High-Suspicion Subcentimeter Thyroid Nodules: Cost Effectiveness of Active Surveillance versus Fine Needle Aspiration.

PURPOSE: To compare the cost-benefit of active surveillance (AS) against immediate fine needle aspiration (FNA) of sonographically suspicious subcentimeter thyroid nodules. MATERIALS AND METHODS: A Markov model was constructed to compare the cost-benefit of 3 strategies from the point of discovery until death: (a) Surveillance of all nodules, (b) Surveillance of nodules with positive cytology, and (c) Surgery of nodules with positive cytology. The reference case was a 40-year-old woman with a sonographically suspicious subcentimeter thyroid nodule. Transition probabilities, costs, and health state utilities were derived from the literature. Sensitivity analyses were performed to evaluate model uncertainty. Willingness-to-pay threshold was set at $100,000/quality-adjusted life year. RESULTS: Surveillance of nodules with positive cytology dominated in the reference scenario and was cost-beneficial over Surveillance of all nodules, independent of the utility of AS. Surveillance of all nodules was cost-beneficial only at a life expectancy of <2.6 years or surveillance duration of <4 years. CONCLUSIONS: While current guidelines recommend AS of sonographically suspicious subcentimeter nodules, the results of this study suggest that immediate FNA (Surveillance of nodules with positive cytology) is more cost-beneficial than AS (Surveillance of all nodules). Patients with positive cytology on FNA may subsequently opt for AS (Surveillance of nodules with positive cytology) or surgery (Surgery of nodules with positive cytology) according to their level of comfort (ie, utility) with AS.

Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis.

BACKGROUND: Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with atrial fibrillation (AF). Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk for ischemic stroke compared with anticoagulation. OBJECTIVE: To determine the optimal strategy for stroke prevention conditional on a patient's individual risks for ischemic stroke and bleeding. DESIGN: Decision analysis with a Markov model. DATA SOURCES: Evidence from the published literature informed model inputs. TARGET POPULATION: Women and men with nonvalvular AF and without prior stroke. TIME HORIZON: Lifetime. PERSPECTIVE: Clinical. INTERVENTION: LAAO versus warfarin or direct oral anticoagulants (DOACs). OUTCOME MEASURES: The primary end point was clinical benefit measured in quality-adjusted life-years. RESULTS OF BASE-CASE ANALYSIS: The baseline risks for stroke and bleeding determined whether LAAO was preferred over anticoagulants in patients with AF. The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks. For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA2DS2-VASc scores between 2 and 5. The probability of LAAO benefit in QALYs (>80%) at lower bleeding risks (HAS-BLED score of 0 to 1) was limited to patients with lower stroke risks (CHA2DS2-VASc score of 2). Because DOACs carry lower bleeding risks than warfarin, the net benefit of LAAO is less certain than that of DOACs. RESULTS OF SENSITIVITY ANALYSIS: Results were consistent using the ORBIT bleeding score instead of the HAS-BLED score, as well as alternative sources for LAAO clinical effectiveness data. LIMITATION: Clinical effectiveness data were drawn primarily from studies on the Watchman device. CONCLUSION: Although LAAO could be an alternative to anticoagulants for stroke prevention in patients with AF and high bleeding risk, the overall benefit from LAAO depends on the combination of stroke and bleeding risks in individual patients. These results suggest the need for a sufficiently low stroke risk for LAAO to be beneficial. The authors believe that these results could improve shared decision making when selecting patients for LAAO. PRIMARY FUNDING SOURCE: None.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association.

BACKGROUND: The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS: The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS: Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS: The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Singapore's health-care system: key features, challenges, and shifts.

Since Singapore became an independent nation in 1965, the development of its health-care system has been underpinned by an emphasis on personal responsibility for health, and active government intervention to ensure access and affordability through targeted subsidies and to reduce unnecessary costs. Singapore is achieving good health outcomes, with a total health expenditure of 4·47% of gross domestic product in 2016. However, the health-care system is contending with increased stress, as reflected in so-called pain points that have led to public concern, including shortages in acute hospital beds and intermediate and long-term care (ILTC) services, and high out-of-pocket payments. The main drivers of these challenges are the rising prevalence of non-communicable diseases and rapid population ageing, limitations in the delivery and organisation of primary care and ILTC, and financial incentives that might inadvertently impede care integration. To address these challenges, Singapore's Ministry of Health implemented a comprehensive set of reforms in 2012 under its Healthcare 2020 Masterplan. These reforms substantially increased the capacity of public hospital beds and ILTC services in the community, expanded subsidies for primary care and long-term care, and introduced a series of financing health-care reforms to strengthen financial protection and coverage. However, it became clear that these measures alone would not address the underlying drivers of system stress in the long term. Instead, the system requires, and is making, much more fundamental changes to its approach. In 2016, the Ministry of Health encapsulated the required shifts in terms of the so-called Three Beyonds-namely, beyond health care to health, beyond hospital to community, and beyond quality to value.

Developing a toolkit for implementing evidence-based guidelines to manage hypertension and diabetes in Cambodia: a descriptive case study.

BACKGROUND: In Cambodia, economic development accompanied by health reforms has led to a rapidly ageing population and an increasing incidence and prevalence of noncommunicable diseases. National strategic plans recognize primary care health centres as the focal points of care for treating and managing chronic conditions, particularly hypertension and type 2 diabetes. However, health centres have limited experience in providing such services. This case study describes the process of developing a toolkit to facilitate the use of evidence-based guidelines to manage hypertension and type 2 diabetes at the health-centre level. METHODS: We developed and revised a preliminary toolkit based on the feedback received from key stakeholders. We gathered feedback through an iterative process of group and one-to-one consultations with representatives of the Ministry of Health, provincial health department, health centres and nongovernmental organizations between April 2019 and March 2021. RESULTS: A toolkit was developed and organized according to the core tasks required to treat and manage hypertension and type 2 diabetes patients. The main tools included patient identification and treatment cards, risk screening forms, a treatment flowchart, referral forms, and patient education material on risk factors and lifestyle recommendations on diet, exercise, and smoking cessation. The toolkit supplements existing guidelines by incorporating context-specific features, including drug availability and the types of medication and dosage guidelines recommended by the Ministry of Health. Referral forms can be extended to incorporate engagement with community health workers and patient education material adapted to the local context. All tools were translated into Khmer and can be modified as needed based on available resources and arrangements with other institutions. CONCLUSIONS: Our study demonstrates how a toolkit can be developed through iterative engagement with relevant stakeholders individually and in groups to support the implementation of evidence-based guidelines. Such toolkits can help strengthen the function and capacity of the primary care system to provide care for noncommunicable diseases, serving as the first step towards developing a more comprehensive and sustainable health system in the context of population ageing and caring for patients with chronic diseases.

Sequential Multiple Assignment Randomized Trial (SMART) to identify optimal sequences of telemedicine interventions for improving initiation of insulin therapy: A simulation study.

BACKGROUND: To examine the value of a Sequential Multiple Assignment Randomized Trial (SMART) design compared to a conventional randomized control trial (RCT) for telemedicine strategies to support titration of insulin therapy for Type 2 Diabetes Mellitus (T2DM) patients new to insulin. METHODS: Microsimulation models were created in R using a synthetic sample based on primary data from 63 subjects enrolled in a pilot study of a smartphone application (App), Diabetes Pal compared to a nurse-based telemedicine strategy (Nurse). For comparability, the SMART and an RCT design were constructed to allow comparison of four (embedded) adaptive interventions (AIs). RESULTS: In the base case scenario, the SMART has similar overall mean expected HbA1c and cost per subject compared with RCT, for sample size of n = 100 over 10,000 simulations. SMART has lower (better) standard deviations of the mean expected HbA1c per AI, and higher efficiency of choosing the correct AI across various sample sizes. The differences between SMART and RCT become apparent as sample size decreases. For both trial designs, the threshold value at which a subject was deemed to have been responsive at an intermediate point in the trial had an optimal choice (i.e., the sensitivity curve had a U-shape). SMART design dominates the RCT, in the overall mean HbA1c (lower value) when the threshold value is close to optimal. CONCLUSIONS: SMART is suited to evaluating the efficacy of different sequences of treatment options, in addition to the advantage of providing information on optimal treatment sequences.

Trends in functional disability and cognitive impairment among the older adult in China up to 2060: estimates from a dynamic multi-state population model.

BACKGROUND: Available evidence suggests that cognitive impairment (CI), which leads to deficits in episodic memory, executive functions, visual attention, and language, is associated with difficulties in the capacity to perform activities of daily living. Hence any forecast of the future prevalence of functional disability should account for the likely impact of cognitive impairment on the onset of functional disability. Thus, this research aims to address this gap in literature by projecting the number of older adults in China with functional disability and cognitive impairment while accounting for the impact of cognitive impairment on the onset of functional disability. METHODS: We developed and validated a dynamic multi-state population model which simulates the population of China and tracks the transition of Chinese older adults (65 years and older) from 2010 to 2060, to and from six health states-(i) active older adults without cognitive impairment, (ii) active older adults with cognitive impairment, (iii) older adults with 1 to 2 ADL limitations, (iv) older adults with cognitive impairment and 1 to 2 ADL limitations, (v) older adults with 3 or more ADL limitations, and (vi) older adults with cognitive impairment and 3 or more ADL limitations. RESULTS: From 2015 to 2060, the number of older adults 65 years and older in China is projected to increase, of which the number with impairment (herein referred to as individuals with cognitive impairment and/or activity of daily living limitations) is projected to increase more than fourfold from 17·9 million (17·8-18·0) million in 2015 to 96·2 (95·3-97·1) million by 2060. Among the older adults with impairment, those with ADL limitations only is projected to increase from 3·7 million (3·6-3·7 million) in 2015 to 23·9 million (23·4-24·6 million) by 2060, with an estimated annual increase of 12·2% (12·1-12·3); while that for cognitive impairment only is estimated to increase from 11·4 million (11·3-11·5 million) in 2015 to 47·8 million (47·5-48·2 million) by 2060-this representing an annual growth of 7·07% (7·05-7·09). CONCLUSION: Our findings suggest there will be an increase in demand for intermediate and long-term care services among the older adults with functional disability and cognitive impairment.

Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore.

BACKGROUND: Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke. METHOD: Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0-3 months (early) and 4-12 months (late) post-stroke. RESULTS: For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits. CONCLUSION: We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.

Changes in Informed Consent Policy and Treatment Delays in Stroke Thrombolysis.

OBJECTIVES: The efficacy of thrombolytic therapy with tissue plasminogen activator (tPA) is highly time dependent. Although clinical guidelines do not recommend written informed consent as it may cause treatment delays, local policy can supersede and require it. From 2014 to 2017, three out of five public hospitals in Singapore changed from written to verbal consent at different time points. We aimed to examine the association of hospital policy changes regarding informed consent on door-to-needle (DTN) times. MATERIALS AND METHODS: Using data from the Singapore Stroke Registry and surveys of local practice, we analyzed data of 915 acute ischemic stroke patients treated with tPA within 3 hours in all public hospitals between July 2014 to Dec 2017. Patient-level DTN times before and after policy changes were examined while adjusting for clinical characteristics, within-hospital clustering, and trends over time. RESULTS: Patient characteristics and stroke severity were similar before and after the policy changes. Overall, the median DTN times decreased from 68 to 53 minutes after the policy changes. After risk adjustment, changing from written to verbal informed consent was associated with a 5.6 minutes reduction (95% CI 1.1-10.0) in DTN times. After the policy changed, the percentage of patients with DTN ≤60 minutes and ≤45 minutes increased from 35.6% to 66.1% (adjusted OR 1.75; 95% CI 1.12-2.74) and 9.3% to 36.0% (adjusted OR 2.42; 95% CI 1.37-4.25), respectively. CONCLUSION: Changing from written to verbal consent is associated with significant improvement in the timeliness of tPA administration in acute ischemic stroke.

Dyadic approach to post-stroke hospitalizations: role of caregiver and patient characteristics.

AIM: To study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3-12 months post-stroke in Singapore. METHODS: Patients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome. RESULTS: Two hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3-12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization. CONCLUSION: Recommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.

A Cost-Effectiveness Analysis of a Randomized Control Trial of a Tailored, Multifactorial Program to Prevent Falls Among the Community-Dwelling Elderly.

OBJECTIVE: To perform a cost-effectiveness analysis of a multifactorial, tailored intervention to reduce falls among a heterogeneous group of high-risk elderly people. DESIGN: Randomized control trial. SETTINGS: Communities. PARTICIPANTS: Adults aged at least 65 years (N=354) seen at the emergency department (ED) for a fall or fall-related injury and discharged home. INTERVENTIONS: The intervention group received a tailored program of physical therapy focused on progressive training in strength, balance, and gait for a period of 3 months. They also received screening and referrals for low vision, polypharmacy, and environmental hazards. The Short Physical Performance Battery (SPPB) test was assessed at regular intervals to allocate participants into either a home-based or group center-based program. The control group received usual care prescribed by a physician and educational materials on falls prevention. MAIN OUTCOME MEASURES: The incremental cost-effectiveness ratio (ICER) over the 9-month study period based on intervention costs and utility in terms of quality-adjusted life years (QALYs) calculated from EuroQol-5D scores. RESULTS: The ICER was 120,667 Singapore dollars (S$) per QALY gained (S$362/0.003 QALYs), above benchmark values (S$70,000). However, the intervention was more effective and cost-saving among those with SPPB scores of greater than 6 at baseline, higher cognitive function, better vision and no more than 1 fall in the preceding 6 months. The intervention was also cost-effective among those with 0-1 critical comorbidities (S$22,646/QALY). CONCLUSION: The intervention was, overall, not cost-effective, compared to usual care. However, the program was cost-effective among healthier subgroups, and even potentially cost-saving among individuals with sufficient reserve to benefit.

Post-stroke patients with moderate function have the greatest risk of falls: a National Cohort Study.

BACKGROUND: Stroke patients have increased risks of falls. We examined national registry data to evaluate the association between post-stroke functional level and the risk of low falls among post-stroke patients. METHODS: This retrospective cohort study analyzed data from national registries to examine the risk factors for post-stroke falls. Data for patients who suffered ischemic strokes and survived the index hospital admission was obtained from the Singapore National Stroke Registry and matched to the National Trauma Registry, from 2011 to 2015. The primary outcome measure was a low fall (fall height ≤ 0.5 m). Competing risk analysis was performed to examine the association between functional level (by modified Rankin score [mRS] at discharge) and the risk of subsequent low falls. RESULTS: In all, 2255 patients who suffered ischemic strokes had recorded mRS. The mean age was 66.6 years and 58.5% were men. By the end of 2015, 54 (2.39%) had a low fall while 93 (4.12%) died. After adjusting for potential confounders, mRS was associated with fall risk with an inverted U-shaped relationship. Compared to patients with a score of zero, the sub-distribution hazard ratio (SHR) increased to a maximum of 3.42 (95%CI:1.21-9.65, p = 0.020) for patients with a score of 2. The SHR then declined to 2.45 (95%CI:0.85-7.12, p = 0.098), 2.86 (95%CI:0.95-8.61, p = 0.062) and 1.93 (95%CI:0.44-8.52, p = 0.38) for patients with scores of 3, 4 and 5 respectively. CONCLUSIONS: An inverted U-shaped relationship between functional status and fall risk was observed. This is consistent with the complex interplay between decreasing mobility (hence decreased opportunity to fall) and increasing susceptibility to falls. Fall prevention intervention could be targeted accordingly. (263 words).

Systems modelling as an approach for understanding and building consensus on non-communicable diseases (NCD) management in Cambodia.

BACKGROUND: This paper aims to demonstrate how systems modeling methodology of Group Model Building (GMD) can be applied for exploring and reaching consensus on non-communicable disease (NCD) management. This exercise was undertaken as a first step for developing a quantitative simulation model for generating credible estimates to make an investment case for the prevention and management of NCDs. METHODS: Stakeholder engagement was facilitated through the use of a Group Model Building (GMB) approach. This approach combines various techniques in order to gain a whole system perspective. RESULTS: A conceptual qualitative model framework that connects prevention-via risk factors reduction-screening and treatment of non-communicable diseases (NCDs) was developed with stakeholders that draws on stakeholders personal experiences, beliefs, and perceptions through a moderated interactions to gain in-depth understanding of NCDs management. CONCLUSION: Managing NCDs in Cambodia will require concerted effort to tackle NCD risk factors, identifying individuals with NCDs through screening and providing adequate and affordable consistent care to improve health and outcomes of NCDs.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors.

BACKGROUND: It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors. METHODS: Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke. RESULTS: Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter. CONCLUSION: Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Can caregivers report their care recipients' post-stroke hospitalizations and outpatient visits accurately? Findings of an Asian prospective stroke cohort.

BACKGROUND: Health services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors' HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients. METHODS: A prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types. RESULTS: We observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%. CONCLUSIONS: The accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.

Randomized Controlled Trial of Screening, Risk Modification, and Physical Therapy to Prevent Falls Among the Elderly Recently Discharged From the Emergency Department to the Community: The Steps to Avoid Falls in the Elderly Study.

OBJECTIVE: To evaluate the effectiveness of a multifactorial, tailored program of physical therapy to reduce the occurrence of falls among a heterogeneous group of high-risk elderly Singaporeans recently discharged from the emergency department (ED). DESIGN: Randomized controlled trial. SETTING: Communities. PARTICIPANTS: Adults (N=354) aged ≥65 years who were seen in the ED for a fall or fall-related injuries and discharged home. INTERVENTIONS: The intervention primarily consisted of a tailored program of physical therapy focused on progressive training in strength, balance, and gait for a period of 3 months. Participants in the intervention group also received screening and follow-up for vision, polypharmacy, and environmental hazards. Participants in the control group received usual care prescribed by a physician and educational materials on falls prevention. MAIN OUTCOME MEASURES: The primary outcome measure was experiencing at least 1 fall during the 9-month study period (a 3-mo active intervention phase and a 6-mo maintenance phase). Secondary outcome measures were the occurrence of at least 1 injurious fall during the study period and a change in the Short Physical Performance Battery (SPPB) score. Participants were assessed both after 3 and 9 months. RESULTS: During the 9-month study period, 37.8% of the control group and 30.5% of the intervention group fell at least once, which was not statistically significantly different (odds ratio [OR]=.72; 95% confidence interval [CI], .46-1.12; P=.146). The intervention group had statistically significantly fewer individuals with injurious falls (OR=.56; 95% CI, .32-.98; P=.041) and less deterioration in physical performance, reflected by a mean difference of 0.6 in SPPB scores (P=.029). Multivariate analyses indicated a strong interaction effect between the intervention and the presence of 2 or more major comorbidities; after accounting for this effect, the intervention program reduced the number of people experiencing at least 1 fall (OR=.34; 95% CI, .17-.67; P=.002). CONCLUSIONS: We observed that in this heterogeneous population, the proportion of participants experiencing at least 1 fall during the study period was not statistically significantly lower in the intervention group compared with the control group. Secondary analyses strongly suggest that individuals with 2 or more major comorbidities do not benefit from a tailored physical therapy program; however, individuals with less comorbidity may substantially benefit.

At-Home Versus In-Clinic INR Monitoring: A Cost-Utility Analysis from The Home INR Study (THINRS).

BACKGROUND: Effective management of patients using warfarin is resource-intensive, requiring frequent in-clinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST. OBJECTIVE: To perform a cost-utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency. PATIENTS/INTERVENTIONS: In this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly in-clinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up. RESULTS: PST and HQACM participants were similar with regard to gender, age, and CHADS2 score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per quality-adjusted life year gained with PST once weekly was $5566 (95 % CI, -$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions. CONCLUSION: Weekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.

Projecting the effects of long-term care policy on the labor market participation of primary informal family caregivers of elderly with disability: insights from a dynamic simulation model.

BACKGROUND: Using Singapore as a case study, this paper aims to understand the effects of the current long-term care policy and various alternative policy options on the labor market participation of primary informal family caregivers of elderly with disability. METHODS: A model of the long-term care system in Singapore was developed using System Dynamics methodology. RESULTS: Under the current long-term care policy, by 2030, 6.9 percent of primary informal family caregivers (0.34 percent of the domestic labor supply) are expected to withdraw from the labor market. Alternative policy options reduce primary informal family caregiver labor market withdrawal; however, the number of workers required to scale up long-term care services is greater than the number of caregivers who can be expected to return to the labor market. CONCLUSIONS: Policymakers may face a dilemma between admitting more foreign workers to provide long-term care services and depending on primary informal family caregivers.

Optimal management of Riata leads with no known electrical abnormalities or externalization: a decision analysis.

INTRODUCTION: Riata and Riata ST implantable cardioverter-defibrillator (ICD) leads (St. Jude Medical, Sylmar, CA, USA) can develop conductor cable externalization and/or electrical failure. Optimal management of these leads remains unknown. METHODS AND RESULTS: A Markov model compared 4 lead management strategies: (1) routine device interrogation for electrical failure, (2) systematic yearly fluoroscopic screening and routine device interrogation, (3) implantation of new ICD lead with capping of the in situ lead, and (4) implantation of new ICD lead with extraction of the in situ lead. The base case was a 64-year-old primary prevention ICD patient. Modeling demonstrated average life expectancies as follows: capping with new lead implanted at 134.5 months, extraction with new lead implanted at 134.0 months, fluoroscopy with routine interrogation at 133.9 months, and routine interrogation at 133.5 months. One-way sensitivity analyses identified capping as the preferred strategy with only one parameter having a threshold value: when risk of nonarrhythmic death associated with lead abandonment is greater than 0.05% per year, lead extraction is preferred over capping. A second-order Monte Carlo simulation (n = 10,000), as a probabilistic sensitivity analysis, found that lead revision was favored with 100% certainty (extraction 76% and capping 24%). CONCLUSIONS: Overall there were minimal differences in survival with monitoring versus active lead management approaches. There is no evidence to support fluoroscopic screening for externalization of Riata or Riata ST leads.

The impact of frequency of patient self-testing of prothrombin time on time in target range within VA Cooperative Study #481: The Home INR Study (THINRS), a randomized, controlled trial.

Anticoagulation (AC) is effective in reducing thromboembolic events for individuals with atrial fibrillation (AF) or mechanical heart valve (MHV), but maintaining patients in target range for international normalized ratio (INR) can be difficult. Evidence suggests increasing INR testing frequency can improve time in target range (TTR), but this can be impractical with in-clinic testing. The objective of this study was to test the hypothesis that more frequent patient-self testing (PST) via home monitoring increases TTR. This planned substudy was conducted as part of The Home INR Study, a randomized controlled trial of in-clinic INR testing every 4 weeks versus PST at three different intervals. The setting for this study was 6 VA centers across the United States. 1,029 candidates with AF or MHV were trained and tested for competency using ProTime INR meters; 787 patients were deemed competent and, after second consent, randomized across four arms: high quality AC management (HQACM) in a dedicated clinic, with venous INR testing once every 4 weeks; and telephone monitored PST once every 4 weeks; weekly; and twice weekly. The primary endpoint was TTR at 1-year follow-up. The secondary endpoints were: major bleed, stroke and death, and quality of life. Results showed that TTR increased as testing frequency increased (59.9 ± 16.7 %, 63.3 ± 14.3 %, and 66.8 ± 13.2 % [mean ± SD] for the groups that underwent PST every 4 weeks, weekly and twice weekly, respectively). The proportion of poorly managed patients (i.e., TTR <50 %) was significantly lower for groups that underwent PST versus HQACM, and the proportion decreased as testing frequency increased. Patients and their care providers were unblinded given the nature of PST and HQACM. In conclusion, more frequent PST improved TTR and reduced the proportion of poorly managed patients.