Developing the Expected Entrustment Score: Accounting for Variation in Resident Assessment.

BACKGROUND: Clinical competency committees (CCCs) and residency program leaders may find it difficult to interpret workplace-based assessment (WBA) ratings knowing that contextual factors and bias play a large role. OBJECTIVE: We describe the development of an expected entrustment score for resident performance within the context of our well-developed Observable Practice Activity (OPA) WBA system. DESIGN: Observational study PARTICIPANTS: Internal medicine residents MAIN MEASURE: Entrustment KEY RESULTS: Each individual resident had observed entrustment scores with a unique relationship to the expected entrustment scores. Many residents' observed scores oscillated closely around the expected scores. However, distinct performance patterns did emerge. CONCLUSIONS: We used regression modeling and leveraged large numbers of historical WBA data points to produce an expected entrustment score that served as a guidepost for performance interpretation.

Racial and sex differences in optimizing anticoagulation therapy for patients with atrial fibrillation.

Study objective: Atrial fibrillation (AF) is the most common cardiac rhythm disorder, responsible for 15 % of strokes in the United States. Studies continue to document underuse of anticoagulation therapy in minority populations and women. Our objective was to compare the proportion of AF patients by race and sex who were receiving non-optimal anticoagulation as determined by an Atrial Fibrillation Decision Support Tool (AFDST). Design setting and participants: Retrospective cohort study including 14,942 patients within University of Cincinnati Health Care system. Data were analyzed between November 18, 2020, and November 20, 2021. Main outcomes and measures: Discordance between current therapy and that recommended by the AFDST. Results: In our two-category analysis 6107 (41 %) received non-optimal anticoagulation therapy, defined as current treatment category ≠ AFDST-recommended treatment category. Non-optimal therapy was highest in Black (42 % [n = 712]) and women (42 % [n = 2668]) and lower in White (39 % [n = 4748]) and male (40 % [n = 3439]) patients. Compared with White patients, unadjusted and adjusted odds ratios of receiving non-optimal anticoagulant therapy for Black patients were 1.13; 95 % CI, 1.02-1.30, p = 0.02; and 1.17; 95%CI, 1.04-1.31, p = 0.01; respectively, and 1.10; 95 % CI 1.03-1.18, p = 0.005; and 1.36; 95 % CI, 1.25-1.47, p < 0.001; for females compared with males. Conclusions and relevance: In patients with atrial fibrillation in the University of Cincinnati Health system, Black race and female sex were independently associated with an increased odds of receiving non-optimal anticoagulant therapy.

Constructing a Validity Map for a Workplace-Based Assessment System: Cross-Walking Messick and Kane.

PROBLEM: Health professions education has shifted to a competency-based paradigm in which many programs rely heavily on workplace-based assessment (WBA) to produce data for summative decisions about learners. However, WBAs are complex and require validity evidence beyond psychometric analysis. Here, the authors describe their use of a rhetorical argumentation process to develop a map of validity evidence for summative decisions in an entrustment-based WBA system. APPROACH: To organize evidence, the authors cross-walked 2 contemporary validity frameworks, one that emphasizes sources of evidence (Messick) and another that stresses inferences in an argument (Kane). They constructed a validity map using 4 steps: (1) Asking critical questions about the stated interpretation and use, (2) Seeking validity evidence as a response, (3) Categorizing evidence using both Messick's and Kane's frameworks, and (4) Building a visual representation of the collected and organized evidence. The authors used an iterative approach, adding new critical questions and evidence over time. OUTCOMES: The first map draft produced 25 boxes of evidence that included all 5 sources of evidence detailed by Messick and spread across all 4 inferences described by Kane. The rhetorical question-response process allowed for structured critical appraisal of the WBA system, leading to the identification of evidentiary gaps. NEXT STEPS: Future map iterations will integrate evidence quality indicators and allow for deeper dives into the evidence. The authors intend to share their map with graduate medical education stakeholders (e.g., accreditors, institutional leaders, learners, patients) to understand if it adds value for evaluating their WBA programs' validity arguments.

Variation in Entrustment When Sharing a Single Assessment System Between University- and Community-Based Residency Programs: A Comparison.

PURPOSE: Given resource constraints, many residency programs would consider adopting an entrustment-based assessment system from another program if given the opportunity. However, it is unclear if a system developed in one context would have similar or different results in another. This study sought to determine if entrustment varied between programs (community based and university based) when a single assessment system was deployed in different contexts. METHOD: The Good Samaritan Hospital (GSH) internal medicine residency program adopted the observable practice activity (OPA) workplace-based assessment system from the University of Cincinnati (UC). Comparisons for OPA-mapped subcompetency entrustment progression for programs and residents were made at specific timepoints over the course of 36 months of residency. Data collection occurred from August 2012 to June 2017 for UC and from September 2013 to June 2017 for GSH. RESULTS: GSH entrustment ratings were higher than UC for all but the 11th, 15th, and 36th months of residency (P < .0001) and were also higher for the majority of subcompetencies and competencies (P < .0001). The rate of change for average monthly entrustment was similar, with GSH having an increase of 0.041 each month versus 0.042 for UC (P = .73). Most residents progressed from lower to higher entrustment, but there was significant variation between residents in each program. CONCLUSIONS: Despite the deployment of a single entrustment-based assessment system, important outcomes may vary by context. Further research is needed to understand the contributions of tool, context, and other factors on the data these systems produce.

Racial Differences and Factors Associated with Pregnancy in ESKD Patients on Dialysis in the United States.

BACKGROUND: Pregnancy in women with ESKD undergoing dialysis is uncommon due to impaired fertility. Data on pregnancy in women on dialysis in the United States is scarce. METHODS: We evaluated a retrospective cohort of 47,555 women aged 15-44 years on dialysis between January 1, 2005 and December 31, 2013 using data from the United States Renal Data System with Medicare as primary payer. We calculated pregnancy rates and identified factors associated with pregnancy. RESULTS: In 47,555 women on dialysis, 2352 pregnancies were identified. Pregnancy rate was 17.8 per thousand person years (PTPY) with the highest rate in women aged 20-24 (40.9 PTPY). In the adjusted time-to-event analysis, a higher likelihood of pregnancy was seen in Native American (HR, 1.77; 95% CI, 1.33 to 2.36), Hispanic (HR, 1.51; 95% CI, 1.32 to 1.73), and black (HR, 1.33; 95% CI, 1.18 to 1.49) women than in white women. A higher rate of pregnancy was seen in women with ESKD due to malignancy (HR, 1.64; 95% CI, 1.27 to 2.12), GN (HR, 1.38; 95% CI, 1.21 to 1.58), hypertension (HR, 1.32; 95% CI, 1.16 to 1.51), and secondary GN/vasculitis (HR, 1.18; 95% CI, 1.02 to 1.37) than ESKD due to diabetes. A lower likelihood of pregnancy was seen among women on peritoneal dialysis than on hemodialysis (HR, 0.47; 95% CI, 0.41 to 0.55). CONCLUSIONS: The pregnancy rate is higher in women on dialysis than previous reports indicate. A higher likelihood of pregnancy was associated with race/ethnicity, ESKD cause, and dialysis modality.

Racial disparities and factors associated with pregnancy in kidney transplant recipients in the United States.

BACKGROUND: Although kidney transplant improves reproductive function in women with end-stage kidney disease (ESKD), pregnancy in kidney transplant recipients' remains challenging due to the risk of adverse maternal and fetal outcomes. METHODS: We evaluated a retrospective cohort of 7,966 women who were aged 15-45 years and received a kidney transplant between January 1, 2005 and December 31, 2011 from the United States Renal Data System with Medicare as the primary payer for the entire three years after the date of transplantation. Unadjusted and adjusted rates of pregnancy in the first three post-transplant years were calculated, using Poisson regression for the adjustment. Factors associated with pregnancy, including race, were examined using logistic regression. RESULTS: Overall, 293 pregnancies were identified in 7966 women. The unadjusted pregnancy rate was 13.8 per thousand person-years (PTPY) (95% confidence interval (CI), 12.3-15.5). Pregnancy rates were roughly constant in the years 2005-2011 except in 2005 and 2010. The rate of pregnancy was highest in Hispanic women (21.4 PTPY; 95% CI, 17.2-26.4) and Hispanic women had a higher likelihood of pregnancy as compared to white women (OR, 1.56; CI, 1.12-2.16). Pregnancy rates were lowest in women aged 30-34 years and 35-45 years at transplant, and women aged 30-34 years and 35-45 years at transplant were less likely to ever become pregnant during the follow-up (odds ratio [OR], 0.69; CI, 0.49-0.98 and OR, 0.14; CI 0.09-0.21 respectively) as compared to women aged 25-29 years at time of transplant. Women had higher rates of pregnancy in the second and third-year post-transplant (16.0 PTPY, CI 13.2-19.2 and 16.9 PTPY, CI 14.0-20.4) than in the first-year post-transplant (9.0 PTPY, CI 7.0-11.4). In transplant recipients, pregnancy was more likely in women with ESKD due to cystic disease (OR, 2.42; CI, 1.02-5.74) or glomerulonephritis (OR, 2.14; CI, 1.07-4.31) as compared to women with ESKD due to diabetes. CONCLUSION: Hispanic race, younger age, and ESKD cause due to cystic disease or glomerulonephritis are significant factors associated with a higher likelihood of pregnancy. Pregnancy rates have been fairly constant over the last decade. This study improves our understanding of factors associated with pregnancy in kidney transplant recipients.

Association Between Weight Loss and the Risk of Cancer after Bariatric Surgery.

OBJECTIVE: The goal of this study was to determine whether the reduction in cancer risk after bariatric surgery is due to weight loss. METHODS: A retrospective matched cohort study of patients undergoing bariatric surgery was conducted using data from a large integrated health insurance and care delivery system with five sites in four states. The study included 18,355 bariatric surgery subjects and 40,524 nonsurgical subjects matched on age, sex, BMI, site, and Elixhauser comorbidity index. Multivariable Cox proportional hazards models examined the relationship between weight loss at 1 year and incident cancer during up to 10 years of follow-up. RESULTS: The study identified 1,196 cases of incident cancer. The average 1-year postsurgical weight loss was 27% among patients undergoing bariatric surgery versus 1% in matched nonsurgical patients. Percent weight loss at 1 year was significantly associated with a reduced risk of any cancer in adjusted models (HR 0.897, 95% CI: 0.832-0.968, P = 0.005 for every 10% weight loss) while bariatric surgery was not a significant independent predictor of cancer incidence. CONCLUSIONS: Weight loss after bariatric surgery was associated with a lower risk of incident cancer. There was no apparent independent effect of the bariatric surgery itself on cancer risk that was independent of weight loss.

Chest Computed Tomographic Image Screening for Cystic Lung Diseases in Patients with Spontaneous Pneumothorax Is Cost Effective.

RATIONALE: Patients without a known history of lung disease presenting with a spontaneous pneumothorax are generally diagnosed as having primary spontaneous pneumothorax. However, occult diffuse cystic lung diseases such as Birt-Hogg-Dubé syndrome (BHD), lymphangioleiomyomatosis (LAM), and pulmonary Langerhans cell histiocytosis (PLCH) can also first present with a spontaneous pneumothorax, and their early identification by high-resolution computed tomographic (HRCT) chest imaging has implications for subsequent management. OBJECTIVES: The objective of our study was to evaluate the cost-effectiveness of HRCT chest imaging to facilitate early diagnosis of LAM, BHD, and PLCH. METHODS: We constructed a Markov state-transition model to assess the cost-effectiveness of screening HRCT to facilitate early diagnosis of diffuse cystic lung diseases in patients presenting with an apparent primary spontaneous pneumothorax. Baseline data for prevalence of BHD, LAM, and PLCH and rates of recurrent pneumothoraces in each of these diseases were derived from the literature. Costs were extracted from 2014 Medicare data. We compared a strategy of HRCT screening followed by pleurodesis in patients with LAM, BHD, or PLCH versus conventional management with no HRCT screening. MEASUREMENTS AND MAIN RESULTS: In our base case analysis, screening for the presence of BHD, LAM, or PLCH in patients presenting with a spontaneous pneumothorax was cost effective, with a marginal cost-effectiveness ratio of $1,427 per quality-adjusted life-year gained. Sensitivity analysis showed that screening HRCT remained cost effective for diffuse cystic lung diseases prevalence as low as 0.01%. CONCLUSIONS: HRCT image screening for BHD, LAM, and PLCH in patients with apparent primary spontaneous pneumothorax is cost effective. Clinicians should consider performing a screening HRCT in patients presenting with apparent primary spontaneous pneumothorax.

Pancreas fistula risk prediction: implications for hospital costs and payments.

BACKGROUND: As payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins. METHODS: A multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US$, and payment data existed. An analytic model detailed POPF risk and post-operative sequelae, and their relationship with hospital cost and payment. RESULTS: Per-patient hospital cost for negligible-risk patients was $37,855. Low-, moderate-, and high- risk patients had incrementally higher hospital costs of $38,125 ($270; 0.7% above negligible-risk), $41,128 ($3273; +8.6%), and $41,983 ($3858; +10.9%), respectively. Similarly, hospital payment for negligible-risk patients was $42,685/patient, with incrementally higher payments for low-risk ($43,265; +1.4%), moderate-risk ($45,439; +6.5%) and high-risk ($46,564; +9.1%) patients. The lowest 30-day readmission rates - with highest net profit - were found for negligible/low-risk patients (10.5%/11.1%), respectively, compared with readmission rates of moderate/high-risk patients (15%/15.7%). CONCLUSION: Financial outcomes following PD can be predicted using the FRS. Such prediction may help hospitals and payers plan for resource allocation and payment matched to patient risk, while providing a benchmark for quality improvement initiatives.

Prophylactic pasireotide administration following pancreatic resection reduces cost while improving outcomes.

BACKGROUND AND OBJECTIVES: Pasireotide decreases leak rates after pancreatic resection, though significant drug cost may be prohibitive. We conducted a cost-effectiveness analysis to determine whether prophylactic pasireotide possesses a reasonable cost profile. METHODS: A cost-effectiveness model compared pasireotide administration after pancreatic resection versus usual care, populated by probabilities of clinical outcomes from a randomized trial and hospital costs (2013 US$) from a university pancreatic disease center. Sensitivity analyses were performed to identify influential clinical components of the model. RESULTS: With the cost of pasireotide included, per patient costs of pancreatectomy, including those for readmission, were lower in the intervention arm (41,769 versus 42,159$; net savings of 390$, or 1%). This was associated with a 56% reduction in pancreatic fistula/pancreatic leak/abscess (PF/PL/A; 21.9-9.2%). Pasireotide cost would need to increase by over 15.4% to make the intervention strategy more costly than usual care. Sensitivity analyses exploring variability of key model inputs demonstrated that the three strongest drivers of cost were (i) cost of pasireotide; (ii) probability of readmission; and (iii) probability of PF/PL/A. CONCLUSIONS: Prophylactic pasireotide administration following pancreatectomy is cost savings, reducing expensive post-operative sequealae (major complications and readmissions). Pasireotide should be utilized as a cost-saving measure in pancreatic resection. J. Surg. Oncol. 2016;113:784-788. © 2016 Wiley Periodicals, Inc.

How Much Should We Pay to Minimize Pancreatic Leak? The Cost-effectiveness of Pasireotide in Pancreatic Resection: RETRACTED.

INTRODUCTION: Pasireotide was recently shown to decrease leak rates after pancreatic resection, though the significant cost of the drug may be prohibitive. We conducted a cost-effectiveness analysis to determine whether prophylactic pasireotide possesses a reasonable cost profile by improving outcomes. METHODS: A cost-effectiveness model was constructed to compare pasireotide administration after pancreatic resection versus usual care, populated by probabilities of clinical outcomes from a recent randomized trial and hospital costs (2013 US$) from a university pancreatic disease center. Sensitivity analyses were performed to identify the most influential clinical components of the model. RESULTS: Without considering pasireotide cost, prophylactic use of the drug saved an average of $8,109 per patient. However, when the cost of pasireotide was included, per patient costs increased from $42,159 to $77,202. This was associated with a 56% reduction in pancreatic fistula/pancreatic leak/abscess (PF/PL/A) (21.9% to 9.2%). The resultant cost per PF/PL/A avoided was $301,628. Threshold analysis demonstrated that for this intervention to be cost neutral, either the purchase price of pasireotide ($43,172) must be reduced by 92.3% (to $3324) or drug reimbursement must be $39,848. Sensitivity analyses exploring variable perioperative mortality, rate of PF/PL/A, and readmission rates did not significantly alter model outcomes. CONCLUSIONS: Our analyses demonstrate that when prophylactic pasireotide is administered, the cost per PF/PL/A avoided is approximately $300,000. Aggressive pricing negotiation, payer reimbursement for the drug, high-volume use, and consensus among the public, payers, and surgical community regarding the value of reducing morbidity will ultimately determine the utility of widespread pasireotide application in pancreatic resection.

Impact of bariatric surgery on life expectancy in severely obese patients with diabetes: a decision analysis.

OBJECTIVE: To create a decision analytic model to estimate the balance between treatment risks and benefits for severely obese patients with diabetes. BACKGROUND: Bariatric surgery leads to many desirable metabolic changes, but long-term impact of bariatric surgery on life expectancy in patients with diabetes has not yet been quantified. METHODS: We developed a Markov state transition model with multiple Cox proportional hazards models and logistic regression models as inputs to compare bariatric surgery versus no surgical treatment for severely obese diabetic patients. The model is informed by data from 3 large cohorts: (1) 159,000 severely obese diabetic patients (4185 had bariatric surgery) from 3 HMO Research Network sites; (2) 23,000 subjects from the Nationwide Inpatient Sample; and (3) 18,000 subjects from the National Health Interview Survey linked to the National Death Index. RESULTS: In our main analyses, we found that a 45-year-old woman with diabetes and a body mass index (BMI) of 45 kg/m gained an additional 6.7 years of life expectancy with bariatric surgery (38.4 years with surgery vs 31.7 years without surgery). Sensitivity analyses revealed that the gain in life expectancy decreased with increasing BMI, until a BMI of 62 kg/m is reached, at which point nonsurgical treatment was associated with greater life expectancy. Similar results were seen for both men and women in all age groups. CONCLUSIONS: For most severely obese patients with diabetes, bariatric surgery seems to improve life expectancy; however, surgery may reduce life expectancy for the super obese with BMIs over 62 kg/m.

Cost-effectiveness of total pancreatectomy and islet cell autotransplantation for the treatment of minimal change chronic pancreatitis.

INTRODUCTION: The current standard of care for the management of minimal change chronic pancreatitis (MCCP) is medical management. Controversy exists, however, regarding the use of surgical intervention for MCCP. We hypothesized that total pancreatectomy and islet cell autotransplantation (TPIAT) decreases long-term resource utilization and improves quality of life, justifying initial costs and risks. METHODS: Detailed perioperative outcomes from 46 patients with MCCP populated a Markov model comparing medical management to TPIAT. Mortality, complications, readmission rates, insulin and narcotic use, imaging, and endoscopy were included in the model. Outcomes reported were survival, measured in quality-adjusted life years (QALYs), and costs, in 2013 US dollars. RESULTS: In medical patients, annual mean hospital admissions were 1.6 (range = 0-11), endoscopy 1.4 (0-6), and imaging (CT/MRI) 1.5 (0-4). In surgical patients, there were no perioperative deaths, with complication and 30-day readmission rates of 47 and 37%. One year after TPIAT, annual mean admissions, endoscopy, and imaging had decreased to 0.9 (0-4), 0.4 (0-2), and 0.9 (0-5); monthly narcotic use decreased from 138 to 37 morphine equivalents (p = 0.012). Cost and survival for TPIAT versus medical management were $153,575/14.9 QALYs and $196,042/11.5 QALYs, respectively. CONCLUSIONS: In patients with MCCP, TPIAT is associated with decreased cost and increased quality-adjusted survival. Providers and insurers should more enthusiastically embrace TPIAT use as a more effective cost-saving strategy.

Distributed Health Outcome Monitoring and Evaluation Using i2b2.

There is a pressing need for better tools to support comparative effectiveness research (CER) on a national scale. In addition, little is known about within-class outcome disparities for commonly used cardiovascular and diabetes medications. In this presentation, we will describe our experience implementing a new i2b2 cell, the Health Outcome Monitoring and Evaluation Cell (HOME), at 5 collaborating Clinical Translational Science Award sites (CTSAs) in the U.S. We will also describe the motivations to developing a common query framework, and findings related to the implementation and use of the HOME cell, to perform distributed CER queries. Our focus is on the assessment of race, gender, and location-based disparities in outcomes for patients treated with similar mediations for hypertension, dyslipidemias, and diabetes.

Cost-effectiveness of latent tuberculosis screening before steroid therapy for idiopathic nephrotic syndrome in children.

BACKGROUND: Guidelines differ on screening recommendations for latent tuberculosis infection (LTBI) prior to immunosuppressive therapy. We aimed to determine the most cost-effective LTBI screening strategy before long-term steroid therapy in a child with new-onset idiopathic nephrotic syndrome. STUDY DESIGN: Markov state-transition model. SETTING & POPULATION: 5-year-old boy with new-onset idiopathic nephrotic syndrome. MODEL, PERSPECTIVE, & TIMEFRAME: The Markov model took a societal perspective over a lifetime horizon. INTERVENTION: 3 strategies were compared: universal tuberculin skin testing (TST), targeted screening using a risk-factor questionnaire, and no screening. A secondary model included the newer interferon γ release assays (IGRAs), requiring only one visit and having greater specificity than TST. OUTCOMES: Marginal cost-effectiveness ratios (2010 US dollars) with effectiveness measured as quality-adjusted life-years (QALYs). RESULTS: At an LTBI prevalence of 1.1% (the average US childhood prevalence in our base case), a no-screening strategy dominated ($2,201; 29.3356 QALYs) targeted screening ($2,218; 29.3356 QALYs) and universal TST ($2,481; 29.3347 QALYs). At a prevalence >10.3%, targeted screening with a risk-factor questionnaire was the most cost-effective option. Higher than a prevalence of 58.5%, universal TST was preferred. In the secondary model, targeted screening with a questionnaire followed by IGRA testing was cost-effective compared with no screening in the base case when the LTBI prevalence was >4.9%. LIMITATIONS: There is no established gold standard for the diagnosis of LTBI. Results of any modeling task are limited by the accuracy of available data. CONCLUSIONS: Prior to starting steroid therapy, only patients in areas with a high prevalence of LTBI will benefit from universal TST. As more evidence becomes available about the use of IGRA testing in children, the assay may become a component of cost-effective screening protocols in populations with a higher burden of LTBI.

Cost-effectiveness of telemetry for hospitalized patients with low-risk chest pain.

BACKGROUND: The majority of chest pain admissions originate in the emergency department (ED). Despite a low incidence of cardiac events, limited telemetry availability, and its questionable benefit, these patients are routinely admitted to a monitored setting. OBJECTIVES: The objectives were to analyze the cost-effectiveness of admission to telemetry versus admission to an unmonitored hospital bed in low-risk chest pain patients and explore when the use of telemetry may be cost-effective. METHODS: The authors constructed a decision analytic model to evaluate the scenario of an ED admission of an otherwise healthy 55-year-old patient with low-risk chest pain defined as an acute coronary syndrome (ACS) probability of 2%. Costs were estimated from 2009 Medicare data for hospital reimbursement and physician services, as well as published data on disability costs. Published studies were used to estimate the risk of ACS, cardiac arrest, time to defibrillation, survival, long-term disability, and quality of life. RESULTS: In the base case, telemetry was more effective (0.0044 quality-adjusted life-years [QALYs]) but more costly ($299.67) than a floor bed, resulting in a high marginal cost-effectiveness ratio (mCER) of $67,484.55 per QALY. In comprehensive sensitivity analyses, the mCER crossed below the willingness-to-pay (WTP) threshold of $50,000 per QALY when the following scenarios were met: the probability of ACS exceeds 3%, the probability of cardiac arrest is greater than 0.4%, the probability of shockable dysrhythmia is above 83%, the probability of delay in telemetry bed availability is below 52%, and the opportunity cost of delay to telemetry bed placement is below $119. CONCLUSIONS: Telemetry may be a "cost-effective" use of health care resources for chest pain patients when patients have a probability of ACS above 3% or for patients with a minimal delay and cost associated with obtaining a monitored bed. Further research is needed to better stratify low-risk chest pain patients to the appropriate inpatient setting and to understand the frequency and costs associated with delays in obtaining monitored beds.

Screening for lymphangioleiomyomatosis by high-resolution computed tomography in young, nonsmoking women presenting with spontaneous pneumothorax is cost-effective.

RATIONALE: Women with pulmonary lymphangioleiomyomatosis (LAM) who present with a sentinel spontaneous pneumothorax (SPTX) will experience an average of 2.5 additional pneumothoraces. The diagnosis of LAM is typically delayed until after the second pneumothorax. OBJECTIVES: We hypothesized that targeted screening of an LAM-enriched population of nonsmoking women between the ages of 25 and 54 years, who present with a sentinel pneumothorax indicated by high-resolution computed tomography (HRCT), will facilitate early identification, definitive therapy, and improved quality of life for patients with LAM. METHODS: We constructed a Markov state-transition model to assess the cost-effectiveness of screening. Rates of SPTX and prevalence of LAM in populations stratified by age, sex, and smoking status were derived from the literature. Costs of testing and treatment were extracted from 2007 Medicare data. We compared a strategy based on HRCT screening followed by pleurodesis for patients with LAM, versus no HRCT screening. MEASUREMENTS AND MAIN RESULTS: The prevalence of LAM in nonsmoking women, between the ages of 25 and 54 years, with SPTX is estimated at 5% on the basis of the available literature. In our base case analysis, screening for LAM by HRCT is the most cost-effective strategy, with a marginal cost-effectiveness ratio of $32,980 per quality-adjusted life-year gained. Sensitivity analysis showed that HRCT screening remains cost-effective for groups in which the prevalence of LAM in the population subset screened is greater than 2.5%. CONCLUSIONS: Screening for LAM by HRCT in nonsmoking women age 25-54 that present with SPTX is cost-effective. Physicians are advised to screen for LAM by HRCT in this population.

Decision modeling to estimate the impact of gastric bypass surgery on life expectancy for the treatment of morbid obesity.

OBJECTIVE: To create a decision analytic model to estimate the balance between treatment risks and benefits for patients with morbid obesity. DESIGN: Decision analytic Markov state transition model with multiple logistic regression models as inputs. Data from the 2005 National Inpatient Survey were used to calculate in-hospital mortality risk associated with bariatric surgery and then adjusted for 30-day mortality. To calculate excess mortality associated with obesity, we used the 1991-1996 National Health Interview Survey linked to the National Death Index. Bariatric surgery was assumed to influence mortality only through its impact on the excess mortality associated with obesity, and the efficacy of surgery was estimated from a recent large observational trial. INTERVENTION: Gastric bypass surgery. Main Outcome Measure Life expectancy. RESULTS: Our base case, a 42-year-old woman with a body mass index of 45, gained an additional 2.95 years of life expectancy with bariatric surgery. No surgical treatment was favored in our base case when the 30-day surgical mortality exceeded 9.5% (baseline 30-day mortality, 0.2%) or when the efficacy of bariatric surgery for reducing mortality decreased to 2% or less (baseline efficacy, 53%). CONCLUSIONS: The optimal decision for individual patients varies based on the balance of risk between perioperative mortality, excess annual mortality risk associated with increasing body mass index, and the efficacy of surgery; however, for the average morbidly obese patient, gastric bypass improves life expectancy.