Eberechukwu Onukwugha

Concordance between administrative claims and registry data for identifying metastasis to the bone: an exploratory analysis in prostate cancer

BackgroundTo assess concordance between Medicare claims and Surveillance, Epidemiology, and End Results (SEER) reports of incident BM among prostate cancer (PCa) patients. The prevalence and consequences of bone metastases (BM) have been examined across tumor sites using healthcare claims data however the reliability of these claims-based BM measures has not been investigated.MethodsThis retrospective cohort study utilized linked registry and claims (SEER-Medicare) data on men diagnosed with incident stage IV M1 PCa between 2005 and 2007. The SEER-based measure of incident BM was cross-tabulated with three separate Medicare claims approaches to assess concordance. Sensitivity, specificity and positive predictive value (PPV) were calculated to assess the concordance between registry- and claims-based measures.ResultsBased on 2,708 PCa patients in SEER-Medicare, there is low to moderate concordance between the SEER- and claims-based measures of incident BM. Across the three approaches, sensitivity ranged from 0.48 (0.456 – 0.504) to 0.598 (0.574 - 0.621), specificity ranged from 0.538 (0.507 - 0.569) to 0.620 (0.590 - 0.650) and PPV ranged from 0.679 (0.651 - 0.705) to 0.690 (0.665 - 0.715). A comparison of utilization patterns between SEER-based and claims-based measures suggested avenues for improving sensitivity.ConclusionClaims-based measures using BM ICD 9 coding may be insufficient to identify patients with incident BM diagnosis and should be validated against chart data to maximize their potential for population-based analyses.

Healthcare Rationing by Proxy

The application of cost-effectiveness analysis in healthcare has become commonplace in the US, but the validity of this approach is in jeopardy unless the proverbial

Cost-Effectiveness of Cytochrome P450 2C19 Genotype Screening for Selection of Antiplatelet Therapy with Clopidogrel or Prasugrel

US50 000 per QALY benchmark for determining value for money is updated for the 21st century.While the initial aim of this articlewas to review the arguments for abandoning the

Sensitivity analysis in cost-effectiveness studies: from guidelines to practice.

US50 000 threshold, it quickly turned to questioning whether we should maintain a fixed threshold at all. Our consideration of the relevance of thresholds was framed by two important historical considerations. First, cost-effectiveness analysis was developed for a resource allocation exercise where a threshold would be determined endogenously by maximizing a fixed budget across all possible interventions and not for piecemeal evaluation where a threshold needs to be set exogenously. Second, the foundations of the

Reasons for discharges against medical advice: a qualitative study

US50 000 threshold are highly dubious, so it would be unacceptablemerely to adjust for inflation or current clinical practice.Upon consideration of both sides of the argument, we conclude that the arguments for abandoning the concept for maintaining a fixed threshold outweigh those for keeping one. Furthermore, we document a variety of reasons why a threshold needs to vary in the US, including variations across payer, over time, in the true budget impact of interventions and in the measurement of the effectiveness of interventions. We conclude that while a threshold may be needed to interpret the results of a cost-effectiveness analysis, that threshold must vary across payers, populations and even procedures.

Health disparities in staging of SEER-Medicare prostate cancer patients in the United States

For example, scenario B has an ICER, as reported in Table 2, of –

Comparative Effectiveness of Different Chemotherapeutic Regimens on Survival of People Aged 66 and Older with Stage III Colon Cancer:: A Real World Analysis Using Surveillance, Epidemiology, and End Results-Medicare Data

11,710 (95% confidence interval [CI] –11,480 to –

Chemotherapy treatment and survival in older women with estrogen receptor-negative metastatic breast cancer: a population-based analysis.

11,950). This is not illustrated correctly in Figure 2. The authors used the inverse of the ICER; in other words, they used the reverse comparison (i.e., prasugrel versus genotyping as opposed to genotyping versus prasugrel). Clearly, the authors did the ICER calculations incorrectly:

Engaging hard-to-reach patients in patient-centered outcomes research

Cost-effectiveness analysis (CEA) is one of the main tools of economic evaluation. Every CEA is based on a number of assumptions, some of which may not be accurate, introducing uncertainty. Sensitivity analysis (SA) formalizes ways to measure and evaluate this uncertainty. Specific sources of uncertainty in CEA have been noted by various researchers. In this work, we consolidate across all sources of uncertainty, discuss the imbalanced attention to SA across different sources, and discuss criteria for conducting and reporting SA to help bridge the gap between guidelines and practice.Guidelines on how to perform SA have been published for many years in response to requests for greater standardization among researchers. Decision makers tasked with reviewing new health technologies also seem to appreciate the additional information conveyed by a robust SA, including the attention to important patient subgroups. Yet, past reviews have shown that there is a substantial gap between the guidelines’ suggestions and the quality of SA in the field. Past reviews have also focused on one or two but not all three sources of uncertainty. The objective of our work is to comprehensively review all different sources of uncertainty and provide a concise set of criteria for conducting and presenting SA, stratified by common modelling approaches, including decision analysis and regression models.We first provide an overview of the three sources of uncertainty in a CEA (parameter, structural and methodological), including patient heterogeneity. We then present results from a literature review of the conduct and reporting of SA based on 406 CEA articles published between 2000 and mid-2009. We find that a minority of papers addressed at least two of the three sources of uncertainty, with no change over time. On the other hand, the use of some sophisticated techniques, such as probabilistic SA, has surged over the past 10 years. Lastly, we identify criteria for reporting uncertainty-robust SA and also discuss how to conduct SA and how to improve the reporting of SA for decision makers. We recommend that researchers take a more comprehensive view of uncertainty when planning SA for an economic evaluation.

A Sustainable Strategy to Prevent Misuse of Antibiotics for Acute Respiratory Infections

Background There is limited information in the literature about reasons for discharges against medical advice (DAMA) as supplied by patients and providers. Information about the reasons for DAMA is necessary for identifying workable strategies to reduce the likelihood and health consequences of DAMA. The objective of this study is to identify the reasons for DAMA based on patient and multicategory provider focus-group interviews (FGIs). Methods Patients who discharged against medical advice between 2006 and 2008 from a large, academic medical centre along with hospital providers reporting contact with patients who left against medical advice were recruited. Three patient-only groups, one physician-only group and one nurse/social worker group were held. Focus-group interviews were transcribed, and a thematic analysis was performed to identify themes within and across groups. Participants discussed the reasons for patient DAMA and identified potential solutions. Results Eighteen patients, five physicians, six nurses and four social workers participated in the FGIs. Seven themes emerged across the separate patient, doctor, nurse/social worker FGIs of reasons why patients leave against medical advice: (1) drug addiction, (2) pain management, (3) external obligations, (4) wait time, (5) doctors bedside manner, (6) teaching hospital setting and (7) communication. Solutions to tackle DAMA identified by participants revolved mainly around enhanced communication and provider education. Conclusions In a large, academic medical centre, the authors find some differences and many similarities across patients and providers in identifying the causes of and solutions to DAMA, many of which relate to communication.