Gustavo R. Heudebert

Choice of long-term strategy for the management of patients with severe esophagitis : A cost-utility analysis

BACKGROUND & AIMS Omeprazole has shown remarkable efficacy and safety in the treatment of patients with gastroesophageal reflux disease (GERD); similarly, laparoscopic techniques have allowed less morbidity in patients undergoing fundoplication procedures. Concerns about the long-term cost and safety of both strategies have prompted a debate of their role in long-term management of patients with severe erosive esophagitis. METHODS A cost-utility analysis was performed to compare two strategies: laparoscopic Nissen fundoplication (LNF) vs. omeprazole. A two-stage Markov model was used to obtain cost and efficacy estimates; all estimates were discounted at 3% per year. The time horizon was 5 years. Sensitivity analyses were performed on all relevant variables. RESULTS Both strategies were similarly effective (4.33 quality-adjusted life years per patient), with omeprazole less expensive than LNF (

Adverse Cardiac Events After Surgery: Assessing Risk in a Veteran Population

6053 vs.

Viewpoint: Taking Apart the Art: The Risk of Anatomizing Clinical Competence

9482 per patient). At 10 years, LNF and omeprazole costs were similar. Efficacy estimates were extremely sensitive to changes in quality of life associated with postoperative symptoms and long-term use of medication. CONCLUSIONS Medical therapy is the preferred treatment strategy for most patients with severe erosive esophagitis. Individuals with a long life expectancy are good candidates for LNF if postoperative morbidity is low and GERD symptoms remain abated for many years.

Cost-effectiveness of screening, surveillance, and primary prophylaxis strategies for esophageal varices.

OBJECTIVE: To establish rates of and risk factors for cardiac complications after noncardiac surgery in veterans.DESIGN: Prospective cohort study.SETTING: A large urban veterans affairs hospital.PARTICIPANTS: One thousand patients with known or suspected cardiac problems undergoing 1,121 noncardiac procedures.MEASUREMENTS: Patients were assessed preoperatively for important clinical variables. Postoperative evaluation was done by an assessor blinded to preoperative status with a daily physical examination, electrocardiogram, and creatine kinase with MB fraction until postoperative day 6, day of discharge, death, or reoperation (whichever occurred earliest). Serial electrocardiograms, enzymes, and chest radiographs were obtained as indicated. Severe cardiac complications included cardiac death, cardiac arrest, myocardial infarction, ventricular tachycardia, and fibrillation and pulmonary edema. Serious cardiac complications included the above, heart failure, and unstable angina.MAIN RESULTS: Severe and serious complications were seen in 24% and 32% of aortic, 8.3% and 10% of carotid, 11.8% and 14.7% of peripheral vascular, 9.0% and 13.1% of intraabdominal/intrathoracic, 2.9% and 3.3% of intermediate-risk (head and neck and major orthopedic procedures), and 0.27% and 1.1% of low-risk procedures respectively. The five associated patient-specific risk factors identified by logistic regression are: myocardial infarction <6 months (odds ratio [OR], 4.5; 95% confidence interval [CI], 1.9 to 12.9), emergency surgery (OR, 2.6; 95% CI, 1.2 to 5.6), myocardial infarction >6 months (OR, 2.2; 95% CI, 1.4 to 3.5), heart failure ever (OR, 1.9; 95% CI, 1.2 to 3.0), and rhythm other than sinus (OR, 1.7; 95% CI, 0.9 to 3.2). Inclusion of the planned operative procedure significantly improves the predictive ability of our risk model.CONCLUSIONS: Five patient-specific risk factors are associated with high risk for cardiac complications in the perioperative period of noncardiac surgery in veterans. Inclusion of the operative procedure significantly improves the predictive ability of the risk model. Overall cardiac complication rates (pretest probabilities) are established for these patients. A simple nomogram is presented for calculation of post-test probabilities by incorporating the operative procedure.

The changing etiology of chronic diarrhea in HIV-infected patients with CD4 cell counts less than 200 cells/mm3.

The Accreditation Council for Graduate Medical Education (ACGME) is encouraging medical residency programs to objectively assess their trainees for possession of six general clinical competencies by the completion of residency training. This is the thrust of the ACGME Outcome Project, now in its seventh year. As residency programs seek to integrate the general competencies into clinical training, educators have begun to suggest that objective assessment of clinical competence may be able to guide decisions about length of training and timing of subspecialization. The authors contend that higher-level competence is not amenable to assessment by the objective comparison of resident performance with learning objectives, even if such objectives are derived from general competencies. Present-day attempts at such assessment echo the uses to which medical schools hoped to put curricular learning objectives in the 1970s. Objective assessment may capture knowledge and skills that amount to the “building blocks” of competence, but it cannot elucidate or scrutinize higher-level clinical competence. Higher-level competence involves sensitivity to clinical context and can be validly appraised only in such a context by fully competent clinical appraisers. Such assessment is necessarily subjective, but it need not be unreproducible if raters are trained and if sampling of trainee performance is sufficiently extensive. If the ACGME approach to clinical competency is indeed brought to bear on decisions about training length and subspecialization timing, the present apprenticeship model for clinical training in the United States, a model both remarkably successful and directly descendant from Oslers innovations, will be under threat.

Do local opinion leaders augment hospital quality improvement efforts? A randomized trial to promote adherence to unstable angina guidelines

OBJECTIVE:Screening for varices is recommended in patients with cirrhosis to institute primary prophylaxis to prevent variceal bleeding. Our aim was to compare the cost-effectiveness of four strategies, including no screening/no prophylaxis, universal screening and primary prophylaxis with β-blockers, universal screening and primary prophylaxis with variceal ligation, and universal institution of primary prophylaxis with β-blockers without screening.METHODS:We constructed a Markov simulation model in two hypothetical cohorts of 50-yr-old patients with cirrhosis (one compensated and one decompensated), who were followed for 5 yr. Transition probabilities were derived from the medical literature, and costs reflected Medicare reimbursement rates at our institution.RESULTS:In patients with compensated cirrhosis, screening and primary prophylaxis with β-blockers is associated with an incremental cost-effectiveness ratio of

What is heartburn worth? A cost-utility analysis of management strategies.

3605 per year of life saved. The results were most sensitive to the prevalence of varices and risk of variceal bleeding. In patients with decompensated liver disease, primary prophylaxis without screening was associated with an incremental cost-effectiveness ratio of

A Pilot Study Using Nominal Group Technique to Assess Residents’ Perceptions of Successful Attending Rounds

1154 per year of life saved. The results were most sensitive to the cost of β-blockers and endoscopy.CONCLUSIONS:Screening for varices is an affordable strategy in compensated liver disease, whereas universal primary prophylaxis with β-blockers is cost-effective in decompensated patients.

Re-examination of the cost-effectiveness of surgical versus medical therapy in patients with gastroesophageal reflux disease: the value of long-term data collection.

PURPOSE:The purpose of this study was to evaluate the incidence and causes of chronic diarrhea in patients with AIDS over a period of time that included the pre-HAART (highly active antiretroviral therapy) era and the introduction of HAART.METHODS:The study cohort was comprised of patients receiving primary care at a university-associated outpatient HIV clinic from January 1, 1995 to December 31, 1997. Patients were identified retrospectively through a clinical database and were included in the study if their diarrhea had persisted for longer than two weeks and their CD4 cell count at time of symptoms was <200 cells/mm3. Further data were obtained by chart review.RESULTS:Over the 36-month period, the occurrence of chronic diarrhea did not change significantly, ranging from 8 to 10.5% per year in patients with CD4 cell counts <200 cells/mm3. The percentage of patients diagnosed with opportunistic infectious etiologies decreased over the three-year period from 53% (1995) to 13% (1997). The percentage of patients diagnosed with noninfectious causes increased from 32% to 70% over this same time period.CONCLUSIONS:Over the three years of the study, the incidence of chronic diarrhea in AIDS patients in our clinic did not change. The etiologies of diarrhea did change significantly, with an increased incidence of noninfectious causes and a decreased incidence of opportunistic infectious causes. This shift in etiologies coincides with the introduction and increased use of HAART in our clinic population (1996).

Cost-effectiveness of low-molecular-weight heparin in the treatment of proximal deep vein thrombosis

Background. The influence of an opinion leader intervention on adherence to Unstable Angina (UA) guidelines compared with a traditional quality improvement model was investigated. Research Design. A group-randomized controlled trial with 2210 patients from 21 hospitals was designed. There were three intervention arms: (1) no intervention (NI); (2) a traditional Health Care Quality Improvement Program (HCQIP); and (3) a physician opinion leader in addition to the HCQIP model (OL). Quality indicators included: electrocardiogram within 20 minutes, antiplatelet therapy within 24 hours and at discharge, and heparin and &bgr;-blockers during hospitalization. Hospitals could determine the specific indicators they wished to target. Potential cases of UA were identified from Medicare claims data. UA confirmation was determined by a clinical algorithm based on data abstracted from medical records. Data analyses included both hospital level analysis (analysis of variance) and patient level analysis (generalized linear models). Results. The only statistically significant postintervention difference in percentage compliant was greater improvement for the OL group in the use of antiplatelet therapy at 24 hours in both hospital level (P = 0.01) and patient level analyses (P <0.05) compared with the HCQIP and NI groups. When analyses were confined to hospitals that targeted specific indicators, compared with the HCQIP hospitals, the OL hospitals showed significantly greater change in percentage compliant postintervention in both antiplatelet therapy during the first 24 hours (20.2% vs. −3.9%, P = 0.02) and heparin (31.0% vs.9.1%, P = 0.05). Conclusions. The influence of physician opinion leaders was unequivocally positive for only one of five quality indicators. To maximize adherence to best practices through physician opinion leaders, more research on how these physicians influence health care delivery in their organizations will be required.