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Sharma SP, Hirsch A, Hunink MGM, Cramer MJM, Mohamed Hoesein FAA, Geluk CA, Kramer G, Gratama JWC, Braam RL, van der Zee PM, Yassi W, Wolters SL, Gürlek C, Pundziute G, Vliegenthart R, Budde RPJ. Addition of FFRct in the diagnostic pathway of patients with stable chest pain to reduce unnecessary invasive coronary angiography (FUSION) : Rationale and design for the multicentre, randomised, controlled FUSION trial. Neth Heart J 2023; 31:52-60. [PMID: 35976610 PMCID: PMC9892409 DOI: 10.1007/s12471-022-01711-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Coronary computed tomography angiography (CCTA) is widely used in the diagnostic work-up of patients with stable chest pain. CCTA has an excellent negative predictive value, but a moderate positive predictive value for detecting coronary stenosis. Computed tomography-derived fractional flow reserve (FFRct) is a non-invasive, well-validated technique that provides functional assessment of coronary stenosis, improving the positive predictive value of CCTA. However, to determine the value of FFRct in routine clinical practice, a pragmatic randomised, controlled trial (RCT) is required. We will conduct an RCT to investigate the impact of adding FFRct analysis in the diagnostic pathway of patients with a coronary stenosis on CCTA on the rate of unnecessary invasive coronary angiography, cost-effectiveness, quality of life and clinical outcome. METHODS The FUSION trial is a prospective, multicentre RCT that will randomise 528 patients with stable chest pain and anatomical stenosis of ≥ 50% but < 90% in at least one coronary artery of ≥ 2 mm on CCTA, to FFRct-guided care or usual care in a 1:1 ratio. Follow-up will be 1 year. The primary endpoint is the rate of unnecessary invasive coronary angiography within 90 days. CONCLUSION The FUSION trial will evaluate the use of FFRct in stable chest pain patients from the Dutch perspective. The trial is funded by the Dutch National Health Care Institute as part of the research programme 'Potentially Promising Care' and the results will be used to assess if FFRct reimbursement should be included in the standard health care package.
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Affiliation(s)
- S. P. Sharma
- Department of Cardiology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands ,Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - A. Hirsch
- Department of Cardiology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands ,Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M. G. M. Hunink
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands ,Department of Epidemiology and Biostatistics, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands ,Centre for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, USA
| | - M. J. M. Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - C. A. Geluk
- Department of Cardiology, Martini Hospital Groningen, Groningen, The Netherlands
| | - G. Kramer
- Department of Radiology, Martini Hospital Groningen, Groningen, The Netherlands
| | - J. W. C. Gratama
- Department of Radiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - R. L. Braam
- Department of Cardiology, Gelre Hospital, Apeldoorn, The Netherlands
| | - P. M. van der Zee
- Department of Cardiology, St Jansdal Hospital, Harderwijk, The Netherlands
| | - W. Yassi
- Department of Cardiology, St Jansdal Hospital, Harderwijk, The Netherlands
| | - S. L. Wolters
- Department of Radiology, Adrz Hospital, Goes, The Netherlands
| | - C. Gürlek
- Department of Cardiology, Adrz Hospital, Goes, The Netherlands
| | - G. Pundziute
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - R. Vliegenthart
- Department of Radiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - R. P. J. Budde
- Department of Cardiology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands ,Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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2
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Dijk SW, Steijlen OFM, Kranenburg LW, Rouwet EV, Luik AI, Bierbooms AE, Kouwenhoven-Pasmooij TA, Rizopoulos D, Swanson SA, Hoogendijk WJG, Hunink MGM. DEcrease STress through RESilience training for Students (DESTRESS) Study: Protocol for a randomized controlled trial nested in a longitudinal observational cohort study. Contemp Clin Trials 2022; 122:106928. [PMID: 36116756 DOI: 10.1016/j.cct.2022.106928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/30/2022] [Accepted: 09/12/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Chronic stress and burnout are highly prevalent among academically trained healthcare professionals, negatively affecting their well-being and capacity to engage in their work. Resilience to stress develops early in one's career path, hence offering resilience training to university students in these professions is one approach to fostering well-being and mental health. The aim of this study is to assess whether offering mindfulness-based resilience training to university students in healthcare professions reduces their perceived chronic stress. METHODS AND ANALYSIS The study has a hybrid design combining a longitudinal observational cohort with a nested randomized controlled trial (RCT) with sequential multiple assignment and multistage adaptive interventions while taking participants' preferences into account. All students in healthcare related programmes at the Erasmus University Rotterdam are invited to participate. Within the observational cohort, students with a score of 14 or higher on the Perceived Stress Scale (PSS) are invited to take part in the RCT (n = 706). Eligible participants are randomized to control or active intervention in a ratio of 1:6. Those randomized to the control group and non-randomized participants in the cohort receive passive web-based psychoeducation about chronic stress and burnout through referral to specific websites. Participants randomized to the intervention group receive one of 8 active mindfulness-based interventions. They select a rank order of 4 preferred interventions and are randomized across these with equal probability. Non-response to the intervention is followed by sequential randomized assignment to another intervention, for a total maximum of 3 sequential interventions. All participants receive questionnaires at baseline, before and after each 8-week intervention period, and at 1- and 2-year follow-up. The primary outcome is perceived chronic stress measured with the PSS. Secondary outcomes include mental well-being, burnout, quality of life, healthcare utilization, drug use, bodyweight, mental and physical stress-related symptoms, resilience, and study progress. ETHICS AND REGISTRATION Approval from the Medical Ethics Review Committee was obtained under protocol number MEC-2018-1645. The trial is registered in the Netherlands National Trial Register by registration number NL7623, 22/03/2019, https://www.trialregister.nl/.
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Affiliation(s)
- S W Dijk
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Netherlands Institute for Health Sciences (NIHES), Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, the Netherlands
| | - O F M Steijlen
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Netherlands Institute for Health Sciences (NIHES), Rotterdam, the Netherlands
| | - L W Kranenburg
- Department of Psychiatry, Erasmus MC University Medical Center, the Netherlands
| | - E V Rouwet
- Department of Public Health, Erasmus MC University Medical Center, the Netherlands
| | - A I Luik
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC University Medical Center, the Netherlands
| | - A E Bierbooms
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - D Rizopoulos
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - S A Swanson
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, University of Pittsburgh, Pittsburgh, United States of America
| | - W J G Hoogendijk
- Department of Psychiatry, Erasmus MC University Medical Center, the Netherlands
| | - M G M Hunink
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Netherlands Institute for Health Sciences (NIHES), Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, the Netherlands; Centre for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, United States of America.
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3
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Pietersma CS, Mulders AGMGJ, Moolenaar LM, Hunink MGM, Koning AHJ, Willemsen SP, Go ATJI, Steegers EAP, Rousian M. First trimester anomaly scan using virtual reality (VR FETUS study): study protocol for a randomized clinical trial. BMC Pregnancy Childbirth 2020; 20:515. [PMID: 32894073 PMCID: PMC7487721 DOI: 10.1186/s12884-020-03180-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 08/14/2020] [Indexed: 02/08/2023] Open
Abstract
Background In recent years it has become clear that fetal anomalies can already be detected at the end of the first trimester of pregnancy by two-dimensional (2D) ultrasound. This is why increasingly in developed countries the first trimester anomaly scan is being offered as part of standard care. We have developed a Virtual Reality (VR) approach to improve the diagnostic abilities of 2D ultrasound. Three-dimensional (3D) ultrasound datasets are used in VR assessment, enabling real depth perception and unique interaction. The aim of this study is to investigate whether first trimester 3D VR ultrasound is of additional value in terms of diagnostic accuracy for the detection of fetal anomalies. Health-related quality of life, cost-effectiveness and also the perspective of both patient and ultrasonographer on the 3D VR modality will be studied. Methods Women in the first trimester of a high risk pregnancy for a fetus with a congenital anomaly are eligible for inclusion. This is a randomized controlled trial with two intervention arms. The control group receives ‘care as usual’: a second trimester 2D advanced ultrasound examination. The intervention group will undergo an additional first trimester 2D and 3D VR ultrasound examination. Following each examination participants will fill in validated questionnaires evaluating their quality of life and healthcare related expenses. Participants’ and ultrasonographers’ perspectives on the 3D VR ultrasound will be surveyed. The primary outcome will be the detection of fetal anomalies. The additional first trimester 3D VR ultrasound examination will be compared to ‘care as usual’. Neonatal or histopathological examinations are considered the gold standard for the detection of congenital anomalies. To reach statistical significance and 80% power with a detection rate of 65% for second trimester ultrasound examination and 70% for the combined detection of first trimester 3D VR and second trimester ultrasound examination, a sample size of 2800 participants is needed. Discussion First trimester 3D VR detection of fetal anomalies may improve patients’ quality of life through reassurance or earlier identification of malformations. Results of this study will provide policymakers and healthcare professionals with the highest level of evidence for cost-effectiveness of first trimester ultrasound using a 3D VR approach. Trial registration Dutch Trial Registration number NTR6309, date of registration 26 January 2017.
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Affiliation(s)
- C S Pietersma
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - A G M G J Mulders
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - L M Moolenaar
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - M G M Hunink
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands.,Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, USA
| | - A H J Koning
- Department of Pathology, Clinical Bioinformatics Unit, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - S P Willemsen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - A T J I Go
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - E A P Steegers
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - M Rousian
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, the Netherlands.
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Kühlmann AYR, de Rooij A, Kroese LF, van Dijk M, Hunink MGM, Jeekel J. Meta-analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg 2018; 105:773-783. [PMID: 29665028 PMCID: PMC6175460 DOI: 10.1002/bjs.10853] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [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: 10/19/2017] [Revised: 12/08/2017] [Accepted: 02/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study aimed to evaluate anxiety and pain following perioperative music interventions compared with control conditions in adult patients. METHODS Eleven electronic databases were searched for full-text publications of RCTs investigating the effect of music interventions on anxiety and pain during invasive surgery published between 1 January 1980 and 20 October 2016. Results and data were double-screened and extracted independently. Random-effects meta-analysis was used to calculate effect sizes as standardized mean differences (MDs). Heterogeneity was investigated in subgroup analyses and metaregression analyses. The review was registered in the PROSPERO database as CRD42016024921. RESULTS Ninety-two RCTs (7385 patients) were included in the systematic review, of which 81 were included in the meta-analysis. Music interventions significantly decreased anxiety (MD -0·69, 95 per cent c.i. -0·88 to -0·50; P < 0·001) and pain (MD -0·50, -0·66 to -0·34; P < 0·001) compared with controls, equivalent to a decrease of 21 mm for anxiety and 10 mm for pain on a 100-mm visual analogue scale. Changes in outcome corrected for baseline were even larger: MD -1·41 (-1·89 to -0·94; P < 0·001) for anxiety and -0·54 (-0·93 to -0·15; P = 0·006) for pain. Music interventions provided during general anaesthesia significantly decreased pain compared with that in controls (MD -0·41, -0·64 to -0·18; P < 0·001). Metaregression analysis found no significant association between the effect of music interventions and age, sex, choice and timing of music, and type of anaesthesia. Risk of bias in the studies was moderate to high. CONCLUSION Music interventions significantly reduce anxiety and pain in adult surgical patients.
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Affiliation(s)
- A Y R Kühlmann
- Department of Paediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - A de Rooij
- Department of Neuroscience, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - L F Kroese
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - M van Dijk
- Department of Paediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - M G M Hunink
- Department of Epidemiology, Erasmus Medical Centre, Rotterdam, The Netherlands.,Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - J Jeekel
- Department of Neuroscience, Erasmus Medical Centre, Rotterdam, The Netherlands
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Lagendijk M, Vos EL, Koning AHJ, Hunink MGM, Pignol JP, Corten EML, de Monye C, van Deurzen CHM, van Dam JH, Vrijland WW, Contant CME, Verhoef C, van Lankeren W, Koppert LB. TUmor-volume to breast-volume RAtio for improving COSmetic results in breast cancer patients (TURACOS); a randomized controlled trial. BMC Cancer 2017; 17:336. [PMID: 28514945 PMCID: PMC5436425 DOI: 10.1186/s12885-017-3280-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 04/12/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cosmetic result following breast conserving surgery (BCS) for cancer influences quality of life and psychosocial functioning in breast cancer patients. A preoperative prediction of expected cosmetic result following BCS is not (yet) standard clinical practice and therefore the choice for either mastectomy or BCS is still subjective. Recently, we showed that tumour volume to breast volume ratio as well as tumour location in the breast are independent predictors of superior cosmetic result following BCS. Implementation of a prediction model including both factors, has not been studied in a prospective manner. This study aims to improve cosmetic outcome by implementation of a prediction model in the treatment decision making for breast cancer patients opting for BCS. METHODS/DESIGN Multicentre, single-blinded, randomized controlled trial comparing standard preoperative work-up to a preoperative work-up with addition of the prediction model. Tumour volume to breast volume ratio and tumour location in the breast will be used to predict cosmetic outcome in invasive breast cancer patients opting for BCS. Three dimensional (3D)-ultrasonography will be used to measure the tumour volume to breast volume ratio needed for the prediction model. Sample size was estimated based on a 14% improvement in incidence of superior cosmetic result one year after BCS (71% in the control group versus 85% in the intervention group). Primarily cosmetic outcome will be evaluated by a 6-member independent panel. Secondary endpoints include; (1) patient reported outcome measured by BREAST-Q, EORTC-QLQ-C30/BR23 and EQ-5D-5 L (2) cosmetic outcome as assessed through the BCCT.core software, (3) radiation-induced reaction (4) surgical treatment performed, (5) pathological result and (6) cost-effectiveness. Follow-up data will be collected for 3 years after surgery or finishing radiotherapy. DISCUSSION This randomized controlled trial examines the value of a preoperative prediction model for the treatment-decision making. It aims for a superior cosmetic result in breast cancer patients opting for BCS. We expect improvement of patients' quality of life and psychosocial functioning in a cost-effective way. TRIAL REGISTRATION Prospectively registered, February 17th 2015, at 'Nederlands Trialregister - NTR4997 '.
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Affiliation(s)
- M. Lagendijk
- Department of Oncological Surgery, Erasmus MC Cancer Institute, DHA-102, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - E. L. Vos
- Department of Oncological Surgery, Erasmus MC Cancer Institute, DHA-102, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - A. H. J. Koning
- Department of Bioinformatics, Erasmus MC, Rotterdam, the Netherlands
| | - M. G. M. Hunink
- Department of Epidemiology and Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - J. P. Pignol
- Department of Radiotherapy, Erasmus MC, Rotterdam, the Netherlands
| | - E. M. L. Corten
- Department of plastic and reconstructive surgery, Erasmus MC, Rotterdam, the Netherlands
| | - C. de Monye
- Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
| | | | - J. H. van Dam
- Department of surgery, Havenziekenhuis, Rotterdam, the Netherlands
| | - W. W. Vrijland
- Department of surgery, Franciscus Gasthuis, Rotterdam, the Netherlands
| | - C. M. E. Contant
- Department of surgery, Maasstad ziekenhuis, Rotterdam, the Netherlands
| | - C. Verhoef
- Department of Oncological Surgery, Erasmus MC Cancer Institute, DHA-102, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - W. van Lankeren
- Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
| | - L. B. Koppert
- Department of Oncological Surgery, Erasmus MC Cancer Institute, DHA-102, PO Box 5201, 3008 AE Rotterdam, The Netherlands
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van den Houten MML, Lauret GJ, Fakhry F, Fokkenrood HJP, van Asselt ADI, Hunink MGM, Teijink JAW. Cost-effectiveness of supervised exercise therapy compared with endovascular revascularization for intermittent claudication. Br J Surg 2016; 103:1616-1625. [DOI: 10.1002/bjs.10247] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/07/2016] [Accepted: 05/04/2016] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Current guidelines recommend supervised exercise therapy (SET) as the preferred initial treatment for patients with intermittent claudication. The availability of SET programmes is, however, limited and such programmes are often not reimbursed. Evidence for the long-term cost-effectiveness of SET compared with endovascular revascularization (ER) as primary treatment for intermittent claudication might aid widespread adoption in clinical practice.
Methods
A Markov model was constructed to determine the incremental costs, incremental quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio of SETversus ER for a hypothetical cohort of patients with newly diagnosed intermittent claudication, from the Dutch healthcare payer's perspective. In the event of primary treatment failure, possible secondary interventions were repeat ER, open revascularization or major amputation. Data sources for model parameters included original data from two RCTs, as well as evidence from the medical literature. The robustness of the results was tested with probabilistic and one-way sensitivity analysis.
Results
Considering a 5-year time horizon, probabilistic sensitivity analysis revealed that SET was associated with cost savings compared with ER (−€6412, 95 per cent credibility interval (CrI) –€11 874 to –€1939). The mean difference in effectiveness was −0·07 (95 per cent CrI −0·27 to 0·16) QALYs. ER was associated with an additional €91 600 per QALY gained compared with SET. One-way sensitivity analysis indicated more favourable cost-effectiveness for ER in subsets of patients with low quality-of-life scores at baseline.
Conclusion
SET is a more cost-effective primary treatment for intermittent claudication than ER. These results support implementation of supervised exercise programmes in clinical practice.
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Affiliation(s)
| | - G J Lauret
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- CAPHRI Research School, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - F Fakhry
- Department of Radiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - H J P Fokkenrood
- CAPHRI Research School, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - A D I van Asselt
- Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - M G M Hunink
- Department of Radiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Centre for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - J A W Teijink
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- CAPHRI Research School, Maastricht University Medical Centre, Maastricht, The Netherlands
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Sanelli PC, Pandya A, Segal AZ, Gupta A, Hurtado-Rua S, Ivanidze J, Kesavabhotla K, Mir D, Mushlin AI, Hunink MGM. Cost-effectiveness of CT angiography and perfusion imaging for delayed cerebral ischemia and vasospasm in aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 2014; 35:1714-20. [PMID: 24812015 DOI: 10.3174/ajnr.a3947] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia and vasospasm are significant complications following SAH leading to cerebral infarction, functional disability, and death. In recent years, CTA and CTP have been used to increase the detection of delayed cerebral ischemia and vasospasm. Our aim was to perform comparative-effectiveness and cost-effectiveness analyses evaluating CTA and CTP for delayed cerebral ischemia and vasospasm in aneurysmal SAH from a health care payer perspective. MATERIALS AND METHODS We developed a decision model comparing CTA and CTP with transcranial Doppler sonography for detection of vasospasm and delayed cerebral ischemia in SAH. The clinical pathways were based on the "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association" (2012). Outcome health states represented mortality and morbidity according to functional outcomes. Input probabilities of symptoms and serial test results from CTA and CTP, transcranial Doppler ultrasound, and digital subtraction angiography were directly derived from an SAH cohort by using a multinomial logistic regression model. Expected benefits, measured as quality-adjusted life years, and costs, measured in 2012 US dollars, were calculated for each imaging strategy. Univariable, multivariable, and probabilistic sensitivity analyses were performed to determine the independent and combined effect of input parameter uncertainty. RESULTS The transcranial Doppler ultrasound strategy yielded 13.62 quality-adjusted life years at a cost of $154,719. The CTA and CTP strategy generated 13.89 quality-adjusted life years at a cost of $147,097, resulting in a gain of 0.27 quality-adjusted life years and cost savings of $7622 over the transcranial Doppler ultrasound strategy. Univariable and multivariable sensitivity analyses indicated that results were robust to plausible input parameter uncertainty. Probabilistic sensitivity analysis results yielded 96.8% of iterations in the right lower quadrant, representing higher benefits and lower costs. CONCLUSIONS Our model results suggest that CTA and CTP are the preferred imaging strategy in SAH, compared with transcranial Doppler ultrasound, leading to improved clinical outcomes and lower health care costs.
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Affiliation(s)
- P C Sanelli
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.) Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - A Pandya
- Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - A Z Segal
- Neurology (A.Z.S.), Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - A Gupta
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | | | - J Ivanidze
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - K Kesavabhotla
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - D Mir
- From the Departments of Radiology (P.C.S., A.G., J.I., K.K., D.M.)
| | - A I Mushlin
- Public Health (P.C.S., A.P., S.H.-R., A.I.M.)
| | - M G M Hunink
- Departments of Radiology and Epidemiology (M.G.M.H.), Erasmus University Medical Center, Rotterdam, the Netherlands
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8
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Fowkes FGR, Murray GD, Butcher I, Folsom AR, Hirsch AT, Couper DJ, Debacker G, Kornitzer M, Newman AB, Sutton-Tyrrell KC, Cushman M, Lee AJ, Price JF, D'Agostino RB, Murabito JM, Norman P, Masaki KH, Bouter LM, Heine RJ, Stehouwer CDA, McDermott MM, Stoffers HEJH, Knottnerus JA, Ogren M, Hedblad B, Koenig W, Meisinger C, Cauley JA, Franco O, Hunink MGM, Hofman A, Witteman JC, Criqui MH, Langer RD, Hiatt WR, Hamman RF. Development and validation of an ankle brachial index risk model for the prediction of cardiovascular events. Eur J Prev Cardiol 2013; 21:310-20. [PMID: 24367001 DOI: 10.1177/2047487313516564] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The ankle brachial index (ABI) is related to risk of cardiovascular events independent of the Framingham risk score (FRS). The aim of this study was to develop and evaluate a risk model for cardiovascular events incorporating the ABI and FRS. DESIGN An analysis of participant data from 18 cohorts in which 24,375 men and 20,377 women free of coronary heart disease had ABI measured and were followed up for events. METHODS Subjects were divided into a development and internal validation dataset and an external validation dataset. Two models, comprising FRS and FRS + ABI, were fitted for the primary outcome of major coronary events. RESULTS In predicting events in the external validation dataset, C-index for the FRS was 0.672 (95% CI 0.599 to 0.737) in men and 0.578 (95% CI 0.492 to 0.661) in women. The FRS + ABI led to a small increase in C-index in men to 0.685 (95% CI 0.612 to 0.749) and large increase in women to 0.690 (95% CI 0.605 to 0.764) with net reclassification improvement (NRI) of 4.3% (95% CI 0.0 to 7.6%, p = 0.050) and 9.6% (95% CI 6.1 to 16.4%, p < 0.001), respectively. Restricting the FRS + ABI model to those with FRS intermediate 10-year risk of 10 to 19% resulted in higher NRI of 15.9% (95% CI 6.1 to 20.6%, p < 0.001) in men and 23.3% (95% CI 13.8 to 62.5%, p = 0.002) in women. However, incorporating ABI in an improved newly fitted risk factor model had a nonsignificant effect: NRI 2.0% (95% CI 2.3 to 4.2%, p = 0.567) in men and 1.1% (95% CI 1.9 to 4.0%, p = 0.483) in women. CONCLUSIONS An ABI risk model may improve prediction especially in individuals at intermediate risk and when performance of the base risk factor model is modest.
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Affiliation(s)
- F G R Fowkes
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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9
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Fakhry F, Rouwet EV, den Hoed PT, Hunink MGM, Spronk S. Long-term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial. Br J Surg 2013; 100:1164-71. [PMID: 23842830 DOI: 10.1002/bjs.9207] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Long-term comparisons of supervised exercise therapy (SET) and endovascular revascularization (ER) for patients with intermittent claudication are scarce. The long-term clinical effectiveness of SET and ER was assessed in patients from a randomized trial. METHODS Consenting patients with intermittent claudication were assigned randomly to either SET or ER. Outcome measures on functional performance (pain-free and maximum walking distance, ankle : brachial pressure index), quality of life (QoL) and number of secondary interventions were measured at baseline and after approximately 7 years of follow-up. Repeated-measurement and Kaplan-Meier methods were used to analyse the data on an intention-to treat-basis. RESULTS A total of 151 patients were randomized initially to either SET or ER. After 7 years, functional performance (P < 0.001) and QoL (P ≤ 0.005) had improved after both SET and ER. Long-term comparison showed no differences between the two treatments, except in the secondary intervention rate, which was significantly higher after SET (P = 0.001). Nevertheless, the total number of endovascular and surgical interventions (primary and secondary) remained higher after ER (P < 0.001). CONCLUSION In the longer term, SET-first or ER-first treatment strategies were equally effective in improving functional performance and QoL in patients with intermittent claudication. The substantially higher number of invasive interventions in the ER-first group supports a SET-first treatment strategy for intermittent claudication. REGISTRATION NUMBER NTR199 (http://www.trialregister.nl).
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Affiliation(s)
- F Fakhry
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
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10
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Rossi A, Dharampal A, Wragg A, Davies LC, van Geuns RJ, Anagnostopoulos C, Klotz E, Kitslaar P, Broersen A, Mathur A, Nieman K, Hunink MGM, de Feyter PJ, Petersen SE, Pugliese F. Diagnostic performance of hyperaemic myocardial blood flow index obtained by dynamic computed tomography: does it predict functionally significant coronary lesions? Eur Heart J Cardiovasc Imaging 2013; 15:85-94. [DOI: 10.1093/ehjci/jet133] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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11
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Spronk S, van Kempen BJH, Boll APM, Jørgensen JJ, Hunink MGM, Kristiansen IS. Cost-effectiveness of screening for abdominal aortic aneurysm in the Netherlands and Norway. Br J Surg 2011; 98:1546-55. [DOI: 10.1002/bjs.7620] [Citation(s) in RCA: 34] [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] [Accepted: 05/06/2011] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim of this study was to determine the cost-effectiveness of ultrasound screening for abdominal aortic aneurysm (AAA) in men aged 65 years, for both the Netherlands and Norway.
Methods
A Markov model was developed to simulate life expectancy, quality-adjusted life-years, net health benefits, lifetime costs and incremental cost-effectiveness ratios for both screening and no screening for AAA. The best available evidence was retrieved from the literature and combined with primary data from the two countries separately, and analysed from a national perspective. A threshold willingness-to-pay (WTP) of €20 000 and €62 500 was used for data from the Netherlands and Norway respectively.
Results
The additional costs of the screening strategy compared with no screening were €421 (95 per cent confidence interval 33 to 806) per person in the Netherlands, and the additional life-years were 0·097 (−0·180 to 0·365), representing €4340 per life-year. For Norway, the values were €562 (59 to 1078), 0·057 (−0·135 to 0·253) life-years and €9860 per life-year respectively. In Norway the results were sensitive to a decrease in the prevalence of AAA in 65-year-old men to 1 per cent, or lower. Probabilistic sensitivity analyses indicated that AAA screening has a 70 per cent probability of being cost-effective in the Netherlands with a WTP threshold of €20 000, and 70 per cent in Norway with a threshold of €62 500.
Conclusion
Using this model, screening for AAA in 65-year-old men would be highly cost-effective in both the Netherlands and Norway.
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Affiliation(s)
- S Spronk
- Department of Epidemiology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - B J H van Kempen
- Department of Epidemiology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - A P M Boll
- Department of Surgery, Canisius-Wilhelmina Hospital Nijmegen, Nijmegen, The Netherlands
| | - J J Jørgensen
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
| | - M G M Hunink
- Department of Epidemiology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - I S Kristiansen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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12
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Odink AE, van der Lugt A, Hofman A, Hunink MGM, Breteler MMB, Krestin GP, Witteman JCM. Risk factors for coronary, aortic arch and carotid calcification; The Rotterdam Study. J Hum Hypertens 2009; 24:86-92. [DOI: 10.1038/jhh.2009.42] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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13
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Fowkes FGR, Murray GD, Butcher I, Heald CL, Lee RJ, Chambless LE, Folsom AR, Hirsch AT, Dramaix M, deBacker G, Wautrecht JC, Kornitzer M, Newman AB, Cushman M, Sutton-Tyrrell K, Fowkes FGR, Lee AJ, Price JF, d'Agostino RB, Murabito JM, Norman PE, Jamrozik K, Curb JD, Masaki KH, Rodríguez BL, Dekker JM, Bouter LM, Heine RJ, Nijpels G, Stehouwer CDA, Ferrucci L, McDermott MM, Stoffers HE, Hooi JD, Knottnerus JA, Ogren M, Hedblad B, Witteman JC, Breteler MMB, Hunink MGM, Hofman A, Criqui MH, Langer RD, Fronek A, Hiatt WR, Hamman R, Resnick HE, Guralnik J, McDermott MM. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA 2008; 300:197-208. [PMID: 18612117 PMCID: PMC2932628 DOI: 10.1001/jama.300.2.197] [Citation(s) in RCA: 1350] [Impact Index Per Article: 84.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index (ABI) is an indicator of atherosclerosis and has the potential to improve prediction. OBJECTIVE To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score (FRS) and can improve risk prediction. DATA SOURCES Relevant studies were identified. A search of MEDLINE (1950 to February 2008) and EMBASE (1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies. STUDY SELECTION Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality. DATA EXTRACTION Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta-analysis was conducted on individuals who had no previous history of coronary heart disease. RESULTS Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480,325 person-years of follow-up of 24,955 men and 23,339 women, the risk of death by ABI had a reverse J-shaped distribution with a normal (low risk) ABI of 1.11 to 1.40. The 10-year cardiovascular mortality in men with a low ABI (< or = 0.90) was 18.7% (95% confidence interval [CI], 13.3%-24.1%) and with normal ABI (1.11-1.40) was 4.4% (95% CI, 3.2%-5.7%) (hazard ratio [HR], 4.2; 95% CI, 3.3-5.4). Corresponding mortalities in women were 12.6% (95% CI, 6.2%-19.0%) and 4.1% (95% CI, 2.2%-6.1%) (HR, 3.5; 95% CI, 2.4-5.1). The HRs remained elevated after adjusting for FRS (2.9 [95% CI, 2.3-3.7] for men vs 3.0 [95% CI, 2.0-4.4] for women). A low ABI (< or = 0.90) was associated with approximately twice the 10-year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women. CONCLUSION Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.
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14
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Pugliese F, Weustink AC, Van Mieghem C, Alberghina F, Otsuka M, Meijboom WB, van Pelt N, Mollet NR, Cademartiri F, Krestin GP, Hunink MGM, de Feyter PJ. Dual source coronary computed tomography angiography for detecting in-stent restenosis. Heart 2008; 94:848-54. [PMID: 17881474 DOI: 10.1136/hrt.2007.126474] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [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] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To evaluate the performance of dual source CT coronary angiography (DSCT-CA) in the detection of in-stent restenosis (>or=50% luminal narrowing) in symptomatic patients referred for conventional angiography (CA). DESIGN/ PATIENTS: 100 patients (78 males, age 62 (SD 10)) with chest pain were prospectively evaluated after coronary stenting. DSCT-CA was performed before CA. SETTING Many patients undergo coronary artery stenting; availability of a non-invasive modality to detect in-stent restenosis would be desirable. RESULTS Average heart rate (HR) was 67 (SD 12) (range 46-106) bpm. There were 178 stented lesions. The interval between stenting and inclusion in the study was 35 (SD 41) (range 3-140) months. 39/100 (39%) patients had angiographically proven restenosis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of DSCT-CA, calculated in all stents, were 94%, 92%, 77% and 98%, respectively. Diagnostic performance at HR <70 bpm (n = 69; mean 58 bpm) was similar to that at HR >or=70 bpm (n = 31; mean 78 bpm); diagnostic performance in single stents (n = 95) was similar to that in overlapping stents and bifurcations (n = 83). In stents >or=3.5 mm (n = 78), sensitivity, specificity, PPV, NPV were 100%; in 3 mm stents (n = 59), sensitivity and NPV were 100%, specificity 97%, PPV 91%; in stents <or=2.75 mm (n = 41), sensitivity was 84%, specificity 64%, PPV 52%, NPV 90%. Nine stents <or=2.75 mm were uninterpretable. Specificity of DSCT-CA in stents >or=3.5 mm was significantly higher than in stents <or=2.75 mm (OR = 6.14; 99%CI: 1.52 to 9.79). CONCLUSION DSCT-CA performs well in the detection of in-stent restenosis. Although DSCT-CA leads to frequent false positive findings in smaller stents (<or=2.75 mm), it reliably rules out in-stent restenosis irrespective of stent size.
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Affiliation(s)
- F Pugliese
- Department of Cardiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
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15
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Smits M, Hunink MGM, van Rijssel DA, Dekker HM, Vos PE, Kool DR, Nederkoorn PJ, Hofman PAM, Twijnstra A, Tanghe HLJ, Dippel DWJ. Outcome after complicated minor head injury. AJNR Am J Neuroradiol 2007; 29:506-13. [PMID: 18065509 DOI: 10.3174/ajnr.a0852] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Functional outcome in patients with minor head injury with neurocranial traumatic findings on CT is largely unknown. We hypothesized that certain CT findings may be predictive of poor functional outcome. MATERIALS AND METHODS All patients from the CT in Head Injury Patients (CHIP) study with neurocranial traumatic CT findings were included. The CHIP study is a prospective, multicenter study of consecutive patients, > or =16 years of age, presenting within 24 hours of blunt head injury, with a Glasgow Coma Scale (GCS) score of 13-14 or a GCS score of 15 and a risk factor. Primary outcome was functional outcome according to the Glasgow Outcome Scale (GOS). Other outcome measures were the modified Rankin Scale (mRS), the Barthel Index (BI), and number and severity of postconcussive symptoms. The association between CT findings and outcome was assessed by using univariable and multivariable regression analysis. RESULTS GOS was assessed in 237/312 patients (76%) at an average of 15 months after injury. There was full recovery in 150 patients (63%), moderate disability in 70 (30%), severe disability in 7 (3.0%), and death in 10 (4.2%). Outcome according to the mRS and BI was also favorable in most patients, but 82% of patients had postconcussive symptoms. Evidence of parenchymal damage was the only independent predictor of poor functional outcome (odds ratio = 1.89, P = .022). CONCLUSION Patients with neurocranial complications after minor head injury generally make a good functional recovery, but postconcussive symptoms may persist. Evidence of parenchymal damage on CT was predictive of poor functional outcome.
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Affiliation(s)
- M Smits
- Department of Radiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
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16
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Smits M, Hunink MGM, Nederkoorn PJ, Dekker HM, Vos PE, Kool DR, Hofman PAM, Twijnstra A, de Haan GG, Tanghe HLJ, Dippel DWJ. A history of loss of consciousness or post-traumatic amnesia in minor head injury: "conditio sine qua non" or one of the risk factors? J Neurol Neurosurg Psychiatry 2007; 78:1359-64. [PMID: 17470468 PMCID: PMC2095595 DOI: 10.1136/jnnp.2007.117143] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [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] [Indexed: 11/04/2022]
Abstract
OBJECTIVE A history of loss of consciousness (LOC) or post-traumatic amnesia (PTA) is commonly considered a prerequisite for minor head injury (MHI), although neurocranial complications also occur when LOC/PTA are absent, particularly in the presence of other risk factors. The purpose of this study was to evaluate whether known risk factors for complications after MHI in the absence of LOC/PTA have the same predictive value as when LOC/PTA are present. METHODS A prospective multicentre study was performed in four university hospitals between February 2002 and August 2004 of consecutive blunt head injury patients (> or = 16 years) presenting with a normal level of consciousness and a risk factor. Outcome measures were any neurocranial traumatic CT finding and neurosurgical intervention. Common odds ratios (OR) were estimated for each of the risk factors and tested for homogeneity. RESULTS 2462 patients were included: 1708 with and 754 without LOC/PTA. Neurocranial traumatic findings on CT were present in 7.5% and were more common when LOC/PTA was present (8.7%). Neurosurgical intervention was required in 0.4%, irrespective of the presence of LOC/PTA. ORs were comparable across the two subgroups (p>0.05), except for clinical evidence of a skull fracture, with high ORs both when LOC/PTA was present (OR = 37, 95% CI 17 to 80) or absent (OR = 6.9, 95% CI 1.8 to 27). LOC and PTA had significant ORs of 1.9 (95% CI 1.0 to 2.7) and 1.7 (95% CI 1.3 to 2.3), respectively. CONCLUSION Known risk factors have comparable ORs in MHI patients with or without LOC or PTA. MHI patients without LOC or PTA need to be explicitly considered in clinical guidelines.
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Affiliation(s)
- M Smits
- Department of Radiology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
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17
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de Vries M, Ouwendijk R, Flobbe K, Nelemans PJ, Kessels AGH, Schurink GWH, van der Vliet JA, Cuypers PWM, Duijm LEM, van Engelshoven JMA, Hunink MGM, de Haan MW. [Peripheral artery disease: clinical and cost comparison between duplex ultrasonography and contrast-enhanced magnetic resonance angiography--a multicenter randomized trial]. Ned Tijdschr Geneeskd 2007; 151:1789-94. [PMID: 17822252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To determine the clinical and economic consequences of replacing duplex ultrasonography (DUS) by contrast-enhanced magnetic resonance angiography (CE-MRA) for the initial diagnostic work-up of patients with peripheral artery disease (PAD). DESIGN Randomised multicentre study. METHOD In the period from January 2002 to August 2003, consecutive patients with PAD were randomly assigned to CE-MRA or DUS. The primary outcome measure was the costs. Secondary outcome measures included the confidence with which the specialist could take a therapeutic decision on the basis of the imaging study, the change in disease severity, and the change in quality of life (QOL) assessed during 6 months of follow-up. In addition, all costs of imaging, therapeutic interventions and outpatient visits were calculated. RESULTS After 6 months of follow-up the data on 352 patients were analysed. Use of CE-MRA reduced the number of additional vascular-imaging procedures by 42% ((69-40)/69) and the specialists felt more confident about their therapeutic decisions. The diagnostic costs of all imaging studies taken together were Euro 167,- higher, on average, in the CE-MRA group (p < 0.001). However, after 6 months of follow-up, no statistically significant differences were found between the two groups with regard to the change in disease severity, the QOL, or the total costs (p > 0.05). CONCLUSION Based on these findings, a specialist that replaces DUS by CE-MRA will feel more confident about taking a therapeutic decision and will feel less need for additional imaging. However, the diagnostic costs were higher with CE-MRA.
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Affiliation(s)
- M de Vries
- Afd. Radiologie, Academisch Ziekenhuis Maastricht, Maastricht.
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Abstract
Considerable geographic variation exists in the relative use of hemodialysis (HD) vs peritoneal dialysis (PD). Studies comparing survival between these modalities have yielded conflicting results. Our aim was to compare the survival of Dutch HD and PD patients. We developed Cox regression models using 16 643 patients from the Dutch End-Stage Renal Disease Registry (RENINE) adjusting for age, gender, primary renal disease, center of dialysis, year of start of renal replacement therapy, and included several interaction terms. We assumed definite treatment assignment at day 91 and performed an intention-to-treat analysis, censoring for transplantation. To account for time dependency, we stratified the analysis into three time periods, >3-6, >6-15, and >15 months. For the first period, the mortality hazard ratio (HR) of PD compared with HD patients was 0.26 (95% confidence interval (CI) 0.17-0.41) for 40-year-old non-diabetics, which increased with age and presence of diabetes to 0.95 (95% CI 0.64-1.39) for 70-year-old patients with diabetes as primary renal disease. The HRs of the second period were generally higher. After 15 months, the HR was 0.86 (95% CI 0.74-1.00) for 40-year-old non-diabetics and 1.42 (95% CI 1.23-1.65) for 70-year-old patients with diabetes as primary renal disease. We conclude that the survival advantage for Dutch PD compared with HD patients decreases over time, with age and in the presence of diabetes as primary disease.
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Affiliation(s)
- Y S Liem
- The Program for the Assessment of Radiological Technology (ART Program), Department of Epidemiology and Biostatistics, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Krijnen P, van Jaarsveld BC, Hunink MGM, Habbema JDF. The effect of treatment on health-related quality of life in patients with hypertension and renal artery stenosis. J Hum Hypertens 2005; 19:467-70. [PMID: 15759023 DOI: 10.1038/sj.jhh.1001847] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [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: 11/09/2022]
Abstract
The quality of life in patients with hypertension is considered to be impaired mainly by side effects of antihypertensive drug therapy. Since balloon angioplasty for renal artery stenosis has a medication-sparing effect, it may lead to an improvement in quality of life. The objective of the study is to compare the effect of antihypertensive drug therapy and balloon angioplasty on quality of life in patients with hypertension and renal artery stenosis. We compared the quality of life in 56 patients randomised to balloon angioplasty to that in 50 patients randomised to antihypertensive drug therapy after 3 and 12 months of follow-up. Quality of life was measured using a questionnaire on physical symptoms associated with hypertension and antihypertensive drugs, and two generic health questionnaires (MOS Survey and EuroQol instrument). After follow-up, the patients who underwent angioplasty used less antihypertensive drugs than the patients who were treated with antihypertensive drugs only (mean+/-s.d., 1.9+/-0.9 vs 2.5+/-1.0 drugs after 3 months, P=0.002). They reported similar physical complaints, however, and a similar quality of life. The results after 12 months of follow-up were the same. In conclusion, for patients with hypertension and renal artery stenosis, the decrease in antihypertensive medication after intervention is too small to lead to a detectable improvement in quality of life.
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Affiliation(s)
- P Krijnen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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20
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Kertai MD, Boersma E, Bax JJ, Heijenbrok-Kal MH, Hunink MGM, L'talien GJ, Roelandt JRTC, van Urk H, Poldermans D. A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart 2003; 89:1327-34. [PMID: 14594892 PMCID: PMC1767930 DOI: 10.1136/heart.89.11.1327] [Citation(s) in RCA: 218] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery. DESIGN Meta-analysis of published reports. METHODS Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests. RESULTS In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9). CONCLUSIONS On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular dysfunction.
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Affiliation(s)
- M D Kertai
- Department of Cardiology, Erasmus Medical Centre Rotterdam, Rotterdam, Netherlands
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21
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Visser K, Bosch JL, Leiner T, van Engelshoven Jm JMA, Passchier J, Hunink MGM. Patients' Preferences for MR Angiography and Duplex US in the Work-up of Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2003; 26:537-43. [PMID: 14532883 DOI: 10.1016/s1078-5884(03)00387-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [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: 11/19/2022]
Abstract
PURPOSE To measure patients' preferences for magnetic resonance (MR) angiography and duplex ultrasound (US) in the imaging work-up of peripheral arterial disease (PAD). METHODS Ninety-eight patients, who underwent both MR angiography and duplex US, received a questionnaire by mail and their preferences for imaging work-up were assessed in a telephone interview. The questionnaire consisted of one question on which imaging test they preferred, a rating scale score ranging from 0 (not bothersome at all) to 10 (extremely bothersome), and specific questions on whether patients experienced discomfort due to the imaging work-up. Responses were presented as means and frequencies, and differences were tested by non-parametric tests. RESULTS Half of the patient population (50%) had no preference for MR angiography or duplex US, 41% had a preference for MR angiography, and 9% had a preference for duplex US. The average rating scale scores for MR angiography (1.6) and duplex US (1.7) were not significantly different (p=0.53). Four out of 98 (4%) patients responded that they experienced pain during the MR angiography versus 18 (18%) for duplex US (p=0.001). Eight out of 98 (8%) patients responded that they were anxious during the MR angiography versus 1 (1%) for duplex US (p=0.02). CONCLUSION The results suggest that the majority of patients have no preference between MR angiography and duplex US in the diagnostic work-up of PAD. Among patients who do have a preference, MR angiography was preferred over duplex US.
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Affiliation(s)
- K Visser
- Assessment of Radiological Technology Program, Department of Epidemiology and Biostatistics, Erasmus University Medical Center Rotterdam, The Netherlands
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Visser K, de Vries SO, Kitslaar PJEHM, van Engelshoven JMA, Hunink MGM. Cost-effectiveness of diagnostic imaging work-up and treatment for patients with intermittent claudication in The Netherlands. Eur J Vasc Endovasc Surg 2003; 25:213-23. [PMID: 12623332 DOI: 10.1053/ejvs.2002.1838] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [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: 11/11/2022]
Abstract
OBJECTIVE to determine the societal cost-effectiveness of various management strategies, including both the diagnostic imaging work-up and treatment, for patients with intermittent claudication in The Netherlands. METHODS a decision-analytic model was used and included probability and quality of life data available from the literature. A cost-analysis was performed in a university setting in The Netherlands. Imaging work-up options included magnetic resonance angiography (MRA), color-guided duplex ultrasound, or intraarterial digital subtraction angiography (DSA) and treatment options were percutaneous transluminal angioplasty with selective stent placement if feasible or bypass surgery. Management strategies were defined as combinations of imaging work-up and treatment options. A conservative strategy with no imaging work-up and walking exercises was considered as reference. Main outcome measures were quality-adjusted life years (QALYs), lifetime costs (euro), and incremental cost-effectiveness (CE) ratios. The base-case analysis evaluated 60-year-old men with severe unilateral intermittent claudication of at least one year duration. RESULTS the range in QALYs and costs across management strategies that considered angioplasty as only treatment option was small (maximum difference: 0.0033 QALYs and 451 euros). Similarly, the range was small across management strategies that considered angioplasty if feasible otherwise bypass surgery (maximum difference: 0.0033 QALYs and 280 euros). MRA in combination with angioplasty (6.1487 QALYs and 8556 euros) had a CE ratio of 20,000 euros/QALY relative to the conservative strategy. The most effective strategy was DSA in combination with angioplasty if feasible otherwise bypass surgery (6.2254 QALYs and 18,583 euros) which had a CE ratio of 131,000 euros/QALY relative to MRA in combination with angioplasty. CONCLUSION the results suggest that the imaging work-up with non-invasive imaging modalities can replace DSA for the work-up of patients with intermittent claudication without a substantial loss in effectiveness and a minimal cost-reduction. Management strategies including angioplasty are cost-effective in the Netherlands but although strategies including bypass surgery are more effective, their incremental costs are very high.
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Affiliation(s)
- K Visser
- Department of Psychiatry, University Hospital Groningen, The Netherlands
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