Michael Rothberg

Management of influenza symptoms in healthy adults

OBJECTIVE: To determine the cost-effectiveness of rapid diagnostic testing and empiric antiviral therapy for healthy adults with symptoms of influenza.DESIGN: Cost-effectiveness analysis using a decision model based on previously published data. Outcome measures included costs and quality-adjusted life expectancy.SETTING: Physician’s office.PATIENTS/PARTICIPANTS: Hypothetically healthy, working adults < 65 years of age presenting with cough and fever during the influenza season.INTERVENTIONS: Rapid testing or clinical diagnosis followed by treatment with amantadine, rimantadine, oseltamivir, or zanamivir compared with no antiviral therapy.RESULTS: Base-case analysis: not giving antiviral therapy is the most expensive and least effective strategy, costing

Can residents learn to be good doctors without harming patients

471 per patient, mostly owing to time lost from work. Amantadine treatment increases life expectancy by 0.0014 quality-adjusted life years (QALYs) while saving

Residents-as-Teachers: Implementing a Toolkit in Morning Report to Redefine Resident Roles

108 per patient relative to no antiviral therapy. Zanamivir is slightly more effective than amantadine, adding 0.0002 QALYs at an incremental cost of

Cost-effective approaches to influenza prevention and treatment

31, or

Cost-Effectiveness of Clopidogrel plus Aspirin versus Aspirin Alone

133,000 per QALY saved. All other strategies, including testing strategies, are both less effective and more expensive.SENSITIVITY ANALYSIS: The model is sensitive to the probability of influenza infection, proportion of influenza caused by type B, the relative efficacy of the various drugs, and the value of a workday. At a clinical probability of influenza infection >20%, antiviral therapy is favored. As the proportion of influenza B increases, zanamivir is favored over amantadine. Testing is rarely indicated. Ignoring the costs of lost workdays, amantadine treatment costs

Ambulatory Morning Report: A Case-Based Method of Teaching EBM Through Experiential Learning.

1,200/QALY saved.CONCLUSIONS: Antiviral therapy with either amantadine or zanamivir is cost-effective for healthy, young patients with influenza-like illness during the influenza season, depending on the prevalence of influenza B.

The effect of patient education in decision making regarding elective percutaneous coronary intervention

One of Dr. Richard Vilters former residents mustered his courage, approached Dr. Vilter and asked Dr. Vilter, you are such a marvelous clinician. To what do you attribute your success? Vilter replied Good judgment. The questioner thought for a moment and, not completely satisfied with the response, asked, But Dr. Vilter, to what do you attribute your good judgment? Vilter replied: Experience. Still not satisfied, the questioner pursued it one step further. But Dr. Vilter, how does one gain experience? Vilters response: Bad judgment. 1 .

The Clinically Inapparent Adrenal Mass: Update in Diagnosis and Management

Background: Morning report was initially created to meet service needs. Purpose: The objective was to improve morning report through a toolkit combining principles of learning theory with resident teaching. Methods: The toolkit consists of three parts: a guideline describing expectations, a worksheet outlining teaching plans, and a feedback form facilitating post-presentation feedback. In 2009–2010, internal medicine residents met with a chief resident before their presentations to refine teaching plans. The chief resident then supported the presenter in achieving their objectives and provided post-presentation feedback. Residents were surveyed before and 6 months after the intervention. Mean scores were compared using an unpaired t test. Results: Residents’ ratings improved in the following domains: understanding expectations (3.10 vs. 4.02, p = .0003), presentation organization (3.50 vs. 4.25, p = .005), and creating and accomplishing learning objectives (3.31 vs. 4.00, p = .002). Residents commented positively on the improved presentations. Conclusions: This toolkit, based on educational principles, improved morning report presentations.

Management of clinically inapparent adrenal mass.

Influenza, the seventh leading cause of death in the USA, accounts for 35,000 deaths and over 200,000 hospitalizations annually in that country alone. Recent advances in influenza vaccines, diagnosis and treatment have created numerous options for practicing clinicians, as well as economic opportunities for the makers of vaccines, rapid diagnostic tests and antiviral drugs. Since influenza-like illness affects up to half of the population each year, selective use of expensive tests and treatments is essential to the practice of cost-effective medicine. Over the past 5 years, dozens of economic evaluations of influenza vaccination, rapid testing and antiviral therapy have been published, many of which are free of commercial bias. The existing literature, drawing practical lessons for clinical practice is reviewed, and new developments on the horizon are explored including vaccines, surveillance methods, antiviral agents and pandemic preparedness.

Characteristics, Managements, and Outcomes of Patients Hospitalized to Intensive Care Unit With an Acute Exacerbation of COPD in US 2008-2012

TO THE EDITOR: As Schleinitz and Heidenreich pointed out (1), their finding that combination antiplatelet therapy with clopidogrel and aspirin in the first year following an acute coronary syndrome represents good value according to traditional limits of cost-effectiveness has serious economic implications if adopted into practice. Although decision analytic models offer valuable insight into treatment decisions, such as the observation that the first month of treatment is much more cost-effective than subsequent months, the simplifying assumptions required for modeling can lead to biased conclusions when comparing the cost-effectiveness of an intervention with an external benchmark. Before making treatment or policy decisions on the basis of a decision model, it is important to examine the key assumptions. In this analysis, the authors apply the 20% reduction in overall vascular events seen in the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial (2) equally to nonfatal myocardial infarctions, strokes, and death from cardiovascular causes. Although patients randomly assigned to clopidogrel did experience a 23% reduction in nonfatal myocardial infarction, the reductions in stroke (14%) and cardiac deaths (7%) did not reach statistical significance. This finding parallels observations of warfarin therapy in acute coronary syndromes (3, 4). In CURE, the 95% CI for the relative risk for cardiac death extended from 0.79 to 1.08, making a 20% reduction unlikely. The authors did perform sensitivity analysis, but the minimum risk reduction considered was 10%, greater than the 7% reduction in cardiovascular mortality seen in the trial. Because there was no long-term quality adjustment for myocardial infarction, any gain in quality-adjusted life-years had to come from decreasing rates of stroke and cardiac death. As neither of these outcomes alone nor the combination of the 2 showed statistically significant decreases with clopidogrel, more data are needed to know the true cost-effectiveness of the treatment. In the meantime, a Monte Carlo analysis using a different relative risk reduction for each outcome based on its 95% CI would offer a truer estimate of the cost-effectiveness of clopidogrel than what has been presented.