Validation of an algorithm to identify incident interstitial lung disease in patients with rheumatoid arthritis.

BACKGROUND/PURPOSE: Interstitial lung disease (ILD) is an important problem for patients with rheumatoid arthritis (RA). However, current approaches to ILD case finding in real-world data have been evaluated only in limited settings and identify only prevalent ILD and not new-onset disease. Our objective was to develop, refine, and validate a claims-based algorithm to identify both prevalent and incident ILD in RA patients compared to the gold standard of medical record review. METHODS: We used administrative claims data 2006-2015 from Medicare to derive a cohort of RA patients. We then identified suspected ILD using variations of ILD algorithms to classify both prevalent and incident ILD based on features of the data that included hospitalization vs. outpatient setting, physician specialty, pulmonary-related diagnosis codes, and exclusions for potentially mimicking pulmonary conditions. Positive predictive values (PPV) of several ILD algorithm variants for both prevalent and incident ILD were evaluated. RESULTS: We identified 234 linkable RA patients with sufficient data to evaluate for ILD. Overall, 108 (46.2%) of suspected cases were confirmed as ILD. Most cases (64%) were diagnosed in the outpatient setting. The best performing algorithm for prevalent ILD had a PPV of 77% (95% CI 67-84%) and for incident ILD was 96% (95% CI 85-100%). CONCLUSION: Case finding in administrative data for both prevalent and incident interstitial lung disease in RA patients is feasible and has reasonable accuracy to support population-based research and real-world evidence generation.

Beyond the pressure ulcer blame game: reflections for the future.

The concept of skin wounds caused primarily as a result of external physical forces has been the focus of many healthcare professionals for decades. Unfortunately, some of the choices made regarding the definition, description, and topical management of pressure ulcers hampers the appreciation of the complexity of issues that generally accompany the occurrence of these wounds. As the healthcare industry increasingly focuses on quality and accountability, industry watchdogs continue to develop metrics to evaluate quality of care while legal professionals demand more accountability for healthcare interventions. The management of pressure ulcers is often scrutinized and many healthcare providers are often unfairly accused of neglect. The occurrence of pressure ulcers, when viewed as a failure of the healthcare system, prevents the comprehensive and constructive attention this topic deserves. Therefore, as wound care providers, we must change the image of pressure ulcers and provide a more balanced portrayal of the influences, treatments, and likely outcomes of these wounds. We must separate fact from fiction and reality from the psychological reaction that pressure ulcers evoke. It is now time to recreate a dialogue for pressure ulcers that is productive, realistic, and likely to result in the advancement of care.

The road to abortion (II): how government got hooked.

The first part of this series traced close links between eugenics (the effort to breed a "better" human race) and population control throughout the greater part of this century up to the 1960s. It stressed the population work of early eugenicists and eugenics sympathizers such as Frederick Osborn, Margaret Sanger, Gunnar Myrdal, Alan Guttmacher, Garrett Hardin and John D. Rockefeller 3rd. This second and concluding part will show how population controllers, from the 60s onward increasingly added economic and foreign-policy concerns to their original "eugenics" motive of improving human genetic stock. Working in both Democratic and Republican administrations, they gained major government backing for their programs and also played a key role in the legalization of abortion. I will use President Richard Nixon's administration as an example of heavy government involvement.

Quality improvement in an integrated urban healthcare system: a necessary journey.

Public hospitals and clinics in the United States provide health care for the needs of large numbers of people who are medically indigent, homeless, chronically mentally ill, and suffer medical and social disorders associated with poverty. These "safety-net" healthcare providers traditionally struggle with barriers to providing high-quality, patient-sensitive care, including decaying physical facilities, burdensome bureaucracies, underfunded capital equipment and construction programs, and complex, politically driven budgets and governance. However, these same institutions now must compete for their own Medicaid and Medicare clientele because the private sector is marketing to those patients. They also must continue to provide increasing services to growing numbers of uninsured patients. To accomplish this, these institutions must reinvent themselves as patient-focused, high-quality, cost-effective healthcare providers. The Denver Health system is the public safety-net provider for the city and county of Denver. This large public institution has instituted a multifaceted performance-improvement program. The program includes training employees for patient-focused service, implementing continuous quality-improvement practices, instituting clinical pathways, revising the preexisting ambulatory quality-management program, reengineering key aspects of ambulatory clinic services, and redesigning the hospital-based patient-care services. Major successes have been achieved in some initiatives, but not in all. Many key "lessons learned" may guide others.

Randomized trial comparing epirubicin, cisplatin, and fluorouracil versus fluorouracil, doxorubicin, and methotrexate in advanced esophagogastric cancer.

PURPOSE: We report the results of a prospectively randomized study that compared the combination of epirubicin, cisplatin, and protracted venous infusion fluorouracil (5-FU) (ECF regimen) with the standard combination of 5-FU, doxorubicin, and methotrexate (FAMTX) in previously untreated patients with advanced esophagogastric cancer. PATIENTS AND METHODS: Two hundred seventy-four patients with adenocarcinoma or undifferentiated carcinoma were randomized and analyzed for survival, tumor response, toxicity, and quality of life (QL). RESULTS: The overall response rate was 45% (95% confidence interval [CI], 36% to 54%) with ECF and 21% (95% CI, 13% to 29%) with FAMTX (P = .0002). Toxicity was tolerable and there were only three toxic deaths. The FAMTX regimen caused more hematologic toxicity and serious infections, but ECF caused more emesis and alopecia. The median survival duration was 8.9 months with ECF and 5.7 months with FAMTX (P = .0009); at 1 year, 36% (95% CI, 27% to 45%) of ECF and 21% (95% CI, 14% to 29%) of FAMTX patients were alive. The median failure-free survival duration was 7.4 months with ECF and 3.4 months with FAMTX (P = .00006). The global QL scores were better for ECF at 24 weeks, but the remaining QL data showed no differences between either arm of the study. Hospital-based cost analysis on a subset of patients was similar for each arm and translated into an increment cost of $975 per life-year gained. CONCLUSION: The ECF regimen results in a survival and response advantage, tolerable toxicity, better QL and cost-effectiveness compared with FAMTX chemotherapy. This regimen should now be considered the standard treatment for advanced esophagogastric cancer.