Cost-effectiveness of Screening for Atrial Fibrillation Using Wearable Devices.

Importance: Undiagnosed atrial fibrillation (AF) is an important cause of stroke. Screening for AF using wrist-worn wearable devices may prevent strokes, but their cost-effectiveness is unknown. Objective: To evaluate the cost-effectiveness of contemporary AF screening strategies, particularly wrist-worn wearable devices. Design Setting and Participants: This economic evaluation used a microsimulation decision-analytic model and was conducted from September 8, 2020, to May 23, 2022, comprising 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older. Interventions: Eight AF screening strategies, with 6 using wrist-worn wearable devices (watch or band photoplethysmography, with or without watch or band electrocardiography) and 2 using traditional modalities (ie, pulse palpation and 12-lead electrocardiogram) vs no screening. Main Outcomes and Measures: The primary outcome was the incremental cost-effectiveness ratio, defined as US dollars per quality-adjusted life-year (QALY). Secondary measures included rates of stroke and major bleeding. Results: In the base case analysis of this model, the mean (SD) age was 72.5 (7.5) years, and 50% of the individuals were women. All 6 screening strategies using wrist-worn wearable devices were estimated to be more effective than no screening (range of QALYs gained vs no screening, 226-957 per 100 000 individuals) and were associated with greater relative benefit than screening using traditional modalities (range of QALYs gained vs no screening, -116 to 93 per 100 000 individuals). Compared with no screening, screening using wrist-worn wearable devices was associated with a reduction in stroke incidence by 20 to 23 per 100 000 person-years but an increase in major bleeding by 20 to 44 per 100 000 person-years. The overall preferred strategy was wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation, which had an incremental cost-effectiveness ratio of $57 894 per QALY, meeting the acceptability threshold of $100 000 per QALY. The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages (eg, ≥50 years), and with variation in the association of anticoagulation with risk of stroke in the setting of screening-detected AF. Conclusions and Relevance: This economic evaluation of AF screening using a microsimulation decision-analytic model suggests that screening using wearable devices is cost-effective compared with either no screening or AF screening using traditional methods.

Comparative Clinical Effectiveness of Population-Based Atrial Fibrillation Screening Using Contemporary Modalities: A Decision-Analytic Model.

Background Atrial fibrillation (AF) screening is endorsed by certain guidelines for individuals aged ≥65 years. Yet many AF screening strategies exist, including the use of wrist-worn wearable devices, and their comparative effectiveness is not well-understood. Methods and Results We developed a decision-analytic model simulating 50 million individuals with an age, sex, and comorbidity profile matching the United States population aged ≥65 years (ie, with a guideline-based AF screening indication). We modeled no screening, in addition to 45 distinct AF screening strategies (comprising different modalities and screening intervals), each initiated at a clinical encounter. The primary effectiveness measure was quality-adjusted life-years, with incident stroke and major bleeding as secondary measures. We defined continuous or nearly continuous modalities as those capable of monitoring beyond a single time-point (eg, patch monitor), and discrete modalities as those capable of only instantaneous AF detection (eg, 12-lead ECG). In total, 10 AF screening strategies were effective compared with no screening (300-1500 quality-adjusted life-years gained/100 000 individuals screened). Nine (90%) effective strategies involved use of a continuous or nearly continuous modality such as patch monitor or wrist-worn wearable device, whereas 1 (10%) relied on discrete modalities alone. Effective strategies reduced stroke incidence (number needed to screen to prevent a stroke: 3087-4445) but increased major bleeding (number needed to screen to cause a major bleed: 1815-4049) and intracranial hemorrhage (number needed to screen to cause intracranial hemorrhage: 7693-16 950). The test specificity was a highly influential model parameter on screening effectiveness. Conclusions When modeled from a clinician-directed perspective, the comparative effectiveness of population-based AF screening varies substantially upon the specific strategy used. Future screening interventions and guidelines should consider the relative effectiveness of specific AF screening strategies.

Comparative Effectiveness of Implantable Defibrillators for Asymptomatic Brugada Syndrome: A Decision-Analytic Model.

Background Optimal management of asymptomatic Brugada syndrome (BrS) with spontaneous type I electrocardiographic pattern is uncertain. Methods and Results We developed an individual-level simulation comprising 2 000 000 average-risk individuals with asymptomatic BrS and spontaneous type I electrocardiographic pattern. We compared (1) observation, (2) electrophysiologic study (EPS)-guided implantable cardioverter-defibrillator (ICD), and (3) upfront ICD, each using either subcutaneous or transvenous ICD, resulting in 6 strategies tested. The primary outcome was quality-adjusted life years (QALYs), with cardiac deaths (arrest or procedural-related) as a secondary outcome. We varied BrS diagnosis age and underlying arrest rate. We assessed cost-effectiveness at $100 000/QALY. Compared with observation, EPS-guided subcutaneous ICD resulted in 0.35 QALY gain/individual and 4130 cardiac deaths avoided/100 000 individuals, and EPS-guided transvenous ICD resulted in 0.26 QALY gain and 3390 cardiac deaths avoided. Compared with observation, upfront ICD reduced cardiac deaths by a greater margin (subcutaneous ICD, 8950; transvenous ICD, 6050), but only subcutaneous ICD improved QALYs (subcutaneous ICD, 0.25 QALY gain; transvenous ICD, 0.01 QALY loss), and complications were higher. ICD-based strategies were more effective at younger ages and higher arrest rates (eg, using subcutaneous devices, upfront ICD was the most effective strategy at ages 20-39.4 years and arrest rates >1.37%/year; EPS-guided ICD was the most effective strategy at ages 39.5-51.3 years and arrest rates 0.47%-1.37%/year, and observation was the most effective strategy at ages >51.3 years and arrest rates <0.47%/year). EPS-guided subcutaneous ICD was cost-effective ($80 508/QALY). Conclusions Device-based approaches (with or without EPS risk stratification) can be more effective than observation among selected patients with asymptomatic BrS. BrS management should be tailored to patient characteristics.

[Exploration of the Care Needs of Post-Chemotherapy Lung Cancer Patients and Related Factors].

BACKGROUND: Chemotherapy (CT) is the first priority treatment for advanced stage lung cancer. However, symptom distress, impaired ability to conduct daily activities, and post-CT care needs are potential side effects of CT. PURPOSE: To explore the factors related to the care needs of post-chemotherapy lung cancer patients. METHODS: A cross-sectional study was used. One hundred and twenty-one adult patients who had been diagnosed with advanced-stage lung cancer and who had undergone CT using the Platinum and Docetaxel doublet regimen were recruited from a medical center in southern Taiwan. The instruments used included a nursing care needs survey, symptoms distress scale, daily activity interference scale, and patient characteristics datasheet. RESULTS: Participants self-prioritized their emergency management, health consultation, and emotional support activities based on their perceived care needs. The top three post-CT symptoms in terms of severity were: fatigue, appetite change, and sleep disorder. Primary disruptions in daily activities during the post-CT period related to: holding social activities, work, and stair climbing. Significant and positive correlations were found among daily activity interference (r = .30, p < .01), symptoms distress (r = .23, p < .01), and care needs. The regression model indicated daily activity interference as a predictor of care needs, accounting for 10.7% of the total variance. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: These results highlight the relationships among care needs, symptom distress, and daily activity interference in post-chemotherapy lung-cancer patients. The present study provides a reference for nursing care to reduce the symptom distress, to enhance the performance of daily activities, and to meet the care needs of lung-cancer patients.

Do late adolescent fathers have more depressive symptoms than older fathers?

Although fathers are increasingly a focus of attention in research, there is a dearth of research on depressive symptoms among fathers, especially young fathers with toddlers. This study used longitudinal data to examine what risk factors, including the age status of fathers (e.g., late adolescence, emerging adulthood, and adulthood), may be associated with depressive symptoms of fathers when their children were 3 and 5 years of age. A subsample of families for which complete data were available on all variables was used in the analyses (n = 1,403). About 46% of study sample was African American, 27% White, 23% Hispanic, and 4% other race/ethnicity. Paternal depressive symptoms were measured using Composite International Diagnostic Interview-Short Form (CIDI-SF). Late adolescent fatherhood was significantly associated with third-year paternal depressive symptoms but not with fifth-year depressive symptoms. Those who reported low social support were more likely to be depressed at both times. Fathers who did not work for regular pay were more likely to be depressed at the third-year follow-up, but not at the fifth-year follow-up. Parenting stress and being booked/charged with a crime were not associated with third-year paternal depressive symptoms, but were with fifth-year paternal depressive symptoms. This study emphasizes the importance of screening for depressive symptoms of fathers even before the birth of their child and monitoring and treating postpartum depressive symptoms, as first-year depressive symptoms was a significant predictor for third- and fifth-year depressive symptoms. Service providers should focus on the mental health of fathers as well as mothers to promote healthy environments for their children.

Federal funding of social work research: high hopes or sour grapes?

Placed in the historical context of government funding ofacademic research, this critical analysis identifies the complexities and implications of schools of social work pursuing federal grants for research. Schools of social work with particular organizational characteristics are better able to compete for federal grants, incurring lower opportunity costs than others. The low probability of grant success for most schools, the organizational adaptations needed for success, and the narrow epistemology of many funding programs call into question whether federal funding of research should be considered the sine qua non for academic social work.

Exposure to community violence and adolescents' internalizing behaviors among African American and asian American adolescents.

Exposure to community violence can seriously threaten healthy adolescent development. This longitudinal study examines the relationship between exposure to violence in the community and the internalizing behaviors of Asian American and African American adolescents. Data analyzed was from 901 adolescents (57.9% female and 42.1% male, and 84.7% African American and 15.3% Asian American) who had participated in both Wave I and II interviews of the National Longitudinal Survey of Adolescent Health conducted between 1994 and 1996. Being female, having prior internalizing behaviors at baseline, and being exposed to violence significantly predicted African American adolescents' subsequent report of internalizing behaviors and their symptoms. Being female and having prior internalizing behaviors also predicted Asian American adolescents' subsequent internalizing behaviors and their symptoms. However, exposure to violence was not associated with Asian American adolescents' internalizing behaviors. Findings suggested a need to conceptualize mental health risk in a more nuanced context of cultural diversity.