery effect. We present several strategies of causal treatment effect estimation that might be applicable for analyzing such data. These include an inverse probability of treatment weighted regression analysis, a marginal weighted analysis, an unweighted regression analysis, and several propensity score-based approaches. In addition, we demonstrate how to evaluate these approaches in a thorough simulation study where we generate various realistic complex confounding patterns akin to the sciatica study.
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Affiliation(s)
- Bart Ja Mertens
- 1 Department of Medical Statistics, Leiden University Medical Center, RC Leiden, The Netherlands
| | - S Datta
- 3 Department of Neurosurgery, Leiden University Medical Center, RC Leiden, The Netherlands
| | - R Brand
- 1 Department of Medical Statistics, Leiden University Medical Center, RC Leiden, The Netherlands
| | - W Peul
- 2 Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY 40292, USA
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14
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Abstract
OBJECTIVE There is limited information on the protective value of Medicare Part D low-income subsidies (LIS). We compared responses to drug costs for LIS recipients with near-poor (≤200 percent of the Federal Poverty Level) and higher income beneficiaries without the LIS. DATA SOURCES/STUDY SETTING Medicare Advantage beneficiaries in 2008. STUDY DESIGN We examined three drug cost responses using multivariate logistic regression: cost-reducing behaviors (e.g., switching to generics), nonadherence (e.g., not refilling prescriptions), and financial stress (e.g., going without necessities). DATA COLLECTION Telephone interviews in a stratified random sample (N = 1,201, 70 percent response rate). PRINCIPAL FINDINGS After adjustment, a comparable percentage of unsubsidized near-poor (26 percent) and higher income beneficiaries reported cost-reducing behaviors (23 percent, p = .63); fewer LIS beneficiaries reported cost-reducing behaviors (15 percent, p = .019 vs near-poor). Unsubsidized near-poor beneficiaries were more likely to reduce adherence (8.2 percent) than higher income (3.5 percent, p = .049) and LIS beneficiaries (3.1 percent, p = .027). Near-poor beneficiaries also more frequently experienced financial stress due to drug costs (20 percent) than higher income beneficiaries (11 percent, p = .050) and LIS beneficiaries (11 percent, p = .015). CONCLUSIONS Low-income subsidies provide protection from drug cost-related nonadherence and financial stress. Beneficiaries just above the LIS income threshold are most at risk for these potentially adverse behaviors.
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Affiliation(s)
- Vicki Fung
- Mongan Institute for Health Policy, Massachusetts General Hospital50 Staniford St, 9th floor, Suite 901, Boston, MA, 02114
| | - Mary Reed
- Division of Research, Kaiser PermanenteOakland, CA
| | - Mary Price
- Division of Research, Kaiser PermanenteOakland, CA
| | - Richard Brand
- Department of Epidemiology and Biostatistics, University of California, San FranciscoSan Francisco, CA
| | - William H Dow
- School of Public Health, U.C. Berkeley, University of CaliforniaBerkeley, CA
| | | | - John Hsu
- Mongan Institute for Health Policy, MGH and HMSBoston, MA
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Fairbrother P, McCloughan L, Adam G, Brand R, Brown C, Watson M, Cotter N, Mackellaig J, McKinstry B. Involving patients in clinical research: the Telescot Patient Panel. Health Expect 2013; 19:691-701. [PMID: 24112277 DOI: 10.1111/hex.12132] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To date, patient involvement in the development of clinical research work has been limited. In 2011, the Telescot research team commenced work on a feasibility trial to investigate home telemonitoring of blood pressure for people who have experienced stroke or transient ischaemic attack (TIA). The team decided to involve patients in the development of the research. OBJECTIVES To improve research design through patient involvement. METHOD OF PATIENT INVOLVEMENT A modified form of the 'Scrutiny Panel' approach was used to involve people who had stroke in the research project. RESULTS The Patient Panel supported the research in three key ways: it informed patient communication; it presented patient perspectives on the applicability and usability of the intervention; and it guided the development of the qualitative study. DISCUSSION The initiative was considered a positive experience for all. However, challenges were identified in terms of the time and cost implications of undertaking patient involvement. IMPLICATION FOR RESEARCH PRACTICE Importance is attached to adequate project planning and development, partnership working with community-based organizations and the necessity for clear role delineation between patients and professionals to enable effective collaborative working. CONCLUSIONS The Telescot Patient Panel was beneficial in supporting the development of the feasibility trial. The Panel approach was considered transferable to other clinical research contexts.
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Affiliation(s)
- Peter Fairbrother
- E-Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Lucy McCloughan
- E-Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Geraldine Adam
- E-Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Richard Brand
- E-Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Cecil Brown
- E-Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Mary Watson
- E-Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Brian McKinstry
- E-Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Reed M, Huang J, Brand R, Graetz I, Neugebauer R, Fireman B, Jaffe M, Ballard DW, Hsu J. Implementation of an outpatient electronic health record and emergency department visits, hospitalizations, and office visits among patients with diabetes. JAMA 2013; 310:1060-5. [PMID: 24026601 PMCID: PMC4503235 DOI: 10.1001/jama.2013.276733] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
IMPORTANCE The US federal government is spending billions of dollars in physician incentives to encourage the meaningful use of electronic health records (EHRs). Although the use of EHRs has potential to improve patient health outcomes, the existing evidence has been limited and inconsistent. OBJECTIVE To examine the association between implementing a commercially available outpatient EHR and emergency department (ED) visits, hospitalizations, and office visits for patients with diabetes mellitus. DESIGN, SETTING, AND POPULATION Staggered EHR implementation across outpatient clinics in an integrated delivery system (Kaiser Permanente Northern California) between 2005 and 2008 created an opportunity for studying changes associated with EHR use. Among a population-based sample of 169,711 patients with diabetes between 2004 and 2009, we analyzed 4,997,585 person-months before EHR implementation and 4,648,572 person-months after an EHR was being used by patients' physicians. MAIN OUTCOMES AND MEASURES We examined the association between EHR use and unfavorable clinical events (ED visits and hospitalizations) and office visit use among patients with diabetes, using multivariable regression with patient-level fixed-effect analyses and adjustment for trends over time. RESULTS In multivariable analyses, use of the EHR was associated with a statistically significantly decreased number of ED visits, 28.80 fewer visits per 1000 patients annually (95% CI, 20.28 to 37.32), from a mean of 519.12 visits per 1000 patients annually without using the EHR to 490.32 per 1000 patients when using the EHR. The EHR was also associated with 13.10 fewer hospitalizations per 1000 patients annually (95% CI, 7.37 to 18.82), from a mean of 251.60 hospitalizations per 1000 patients annually with no EHR to 238.50 per 1000 patients annually when using the EHR. There were similar statistically significant reductions in nonelective hospitalizations (10.92 fewer per 1000 patients annually) and hospitalizations for ambulatory care-sensitive conditions (7.08 fewer per 1000 patients annually). There was no statistically significant association between EHR use and office visit rates. CONCLUSIONS AND RELEVANCE Among patients with diabetes, use of an outpatient EHR in an integrated delivery system was associated with modest reductions in ED visits and hospitalizations but not office visit rates. Further studies are needed to quantify the association of EHR use with changes in costs.
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Affiliation(s)
- Mary Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, California 94610, USA.
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Reed M, Huang J, Graetz I, Brand R, Hsu J, Fireman B, Jaffe M. Outpatient electronic health records and the clinical care and outcomes of patients with diabetes mellitus. Ann Intern Med 2012; 157:482-9. [PMID: 23027319 PMCID: PMC3603566 DOI: 10.7326/0003-4819-157-7-201210020-00004] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Physicians can receive federal payments for meaningful use of complete certified electronic health records (EHRs). Evidence is limited on how EHR use affects clinical care and outcomes. OBJECTIVE To examine the association between use of a commercially available certified EHR and clinical care processes and disease control in patients with diabetes. DESIGN Quasi-experimental design with outpatient EHR implementation sequentially across 17 medical centers. Multivariate analyses adjusted for patient characteristics, medical center, time trends, and facility-level clustering. SETTING Kaiser Permanente Northern California, an integrated delivery system. PATIENTS 169 711 patients with diabetes mellitus. INTERVENTION Use of a commercially available certified EHR. MEASUREMENTS Drug treatment intensification and hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein cholesterol (LDL-C) testing and values. RESULTS Use of an EHR was associated with statistically significant improvements in treatment intensification after HbA(1c) values of 9% or greater (odds ratio, 1.10 [95% CI, 1.05 to 1.15]) or LDL-C values of 2.6 to 3.3 mmol/L (100 to 129 mg/dL) (odds ratio, 1.06 [CI, 1.00 to 1.12]); increases in 1-year retesting for HbA(1c) and LDL-C levels among all patients, with the most dramatic change among patients with the worst disease control (HbA(1c) levels ≥9% or LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]); and decreased 90-day retesting among patients with HbA(1c) levels less than 7% or LDL-C levels less than 2.6 mmol/L (<100 mg/dL). The EHR was also associated with statistically significant reductions in HbA(1c) and LDL-C levels, with the largest reductions among patients with the worst control (0.06-mmol/L [2.19-mg/dL] reduction among patients with baseline LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]; P < 0.001). LIMITATION The EHR was implemented in a setting with strong baseline performance on cardiovascular care quality measures. CONCLUSION Use of a commercially available certified EHR was associated with improved drug treatment intensification, monitoring, and physiologic control among patients with diabetes, with greater improvements among patients with worse control and less testing in patients already meeting guideline-recommended glycemic and lipid targets. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Mary Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA.
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de Witte PB, Brand R, Vermeer HGW, van der Heide HJL, Barnaart AFW. Mid-term results of total hip arthroplasty with the CementLess Spotorno (CLS) system. J Bone Joint Surg Am 2011; 93:1249-55. [PMID: 21776579 DOI: 10.2106/jbjs.i.01792] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Except for those reported by the designers, there are no published mid-term results of the use of the CementLess Spotorno (CLS) Total Hip Arthroplasty system. We present the results of (1) a ten to seventeen-year follow-up prospective cohort study of this system, and (2) retrospective analyses of factors influencing clinical and radiographic outcomes. METHODS We studied a series of 102 consecutive CLS arthroplasties with a minimal duration of follow-up of ten years. Indications for the procedures were osteoarthritis (n = 90), rheumatoid arthritis (n = 8), and femoral head osteonecrosis (n = 4). The Merle d'Aubigné-Postel score, polyethylene wear, and radiographic status were recorded at regular intervals. Survival analyses, repeated-measures analysis of variance, and a nested case-control study (with the cases having early revision due to aseptic cup loosening within ten years after the index procedure and the controls having no early cup revision) were used for evaluation. RESULTS There were fourteen revisions, including nine due to aseptic cup loosening. The ten-year Kaplan-Meier survival rate was 92.2% (95% confidence interval [CI] = 86.9 to 97.5) with revision for any reason as the end point. The fifteen-year survival rate was 78.4% (95% CI = 63.9 to 92.9) with revision for any reason as the end point, 81.6% (95% CI = 66.7 to 96.5) with revision due to aseptic cup loosening as the end point, and 99.0% (95% CI = 97.0 to 100.0) with revision due to aseptic stem loosening as the end point. The average amount of polyethylene wear at the time of final follow-up was 1.92 mm (range, 0.6 to 4.3 mm). The wear rate in the cases was significantly higher than that in the controls (0.31 vs. 0.16 mm/yr, p < 0.001). Factors with a significant effect on polyethylene wear were age at surgery (a 0.3-mm increase per every ten years younger, p = 0.001) and a larger head component (an effect of 0.53 mm for the 32 vs. the 28-mm component; p < 0.0001). Male sex had an effect of -0.66 point (p = 0.07) on the final Merle d'Aubigné-Postel score. CONCLUSIONS The results of this CLS system, particularly with regard to the femoral stem, are comparable with those with other reliable cementless systems. Nevertheless, the prevalence of aseptic acetabular cup loosening in the second decade after the operation demonstrates a potentially substantial problem with regard to long-term survival. A high polyethylene wear rate, male sex, a younger age at the time of surgery, and a 32-mm head component size are related to inferior clinical outcomes and a higher risk of implant revision.
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Affiliation(s)
- P B de Witte
- Meander Medical Center, Amersfoort, The Netherlands.
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Jonker JT, Wijngaarden MA, Kloek J, Groeneveld Y, Gerhardt C, Brand R, Kies AK, Romijn JA, Smit JWA. Effects of low doses of casein hydrolysate on post-challenge glucose and insulin levels. Eur J Intern Med 2011; 22:245-8. [PMID: 21570642 DOI: 10.1016/j.ejim.2010.12.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 11/26/2010] [Accepted: 12/30/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ingestion of high doses of casein hydrolysate stimulates insulin secretion in healthy subjects and patients with type 2 diabetes. The effects of low doses have not been studied. The aim of this study was to assess the effect of lower doses of a casein hydrolysate on the glucose and insulin responses to an oral glucose tolerance test in patients with type 2 diabetes. METHODS In this randomized, placebo-controlled, double-blind study, thirteen patients with type 2 diabetes (age: 58±1 years) were studied. Glucose, insulin and C-peptide responses were determined after the oral administration of 0 (control), 6 or 12 g protein hydrolysate in combination with 50 g carbohydrate. RESULTS Twelve grams of casein hydrolysate, but not 6g, elevated insulin levels and decreased glucose levels post-challenge. These changes over time were not large enough to also affect the total area under the curve of glucose and insulin. C-peptide levels did not change after both treatments. CONCLUSION Ingestion of six grams of casein hydrolysate did not affect glucose or insulin responses. Intake of 12 g of casein hydrolysate has a small positive effect on post-challenge insulin and glucose levels in patients with type 2 diabetes.
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Affiliation(s)
- J T Jonker
- Department of Endocrinology and Metabolism, Leiden University Medical Center, PO box 9600, 2300RC, Leiden, The Netherlands.
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Reed M, Fung V, Price M, Brand R, Benedetti N, Derose SF, Newhouse JP, Hsu J. High-deductible health insurance plans: efforts to sharpen a blunt instrument. Health Aff (Millwood) 2011; 28:1145-54. [PMID: 19597214 DOI: 10.1377/hlthaff.28.4.1145] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High deductible-based health insurance plans require consumers to pay for care until reaching the deductible amount. However, information is limited on how well consumers understand their benefits and how they respond to these costs. In telephone interviews, we found that consumers had limited knowledge about their deductibles yet frequently reported changing their care-seeking behavior because of the cost. Poor knowledge limited the effects of the deductible design, with some consumers avoiding care for services that were exempt from the deductible. Consumers need more information and decision support to understand their benefits and to differentiate when care is necessary, discretionary, or unnecessary.
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Affiliation(s)
- Mary Reed
- Division of Research, Kaiser Permanente, Oakland, California, USA.
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Hsu J, Fung V, Huang J, Price M, Brand R, Hui R, Fireman B, Dow WH, Bertko J, Newhouse JP. Fixing flaws in Medicare drug coverage that prompt insurers to avoid low-income patients. Health Aff (Millwood) 2010; 29:2335-43. [PMID: 21030394 DOI: 10.1377/hlthaff.2009.0323] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since 2006 numerous insurers have stopped serving the low-income segment of the Medicare Part D program, forcing millions of beneficiaries to change prescription drug plans. Using data from participating plans, we found that Medicare payments do not sufficiently reimburse insurers for the relatively high medication use among this population, creating perverse incentives for plans to avoid this part of the Part D market. Plans can accomplish this by increasing their premiums for all beneficiaries to an amount above regional benchmarks. We demonstrate that improving the accuracy of Medicare's risk and subsidy adjustments could mitigate these perverse incentives.
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Affiliation(s)
- John Hsu
- Clinical Economics and Policy Analysis program, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, USA.
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Michallet M, Sobh M, Milligan D, Morisset S, Niederwieser D, Koza V, Ruutu T, Russell NH, Verdonck L, Dhedin N, Vitek A, Boogaerts M, Vindelov L, Finke J, Dubois V, van Biezen A, Brand R, de Witte T, Dreger P. The impact of HLA matching on long-term transplant outcome after allogeneic hematopoietic stem cell transplantation for CLL: a retrospective study from the EBMT registry. Leukemia 2010; 24:1725-31. [PMID: 20703257 DOI: 10.1038/leu.2010.165] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We analyzed 368 chronic lymphocytic leukemia patients who underwent allogeneic hematopoietic stem cell transplantation reported to the EBMT registry between 1995 and 2007. There were 198 human leukocyte antigen (HLA)-identical siblings; among unrelated transplants, 31 were well matched in high resolution ('well matched' unrelated donor, WMUD), and 139 were mismatched (MM), including 30 matched in low resolution; 266 patients (72%) received reduced-intensity conditioning and 102 (28%) received standard. According to the EBMT risk score, 11% were in scores 1-3, 23% in score 4, 40% in score 5, 22% in score 6 and 4% in score 7. There was no difference in overall survival (OS) at 5 years between HLA-identical siblings (55% (48-64)) and WMUD (59% (41-84)), P=0.82. In contrast, OS was significantly worse for MM (37% (29-48) P=0.005) due to a significant excess of transplant-related mortality. Also OS worsened significantly when EBMT risk score increased. HLA matching had no significant impact on relapse (siblings: 24% (21-27); WMUD: 35% (26-44), P=0.11 and MM: 21% (18-24), P=0.81); alemtuzumab T-cell depletion and stem cell source (peripheral blood) were associated with an increased risk. Our findings support the use of WMUD as equivalent alternative to HLA-matched sibling donors for allogeneic HSCT in CLL, and justify the application of EBMT risk score in this disease.
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Affiliation(s)
- M Michallet
- Department of Hematology, Edouard Herriot Hospital, Lyon, France.
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Krause N, Brand R, Kaplan G, Kurl S, Kauhanen J. MS521 SITTING, STANDING, WALKING OR CLIMBING STAIRS AT WORK AND 11-YEAR PROGRESSION OF CAROTID ATHEROSCLEROSIS IN MEN WITH AND WITHOUT CVD. ATHEROSCLEROSIS SUPP 2010. [DOI: 10.1016/s1567-5688(10)71021-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mutis T, Brand R, Gallardo D, van Biezen A, Niederwieser D, Goulmy E. Graft-versus-host driven graft-versus-leukemia effect of minor histocompatibility antigen HA-1 in chronic myeloid leukemia patients. Leukemia 2010; 24:1388-92. [PMID: 20508613 DOI: 10.1038/leu.2010.115] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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So-Osman C, Nelissen R, Te Slaa R, Coene L, Brand R, Brand A. A randomized comparison of transfusion triggers in elective orthopaedic surgery using leucocyte-depleted red blood cells. Vox Sang 2010; 98:56-64. [DOI: 10.1111/j.1423-0410.2009.01225.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ballard DW, Price M, Fung V, Brand R, Reed ME, Fireman B, Newhouse JP, Selby JV, Hsu J. Validation of an algorithm for categorizing the severity of hospital emergency department visits. Med Care 2010; 48:58-63. [PMID: 19952803 PMCID: PMC3881233 DOI: 10.1097/mlr.0b013e3181bd49ad] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED) visit severity algorithm attempts to classify visits to the ED based on diagnosis, but it has not been formally validated. OBJECTIVE To assess the validity of the NYU algorithm. RESEARCH DESIGN A longitudinal study in a single integrated delivery system from January 1999 to December 2001. SUBJECTS A total of 2,257,445 commercial and 261,091 Medicare members of an integrated delivery system. MEASURES ED visits were classified as emergent, nonemergent, or intermediate severity, using the NYU ED algorithm. We examined the relationship between visit-severity and the probability of future hospitalizations and death using a logistic model with a general estimating equation approach. RESULTS Among commercially insured subjects, ED visits categorized as emergent were significantly more likely to result in a hospitalization within 1-day (odds ratio = 3.37, 95% CI: 3.31-3.44) or death within 30-days (odds ratio = 2.81, 95% CI: 2.62-3.00) than visits categorized as nonemergent. We found similar results in Medicare patients and in sensitivity analyses using different probability thresholds. ED overuse for nonemergent conditions was not related to socio-economic status or insurance type. CONCLUSIONS The evidence presented supports the validity of the NYU ED visit severity algorithm for differentiating ED visits based on need for hospitalization and/or mortality risk; therefore, it can contribute to evidence-based policies aimed at reducing the use of the ED for nonemergencies.
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Affiliation(s)
- Dustin W Ballard
- Emergency Department, Kaiser Permanente San Rafael, San Rafael, CA 94903, USA.
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Reed M, Benedetti N, Brand R, Newhouse JP, Hsu J. Perspectives from deductible plan enrollees: plan knowledge and anticipated care-seeking changes. BMC Health Serv Res 2009; 9:244. [PMID: 20040076 PMCID: PMC2811111 DOI: 10.1186/1472-6963-9-244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 12/29/2009] [Indexed: 11/10/2022] Open
Abstract
Background Consumer directed health care proposes that patients will engage as informed consumers of health care services by sharing in more of their medical costs, often through deductibles. We examined knowledge of deductible plan details among new enrollees, as well as anticipated care-seeking changes in response to the deductible. Methods In a large integrated delivery system with a range of deductible-based health plans which varied in services included or exempted from deductible, we conducted a mixed-method, cross-sectional telephone interview study. Results Among 458 adults newly enrolled in a deductible plan (71% response rate), 51% knew they had a deductible, 26% knew the deductible amount, and 6% knew which medical services were included or exempted from their deductible. After adjusting for respondent characteristics, those with more deductible-applicable services and those with lower self-reported health status were significantly more likely to know they had a deductible. Among those who knew of their deductible, half anticipated that it would cause them to delay or avoid medical care, including avoiding doctor's office visits and medical tests, even services that they believed were medically necessary. Many expressed concern about their costs, anticipating the inability to afford care and expressing the desire to change plans. Conclusion Early in their experience with a deductible, patients had limited awareness of the deductible and little knowledge of the details. Many who knew of the deductible reported that it would cause them to delay or avoid seeking care and were concerned about their healthcare costs.
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Affiliation(s)
- Mary Reed
- Division of Research, Center for Health Policy Studies, Oakland, California 94612, USA.
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Graetz I, Reed M, Rundall T, Bellows J, Brand R, Hsu J. Care coordination and electronic health records: connecting clinicians. AMIA Annu Symp Proc 2009; 2009:208-12. [PMID: 20351851 PMCID: PMC2815429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To examine the association between use of electronic health records (EHR) and care coordination. STUDY DESIGN Two surveys, in 2005 and again in 2006, of primary care clinicians working in a prepaid integrated delivery system during the staggered implementation of an EHR system. Using multivariate logistic regression to adjust for clinician characteristics, we examined the association between EHR use and clinicians' perceptions of three dimensions of care coordination: timely access to complete information; treatment goal agreement; and role/responsibility agreement. RESULTS Compared to clinicians without EHR, clinicians with 6+ months of EHR use more frequently reported timely access to complete information, and being in agreement on treatment goals with other involved clinicians. There was no significant association between EHR use and being in agreement on roles and responsibilities with other clinicians. CONCLUSIONS EHR use is associated with aspects of care coordination involving information transfer and communication of treatment goals.
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Affiliation(s)
- Ilana Graetz
- Center for Health Policy Studies, Division of Research, Kaiser Permanente Medical Care Program, Oakland, California, USA
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Affiliation(s)
- P. Lunkenheimer
- a Experimentalphysik V , Universität Augsburg , D-86135, Augsburg , Germany
| | - R. Brand
- a Experimentalphysik V , Universität Augsburg , D-86135, Augsburg , Germany
| | - U. Schneider
- a Experimentalphysik V , Universität Augsburg , D-86135, Augsburg , Germany
| | - A. Loidl
- a Experimentalphysik V , Universität Augsburg , D-86135, Augsburg , Germany
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Bardach NS, Huang J, Brand R, Hsu J. Evolving health information technology and the timely availability of visit diagnoses from ambulatory visits: a natural experiment in an integrated delivery system. BMC Med Inform Decis Mak 2009; 9:35. [PMID: 19615081 PMCID: PMC2731742 DOI: 10.1186/1472-6947-9-35] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Accepted: 07/17/2009] [Indexed: 12/05/2022] Open
Abstract
Background Health information technology (HIT) may improve health care quality and outcomes, in part by making information available in a timelier manner. However, there are few studies documenting the changes in timely availability of data with the use of a sophisticated electronic medical record (EMR), nor a description of how the timely availability of data might differ with different types of EMRs. We hypothesized that timely availability of data would improve with use of increasingly sophisticated forms of HIT. Methods We used an historical observation design (2004–2006) using electronic data from office visits in an integrated delivery system with three types of HIT: Basic, Intermediate, and Advanced. We calculated the monthly percentage of visits using the various types of HIT for entry of visit diagnoses into the delivery system's electronic database, and the time between the visit and the availability of the visit diagnoses in the database. Results In January 2004, when only Basic HIT was available, 10% of office visits had diagnoses entered on the same day as the visit and 90% within a week; 85% of office visits used paper forms for recording visit diagnoses, 16% used Basic at that time. By December 2006, 95% of all office visits had diagnoses available on the same day as the visit, when 98% of office visits used some form of HIT for entry of visit diagnoses (Advanced HIT for 67% of visits). Conclusion Use of HIT systems is associated with dramatic increases in the timely availability of diagnostic information, though the effects may vary by sophistication of HIT system. Timely clinical data are critical for real-time population surveillance, and valuable for routine clinical care.
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Affiliation(s)
- Naomi S Bardach
- Department of General Pediatrics, University of California, San Francisco, 3333 California St, Suite 245, San Francisco, CA 94118, USA.
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Abstract
OBJECTIVE To provide estimates of patient outcomes following shoulder arthroplasty using Neer-II type humeral prosthesis and to examine variation in outcomes due to patient and prosthesis characteristics. METHODS North American and Western European published articles were identified through a computerized literature search and bibliography review. Studies were included if they enrolled 15 or more patients, discriminated between hemi-arthroplasty (HEMI) and total shoulder arthroplasty (TSA) and measured pain relief, gain in range of motion (ROM), radiographic follow-up (> 2 years), short- and long-term complications, and revision surgery. RESULTS A total of 40 studies satisfied the inclusion criteria. The total number of patients enrolled was 3584. The mean follow-up was 59 months. The mean patient age was 62 years, 65% of patients were women and 73% underwent TSA. All reports showed relevant pain relief, increase in ROM, and high satisfaction rates for HEMI and TSA in both osteoarthritis (OA) and rheumatoid arthritis (RA). The overall rate of revision was 8%. Significant differences between HEMI and TSA for both diagnoses were found for all outcome parameters. CONCLUSION Shoulder arthroplasty is a safe and effective procedure for OA and RA patients. The diagnosis, shoulder pathology, and prosthesis specifics were significant predictors of outcomes. We therefore emphasize that conclusions on the outcome of shoulder arthroplasty can only be made if differentiated between these patient and prosthesis specifics. Limitations in the reporting style of these articles severely constrain the ability to explore variation in outcomes due to study, patient, or prosthesis characteristics and restrict their generalisability.
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Affiliation(s)
- M A J van de Sande
- Departments of Orthopaedics, University of Leiden, Leiden, The Netherlands.
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Hsu J, Huang J, Fung V, Price M, Brand R, Hui R, Fireman B, Dow W, Bertko J, Newhouse JP. Distributing $800 billion: an early assessment of Medicare Part D risk adjustment. Health Aff (Millwood) 2009; 28:215-25. [PMID: 19124873 DOI: 10.1377/hlthaff.28.1.215] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The viability and stability of the Medicare Part D prescription drug program depend on accurate risk-adjusted payments. The current approach, prescription drug hierarchical condition categories (RxHCCs), uses diagnosis and demographic information to predict future drug costs. We evaluated the performance of multiple approaches for predicting 2006 Part D drug costs and plan liability. RxHCCs explain 12 percent of the variation in actual drug costs, overpredict costs for beneficiaries with low actual costs, and underpredict costs for beneficiaries with high actual costs. Combining RxHCCs with individual-level information on prior-year drug use greatly improves performance and decreases incentives for plans to select against bad risks.
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Affiliation(s)
- John Hsu
- Center for Health Policy Studies and Division of Research, Kaiser Permanente Medical Care Program, Oakland, California, USA.
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Henkus HE, de Witte PB, Nelissen RGHH, Brand R, van Arkel ERA. Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study. ACTA ACUST UNITED AC 2009; 91:504-10. [PMID: 19336812 DOI: 10.1302/0301-620x.91b4.21442] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In a prospective randomised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty. A total of 57 patients with a mean age of 47 years (31 to 60) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial. The type of acromion was classified according to Bigliani. Patients were assessed at follow-up using the Constant score, the simple shoulder test and visual analogue scores for pain and functional impairment. One patient was lost to follow-up. At a mean follow-up of 2.5 years (1 to 5) both bursectomy and acromioplasty gave good clinical results. No statistically significant differences were found between the two treatments. The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment. As a result, we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder.
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Affiliation(s)
- H E Henkus
- Department of Orthopaedics, Haga ziekenhuis, lokatie RKZ, Sportlaan 600, 2566MJ, The Hague, The Netherlands.
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Michallet M, Le Q, Dreger P, Sobh M, Niederwieser D, Koza V, Ruutu T, Russel N, Verdonck L, Milligan D, Dhedin N, Kozak T, Boogaerts M, Finke J, Van Biezen A, Brand R, De Witte T. Standard and Reduced Intensity Allogeneic Hematopoietic Stem Cell Transplantations (HSCT) From Related and Unrelated Donors for Chronic Lymphocytic Leukemia (CLL). A Long-Term Follow-Up (10 Years) Study From the EBMT Registry. Biol Blood Marrow Transplant 2009. [DOI: 10.1016/j.bbmt.2008.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gorschinski A, Khelashvili G, Schild D, Habicht W, Brand R, Ghafari M, Bönnemann H, Dinjus E, Behrens S. A simple aminoalkyl siloxane-mediated route to functional magnetic metal nanoparticles and magnetic nanocomposites. ACTA ACUST UNITED AC 2009. [DOI: 10.1039/b911738e] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Stern M, Brand R, de Witte T, Sureda A, Rocha V, Passweg J, Baldomero H, Niederwieser D, Gratwohl A. Female-versus-male alloreactivity as a model for minor histocompatibility antigens in hematopoietic stem cell transplantation. Am J Transplant 2008; 8:2149-57. [PMID: 18828773 DOI: 10.1111/j.1600-6143.2008.02374.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
H-Y encoded gene products were the first to be recognized as clinically relevant minor histocompatibility antigens. Compared to other gender combinations, female donor/male recipient (FDMR) transplants are associated with increased graft-versus-host disease (GvHD), increased transplant-related mortality (TRM) and reduced risk of relapse. Still, their relative impact on transplant outcome remains controversial. We analyzed donor/recipient sex combination in 53,988 patients treated with allogeneic hematopoietic stem cell transplantation (HSCT) between 1980 and 2005. We found a strong increase in chronic GvHD and late TRM and decreased survival in FDMR transplants irrespective of underlying disease. Conversely, FDMR patients had lower relapse rates. The negative effect on survival decreased with advancing disease stage as relapse protection became more important. Effects of H-Y alloreactivity were most pronounced in patients transplanted from HLA-matched donors and in those receiving transplants from an adult donor. Adjustment for acute and chronic GvHD only partially corrected the effects of H-Y alloreactivity. Analysis of the FDMR proportion over time indicated that the frequency of this gender combination has declined in unrelated transplants over the last 10 years. These data define the role of H-Y mismatching in allogeneic HSCT and support the current practice of avoiding female donors for male patients, if possible.
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Affiliation(s)
- M Stern
- Department of Hematology, University Hospital, Basel, Switzerland.
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Fung V, Tager IB, Brand R, Newhouse JP, Hsu J. The impact of generic-only drug benefits on patients' use of inhaled corticosteroids in a Medicare population with asthma. BMC Health Serv Res 2008; 8:151. [PMID: 18638405 PMCID: PMC2488344 DOI: 10.1186/1472-6963-8-151] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 07/18/2008] [Indexed: 11/10/2022] Open
Abstract
Background Patients face increasing insurance restrictions on prescription drugs, including generic-only coverage. There are no generic inhaled corticosteroids (ICS), which are a mainstay of asthma therapy, and patients pay the full price for these drugs under generic-only policies. We examined changes in ICS use following the introduction of generic-only coverage in a Medicare Advantage population from 2003–2004. Methods Subjects were age 65+, with asthma, prior ICS use, and no chronic obstructive pulmonary disorder (n = 1,802). In 2004, 74.0% switched from having a $30 brand-copayment plan to a generic-only coverage plan (restricted coverage); 26% had $15–25 brand copayments in 2003–2004 (unrestricted coverage). Using linear difference-in-difference models, we examined annual changes in ICS use (measured by days-of-supply dispensed). There was a lower-cost ICS available within the study setting and we also examined changes in drug choice (higher- vs. lower-cost ICS). In multivariable models we adjusted for socio-demographic, clinical, and asthma characteristics. Results In 2003 subjects had an average of 188 days of ICS supply. Restricted compared with unrestricted coverage was associated with reductions in ICS use from 2003–2004 (-15.5 days-of-supply, 95% confidence interval (CI): -25.0 to -6.0). Among patients using higher-cost ICS drugs in 2003 (n = 662), more restricted versus unrestricted coverage subjects switched to the lower-cost ICS in 2004 (39.8% vs. 10.3%). Restricted coverage was not associated with decreased ICS use (2003–2004) among patients who switched to the lower-cost ICS (18.7 days-of-supply, CI: -27.5 to 65.0), but was among patients who did not switch (-38.6 days-of-supply, CI: -57.0 to -20.3). In addition, restricted coverage was associated with decreases in ICS use among patients with both higher- and lower-risk asthma (-15.0 days-of-supply, CI: -41.4 to 11.44; and -15.6 days-of-supply, CI: -25.8 to -5.3, respectively). Conclusion In this elderly population, patients reduced their already low ICS use in response to losing drug coverage. Switching to the lower-cost ICS mitigated reductions in use among patients who previously used higher-cost drugs. Additional work is needed to assess barriers to switching ICS drugs and the clinical effects of these drug use changes.
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Affiliation(s)
- Vicki Fung
- Center for Health Policy Studies, Kaiser Permanente Division of Research, Oakland, California, USA.
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de Jonge GA, Ruys JH, Semmekrot BA, Brand R. [Serious concerns regarding research linking cot death with child day care]. Ned Tijdschr Geneeskd 2008; 152:1446-1447. [PMID: 18624011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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de Jonge GA, Ruys JH, Semmekrot BA, Brand R. [More cot deaths in child care settings than during the same hours at home: 10-year statistics]. Ned Tijdschr Geneeskd 2008; 152:1377-1381. [PMID: 18664216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To determine whether the incidence of sudden infant death syndrome (SIDS) in child care settings (child care centres or child minders) is different from that in the home setting, and to search for any differences in the prevalence of SIDS risk factors in both settings. DESIGN Descriptive and comparative. METHOD All SIDS cases (< 2 years), that occurred between September 1996-August 2006 and known to the 'Landelijke Werkgroep Wiegendood' (the National Cot Death Study Group) of the Dutch Paediatric Association were analysed. The percentage of children involved in child care and the mean duration of their participation in child care, was calculated from national surveys carried out in well-baby clinics. RESULTS In the 10 years of the study, 216 cases of SIDS became known to the Cot Death Study Group. In the first year of life, the number was 75% of the number registered by Statistics Netherlands. 28 of these infants died from SIDS between the ages of 3-6 months and on Monday-Friday between 8:00 am-5:00 pm: the usual hours of opening of child care facilities. Based on the uptake of child care during this period, 15% of this mortality was expected to have occurred in a child care setting and 85% at home. In reality, 61% (17/28) of the deaths occurred at a child care facility and 39% (11/28) at home. The relative risk was 8.8 (95% CI: 4.1-19.0). This high incidence of SIDS in a child care setting did not appear to be due to a higher prevalence of known risk factors for SIDS at child care facilities i.e. sleeping position (prone or side), passive smoking, heat congestion, or use of a quilt or pillow. CONCLUSION For infants aged 3-6 months, the relative risk ofSIDS during child care appeared to be increased 8.8 times (95% CI: 4.1-19.0) when compared with home settings in The Netherlands in September 1996-August 2006.
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Affiliation(s)
- G A de Jonge
- Canisius-Wilhelmina Ziekenhuis, afd. Kindergeneeskunde, Nijmegen
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Abstract
OBJECTIVE Assess patient knowledge of and response to drug cost sharing. STUDY SETTING Adult members of a large prepaid, integrated delivery system. STUDY DESIGN/DATA COLLECTION Telephone interviews with 932 participants (72 percent response rate) who reported knowledge of the structures and amounts of their prescription drug cost sharing. Participants reported cost-related changes in their drug adherence, any financial burden, and other cost-coping behaviors. Actual cost sharing amounts came from administrative databases. PRINCIPAL FINDINGS Overall, 27 percent of patients knew all of their drug cost sharing structures and amounts. After adjustment for individual characteristics, additional patient cost sharing structures (tiers and caps), and higher copayment amounts were associated with reporting decreased adherence, financial burden, or other cost-coping behaviors. CONCLUSIONS Patient knowledge of their drug benefits is limited, especially for more complex cost sharing structures. Patients also report a range of responses to greater cost sharing, including decreasing adherence.
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Affiliation(s)
- Mary Reed
- Division of Research, Kaiser Permanente Medical Care Program, 2000 Broadway, Oakland, CA 94612, USA
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Hsu J, Fung V, Price M, Huang J, Brand R, Hui R, Fireman B, Newhouse JP. Medicare beneficiaries' knowledge of Part D prescription drug program benefits and responses to drug costs. JAMA 2008; 299:1929-36. [PMID: 18430912 DOI: 10.1001/jama.299.16.1929] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Medicare Part D drug benefits include substantial cost sharing. OBJECTIVE To determine beneficiaries' knowledge of benefits and cost responses. DESIGN, SETTING, AND PARTICIPANTS Telephone interviews were conducted in 2007 in a stratified random sample of community-dwelling Kaiser Permanente-Northern California Medicare Advantage beneficiaries aged 65 years or older, with a gap in coverage if they exceeded $2250 in drug costs (N = 1040; 74.9% response rate). Half were selected to have reached the gap in 2006. In the source population of Medicare Advantage Prescription Drug plan beneficiaries, 8% entered the coverage gap in 2006. Models were adjusted for individual characteristics and weighted for sampling proportions. MAIN OUTCOME MEASURES Knowledge of cost sharing including awareness of the coverage gap, gap start and end amounts, and drug cost sharing before, during, and after the gap. Cost-related responses including cost-coping behaviors (eg, switching to lower-cost medications), reduced adherence (eg, not refilling prescriptions), and financial burden (eg, going without necessities). RESULTS An estimated 40% (95% confidence interval [CI], 35%-45%) of beneficiaries were aware that their drug plan in 2006 included a coverage gap; knowledge of the gap was greater among individuals who reached the gap during the year. Approximately 36% (95% CI, 32%-41%) of beneficiaries reported at least 1 of the following responses to drug costs: cost-coping behavior (26%), reduced adherence (15%), or experiencing financial burden (7%). In multivariate analyses, beneficiaries with lower household income more frequently reported cost responses (difference of 14.5 percentage points for < $40,000/y vs > or = $40,000/y [95% CI, 3.6-25.4 percentage points]). Compared with beneficiaries who were unaware of having a coverage gap, those who were aware more frequently reported any cost response (difference of 11.3 percentage points [95% CI, 0.8-21.9 percentage points]), but had fewer reports of borrowing money or going without necessities (difference of 5.5 percentage points [95% CI, 1.1-10.0 percentage points]). CONCLUSIONS Beneficiaries in this Medicare Advantage plan have limited knowledge of Part D cost sharing and often report behavioral responses to drug costs. Limited knowledge is associated with fewer reports of cost responses overall, but more reports of financial burden.
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Affiliation(s)
- John Hsu
- Center for Health Policy Studies and the Division of Research, Kaiser Permanente Medical Care Program, 2000 Broadway, Third Floor, Oakland, California 94612, USA.
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Brand R, Buckwalter JA, Canale ST, Cooney WP, D'Ambrosia R, Grana WA, Heckman JD, Hensinger RN, Koman LA, McCann PD, Poehling GG, Thordarson D. Patient care, professionalism, and relations with industry. J Orthop Res 2008; 26:279-80. [PMID: 18273897 DOI: 10.1002/jor.20613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Peul W, Brand R, Tans J, Koes B. PL5.3 Timing of surgery for sciatica. Parkinsonism Relat Disord 2008. [DOI: 10.1016/s1353-8020(08)70087-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Thordarson D, Brand R, Buckwalter JA, Wright TM, Canale ST, Cooney WP, D'Ambrosia R, Frassica FJ, Grana WA, Heckman JD, Hensinger RN, Thompson GH, Koman LA, McCann PD, Neviaser RJ, Poehling GG, Lubowitz JH. Editorial: patient care, professionalism, and relations with industry. Foot Ankle Int 2008; 29:121-3. [PMID: 18315964 DOI: 10.3113/fai.2008.0121] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Brand R, Buckwalter JA, Wright TM, Canale ST, Cooney WP, D'Ambrosia R, Frassica FJ, Grana WA, Heckman JD, Hensinger RN, Thompson GH, Koman LA, McCann PD, Neviaser RJ, Poehling GG, Lubowitz JH, Thordarson D. Patient care, professionalism, and relations with industry. Orthopedics 2008; 31:11-2. [PMID: 18269161 DOI: 10.3928/01477447-20080101-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Poehling GG, Lubowitz JH, Brand R, Buckwalter JA, Wright TM, Canale ST, Cooney WP, D'Ambrosia R, Frassica FJ, Grana WA, Heckman JD, Hensinger RN, Thompson GH, Koman LA, McCann PD, Thordarson D. Patient care, professionalism, and relations with industry. Arthroscopy 2008; 24:4-6. [PMID: 18182194 DOI: 10.1016/j.arthro.2007.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 11/16/2007] [Indexed: 02/02/2023]
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Brand R, Buckwalter JA, Wright TM, Canale ST, Cooney WP, D'Ambrosia R, Frassica FJ, Grana WA, Heckman JD, Hensinger RN, Thompson GH, Koman LA, McCann PD, Poehling GG, Lubowitz JH, Thordarson D. Patient care, professionalism, and relations with industry. J Surg Orthop Adv 2008; 17:67-68. [PMID: 18549733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Peul WC, Van Houwelingen HC, Van den Hout WB, Brand R, Eekhof JAH, Tans JTJ, Thomeer RTWM, Koes BW. [Early surgery or a wait-and-see policy in lumbosacral radicular syndrome: a randomized study]. Ned Tijdschr Geneeskd 2007; 151:2512-2523. [PMID: 18062596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To compare early surgery with expectative policy and later surgery if necessary in patients with sciatica that did not resolve within 6 weeks. DESIGN Randomized multicentre clinical trial (ISRCTN 26872154). METHODS Patients who had had severe sciatica for 6 to 12 weeks were randomized to early surgery or to prolonged conservative treatment with later surgery if necessary. The primary outcomes were the Roland Disability Questionnaire score, the visual-analogue scale for leg pain score, and the patient's report of their perceived recovery over the first year after randomization. Repeated measures analysis according to the intention-to-treat principle was used to analyse the outcome curves for both groups. RESULTS A total of 283 patients were included and randomized. Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy after a mean of 2.2 weeks. Of 142 patients assigned to conservative treatment, 55 (39%) still had to undergo surgical treatment after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (p = 0.13). Leg pain lessened more quickly in patients assigned to early surgery (p < 0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio (HR): 1.97; 95% CI: 1.72-2.22; p < 0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%. CONCLUSIONS The 1-year outcomes were similar for patients assigned to early surgery and those assigned to extended conservative treatment with later surgery if necessary but the rates of reduction of leg pain and of perceived recovery were faster in those assigned to early surgery.
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Affiliation(s)
- W C Peul
- Leids Universitair Medisch Centrum, Postbus 9600, 2300 RC Leiden.
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Wiggenraad RGJ, Flierman L, Goossens A, Brand R, Verschuur HP, Croll GA, Moser LEC, Vriesendorp R. Prophylactic gastrostomy placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study. Clin Otolaryngol 2007; 32:384-90. [PMID: 17883560 DOI: 10.1111/j.1749-4486.2007.01533.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Most patients with advanced head and neck cancer receiving chemoradiotherapy need tube feeding for at least some weeks. For these periods gastrostomy tubes have advantages over nasogastric tubes. Tube feeding may start earlier and thus loss of weight may be limited if the gastrostomy tube already is in place. The objective of this study is to analyse the results of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement and early tube feeding. DESIGN Retrospective chart review. SETTING Multidisciplinary head and neck oncology team in a general hospital. PARTICIPANTS Fifty consecutive patients with unresectable stage III and IV head and neck cancer treated with concurrent chemoradiotherapy. In all patients prophylactic PEG placement was performed. Tube feeding was initiated if food-intake became insufficient or loss of weight occurred. MAIN OUTCOME MEASURES Loss of weight during treatment, complication rate, PEG duration. RESULTS The mean loss of weight during treatment for all patients was only 2.8%. One complication of tube placement occurred: a colon perforation, treated successfully by surgery. The median duration of the PEG was 178 days. Three of the 17 patients (18%) with no evidence of disease (NED) still had a PEG at their last follow-up visit. Of the 26 patients who died of their cancer, 13 used the PEG until death. CONCLUSIONS Loss of weight was limited after prophylactic gastrostomy placement and early tube feeding. Moreover, the complication rate was low. In 82% of the NED patients the PEG could eventually be removed.
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Affiliation(s)
- R G J Wiggenraad
- Department of Radiotherapy, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
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