Can a best practice advisory improve anticoagulation prescribing to reduce stroke risk in patients with atrial fibrillation?

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac rhythm disorder and a risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce strokes in AF patients. Yet, widespread underutilization of this therapy continues. To address this practice gap, we designed a study to implement and evaluate the effectiveness of a best practice advisory (BPA) for an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record. METHODS: Our intervention is provider-facing, focused on decision support. Clinical setting is ambulatory patients being seen by primary care physicians. We prospectively enrolled 608 patients in our health system who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST and randomized them to one of two arms - 1) usual care, in which the AFDST is available for use; or 2) addition of a BPA to the AFDST notifying clinicians that their patient stands to gain significant benefit from a change in current therapy. Primary outcome was effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post-enrollment. Secondary endpoints included Reach and Adoption from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, & Maintenance) framework for implementation studies. RESULTS: Among 562 patients with a minimum follow-up of 3 months, addition of a BPA to the AFDST resulted in significant improvement in anticoagulation therapy, 5 % (12/248) versus 11 % (33/314) p = 0.02, odds ratio 2.31 (95 % CI, 1.17-4.87). CONCLUSIONS: A BPA added to an AF decision support tool improved anticoagulation therapy among AF patients in a primary care academic health system setting.

Assessment of a venous thromboembolism prophylaxis shared decision-making intervention (DASH-TOP) using the decisional conflict scale: a mixed-method study.

BACKGROUND: Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and death. The use of low-molecular-weight heparin (LMWH), despite being the standard of care to prevent VTE, comes with some challenges. Shared decision-making (SDM) interventions are recommended to support patients and clinicians in making preference-sensitive decisions. The quality of the SDM process has been widely assessed with the decisional conflict scale (DCS). Our aim is to report participants' perspectives of each of the components of an SDM intervention (DASH-TOP) in relation to the different subscales of the DCS. METHODS: Design: A convergent, parallel, mixed-methods design. PARTICIPANTS: The sample consisted of 22 health care professionals, students of an Applied Clinical Research in Health Sciences (ICACS) master program. INTERVENTION: We randomly divided the participants in three groups: Group 1 received one component (evidence -based information), Group 2 received two components (first component and value elicitation exercises), and Group 3 received all three components (the first two and a decision analysis recommendation) of the SDM intervention. ANALYSIS: For the quantitative strand, we used a non-parametric test to analyze the differences in the DCS subscales between the three groups. For the qualitative strand, we conducted a content analysis using the decisional conflict domains to deductively categorize the responses. RESULTS: Groups that received more intervention components experienced less conflict and better decision-making quality, although the differences between groups were not statistically significant. The decision analysis recommendation improved the efficacy with the decision-making process, however there are some challenges when implementing it in clinical practice. The uncertainty subscale showed a high decisional conflict for all three groups; contributing factors included low certainty of the evidence-based information provided and a perceived small effect of the drug to reduce the risk of a VTE event. CONCLUSIONS: The DASH-TOP intervention reduced decisional conflict in the decision -making process, with decision analysis being the most effective component to improve the quality of the decision. There is a need for more implementation research to improve the delivery of SDM interventions in the clinical encounter.

Lung cancer screening utilization rate varies based on patient, provider, and hospital factors.

OBJECTIVE: Low-dose computed tomography has been proven to reduce mortality, yet utilization remains low. The purpose of this study is to identify factors that impact the utilization of lung cancer screening. METHODS: We performed a retrospective review of our institution's primary care network from November 2012 to June 2022 to identify patients who were eligible for lung cancer screening. Eligible patients were 55 to 80 years of age and current or former smokers with at least a 30 pack-year history. Analyses were performed on the screened populations and patients who met eligibility criteria but were not screened. RESULTS: A total of 35,279 patients in our primary care network were current/former smokers aged 55 to 80 years. A total of 6731 patients (19%) had a 30 pack-year or more cigarette history, and 11,602 patients (33%) had an unknown pack-year history. A total of 1218 patients received low-dose computed tomography. The utilization rate of low-dose computed tomography was 18%. The utilization rate was significantly lower (9%) if patients with unknown pack-year history were included (P < .001). The utilization rates between primary care clinic locations were significantly different (range, 18% vs 41%, P < .05). Utilization of low-dose computed tomography on multivariate analysis was associated with Black race, former smoker, chronic obstructive pulmonary disease, bronchitis, family history of lung cancer, and number of primary care visits (all P < .05). CONCLUSIONS: Lung cancer screening utilization rates are low and vary significantly on the basis of patient comorbidities, family history of lung cancer, primary care clinic location, and accurate documentation of pack-year cigarette history. The development of programs to address patient, provider, and hospital-level factors is needed to ensure appropriate lung cancer screening.

Should asymptomatic patients with congenital lung malformations undergo surgery? A decision analysis.

BACKGROUND: Congenital lung malformations (CLMs) are being detected more frequently during pregnancy. There is controversy regarding the optimal treatment for an asymptomatic child with prenatally diagnosed CLMs. Due to the paucity of information from clinical trials, we developed decision analytic models to compare two treatment strategies for such patients-elective surgical resection versus expectant management. METHODS: We built decision analytic models stratified by lesion size. We used data from English language literature identified through PubMed searches along with estimates from expert opinions of surgical colleagues. We analyzed results for two hypothetical asymptomatic 6-month-old children with CLMs; one has a large lesion occupying more than 50% of the involved lobe, while the other has a small lesion occupying less than 50% of the involved lobe. We used quality-adjusted life years (QALYs) to measure effectiveness. RESULTS: For an asymptomatic child with a small or large lesion, expectant management resulted in a small gain of 0.09 or 0.15 QALYs, respectively. Sensitivity analyses showed that surgical resection would be preferred if the probability of remaining asymptomatic was low. CONCLUSIONS: In contrast to current practice, expectant management may be a better alternative for asymptomatic children born with CLMs. More longitudinal studies are required to improve the accuracy of the model.

Anticoagulant Therapy for Cancer-Associated Thrombosis : A Cost-Effectiveness Analysis.

BACKGROUND: Direct oral anticoagulants (DOACs) offer an alternative to low-molecular-weight heparin (LMWH) and warfarin for treating cancer-associated thrombosis (CAT). OBJECTIVE: To determine the cost and effectiveness of DOACs versus LMWH. DESIGN: Cohort-state transition decision analytic model. DATA SOURCES: Network meta-analysis comparing DOACs versus LMWH. TARGET POPULATION: Adult patients with cancer at the time they develop thrombosis. TIME HORIZON: Lifetime. PERSPECTIVE: Health care sector. INTERVENTION: Strategies of 1) enoxaparin, 2) apixaban, 3) edoxaban, and 4) rivaroxaban for treatment of CAT. OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER) in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS: In the base-case scenario, using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule, apixaban dominated enoxaparin and edoxaban by being less costly and more effective. Rivaroxaban was slightly more effective than apixaban, with an ICER of $493 246. In a scenario analysis using "real-world" drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50 053 per QALY. RESULTS OF SENSITIVITY ANALYSIS: Results were highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50 000 per QALY, apixaban was preferred in 80% of simulations. However, sensitivity analyses also demonstrated that apixaban only remained cost-effective if monthly medication costs were below $530. Above this, rivaroxaban became cost-effective. LIMITATIONS: An assumption was made that patients would continue anticoagulation indefinitely unless they suffered a major bleed. Nonmedical costs such as patient and caregiver loss of productivity were not accounted for, and long-term thrombotic complications were not explicitly modeled. CONCLUSION: The 3 DOACs are more effective and more cost-effective than LMWH. The most cost-effective DOAC depends on the relative cost of each of these agents. These are important considerations for treating physicians and health policymakers. PRIMARY FUNDING SOURCE: None.

Efficacy of supermarket and web-based interventions for improving dietary quality: a randomized, controlled trial.

Dietary interventions may best be delivered at supermarkets, which offer convenience, accessibility, full food inventories and, increasingly, in-store registered dietitians, online shopping and delivery services. In collaboration with a large retail supermarket chain, we conducted a multisite supermarket and web-based intervention targeting nutrition trial (no. NCT03895580), randomizing participants (n = 247 (139 women and 108 men)) 2:2:1 to two levels of dietary education (Strategy 1 and Strategy 2) or an enhanced control group that included educational components beyond the routine standard of care. Both Strategies 1 and 2 included individualized, in-person, dietitian-led, purchasing data-guided interventions. Strategy 2 also included online tools for shopping, home delivery, selection of healthier purchases, meal planning and healthy recipes. The primary endpoint was change in dietary approaches to stop hypertension (DASH) score (a measure of adherence to the DASH diet) from baseline to 3 months. The primary endpoint was met because, at 3 months, the DASH score increased by 4.7 more for the combined Strategy 1 and Strategy 2 groups than for the control group (95% confidence interval (CI) (0.9, 8.5), P = 0.02). In a prespecified hierarchical test, at 3 months, DASH score increased by 3.8 more for the Strategy 2 group than for the Strategy 1 group (95% CI (0.8, 6.)9, P = 0.01). This trial demonstrates the efficacy of data-guided, supermarket-based, dietary interventions and modern online shopping tools in improving dietary quality in a free-living, community-based population. The trial also demonstrates the opportunity for academic investigators to collaborate with retailers to design and rigorously test comprehensive healthcare interventions.

Implementing a Health Utility Assessment Platform to Acquire Health Utilities in a Hemodialysis Outpatient Setting: Feasibility Study.

BACKGROUND: Patients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is using hepatitis C virus (HCV)-viremic kidneys. OBJECTIVE: As preparation for developing a shared decision-making tool to assist patients with ESKD with the decision to accept an HCV-viremic kidney transplant, our initial goal was to assess the feasibility of using The Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Our secondary goals were to collect health utilities for patients with ESKD and to explore whether the use of race-matched versus race-mismatched exemplars impacted the knowledge gained during the assessment process. METHODS: We used The Gambler II to elicit utilities for the following ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and postintervention knowledge assessments. RESULTS: A total of 63 patients with hemodialysis from 4 outpatient Dialysis Center Inc sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5, respectively. General group knowledge assessment scores improved by 10 points (P<.05) following utility assessment process. The use of race-matched exemplars had little effect on the results of the knowledge assessment of patients. CONCLUSIONS: Using The Gambler II to collect utilities for patients with ESKD in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients' knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. A wide variation in patient health state utilities reinforces the importance of incorporating patients' preferences into decisions regarding use of HCV-viremic kidneys for transplantation.

Prescribing of anticoagulation for atrial fibrillation in primary care.

Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.

A Cost-effectiveness Analysis of Adherence Promotion Strategies to Improve Rejection Rates in Adolescent Kidney Transplant Recipients.

RATIONALE & OBJECTIVE: Nonadherence to medical regimens increases the risk of graft loss among adolescent and young adult recipients of kidney transplants. Interventions that improve adherence may decrease rejection rates, but their perceived costs are a barrier to clinical implementation. We developed a model to assess the cost-effectiveness of an adherence promotion strategy, the Medication Adherence Promotion System (MAPS). STUDY DESIGN: Simulation-based. Data sources included published articles indexed in Medline or referenced in bibliographies of relevant English-language articles. Data on costs and outcomes were taken from a single clinical center. SETTING & POPULATION: US adolescent patients after their first kidney transplant. INTERVENTION: Usual posttransplant care versus usual care plus MAPS. OUTCOME: Effectiveness measured in quality-adjusted life years (QALYs) and costs measured in 2020 US dollars. MODEL, PERSPECTIVE, & TIMEFRAME: Markov state transition decision model. We used a health care system perspective with a lifelong time horizon. RESULTS: In the base-case analysis, MAPS was more effective and less costly than usual care. MAPS cost $9,106 per patient less than usual care and resulted in a gain of 0.32 QALYs. In probabilistic sensitivity analyses, MAPS was cost saving 100% of the time. Extending results to a program level with 100 patients, any adherence promotion intervention similar in effectiveness to MAPS would cost less than $50,000/QALY if the start-up costs were <$2.5 million and annual costs <$188,000. Strategies with costs similar to MAPS that reduce the risk of rejection by as little as 3% would also have similar cost-effectiveness. LIMITATIONS: Estimates of components and costs for MAPS were based on a single center. CONCLUSIONS: Adherence promotion strategies with costs similar to MAPS can be cost-effective as long as they reduce rejection rates by at least 3%. This model can be applied to study the cost-effectiveness of adherence promotion strategies with varying costs and outcomes.

Design and rationale for the supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial.

PURPOSE: The prevalence of chronic diseases is increasing largely due to suboptimal dietary habits. It is not known whether individualized, supermarket-based, nutrition education delivered by registered dietitians, utilizing the advantages of the in-store and online environments, and electronically collected purchasing data, can increase dietary quality. METHODS AND RESULTS: The supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial is a randomized, controlled dietary intervention study. Adults identified from a primary care network with 1 or more risk factors were randomized at their preferred store to: (1) standard of care plus individualized, point- of-purchase nutrition education; (2) standard of care plus individualized, point- of-purchase nutrition education enhanced with online shopping technologies and training; or (3) standard of care alone. Educational sessions within each store's clinic and aisles, emphasized the dietary approaches to stop hypertension (DASH) diet. The primary assessment was an intention-to-treat comparison on the effects of the dietary interventions on mean change in DASH score (90-point range) from baseline to 3 months (post-intervention). Additional outcomes included blood pressure, lipids, weight, purchasing behavior, food literacy, and intervention feedback. Between April 2019 to February 2021, 267 participants were randomized (20 excluded due to coronavirus disease pandemic). Median age was 58 years, 69% were female, 64% had a college degree, 53% worked full-time, 64% were obese, 73% were treated with blood pressure and 42% with cholesterol medications, and most had low-to-moderate diet quality. CONCLUSION: The SuperWIN trial was designed to provide a rigorous evaluation of the efficacy of 2 novel, comprehensive, supermarket-based dietary intervention programs.

Electronic health record-embedded decision support to reduce stroke risk in patients with atrial fibrillation - Study protocol.

BACKGROUND: Atrial fibrillation (AF) is the most common significant cardiac rhythm disorder and is a powerful common risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce the risk of stroke in patients with AF. Yet, there continues to be widespread underutilization of this therapy. To address this practice gap locally and improve efforts to reduce the risk of stroke for patients with AF in our health system, we have designed a study to implement and evaluate the effectiveness of an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record. METHODS: Our intervention is provider-facing and focused on decision support. The clinical setting is ambulatory patients being seen by primary care physicians. Patients include those with both incident and prevalent AF. This randomized, prospective trial will enroll 800 patients in our University of Cincinnati Health System who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST. Patients will be randomized to one of two arms - 1) usual care, in which the AFDST is available for use; 2) addition of a best practice advisory (BPA) to the AFDST notifying the clinician that their patient stands to gain a significant benefit from a change in their current thromboprophylactic therapy. RESULTS: The primary outcome is effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post randomization. Secondary endpoints include Reach and Adoption, from the RE-AIM framework for implementation studies. Sample size is based upon an improvement from inappropriate to appropriate anticoagulation therapy estimated at 4% in the usual care arm and ≥10% in the experimental arm. CONCLUSION: Our goal is to examine whether addition of a BPA to an AFDST focused on primary care physicians in an ambulatory care setting will improve "appropriate thromboprophylaxis" compared with usual care. Results will be examined at 3 months post randomization and at the end of the study to evaluate durability of changes. We expect to complete patient enrollment by the end of June 2022. TRIAL REGISTRATION: Clinicaltrials.gov NCT04099485.

Predicting Adverse Events Among Patients With COPD Exacerbations in the Emergency Department.

BACKGROUND: COPD exacerbations lead to excessive health care utilization, morbidity, and mortality. The Ottawa COPD Risk Scale (OCRS) was developed to predict short-term serious adverse events (SAEs) among patients in the emergency department (ED) with COPD exacerbations. We assessed the utility of the OCRS, its component elements, and other clinical variables for ED disposition decisions in a United States population. METHODS: We compared the OCRS and other factors in predicting SAEs among a retrospective cohort of ED patients with COPD exacerbations. We followed subjects for 30 d, and the primary outcome, SAE, was defined as any death, admission to monitored unit, intubation, noninvasive ventilation, major procedure, myocardial infarction, or revisit with hospital admission. RESULTS: A total of 246 subjects (median 61-y old, 46% male, total admission rate to ward 52%) were included, with 46 (18.7%) experiencing SAEs. Median OCRS scores did not differ significantly between those with and without an SAE (difference: 0 [interquartile range 0-1)]. The OCRS predicted SAEs poorly (Hosmer-Lemeshow goodness of fit [H-L GOF] P ≤ .001, area under the receiver operating characteristic [ROC] curve 0.519). Three variables were significantly related to SAEs in our final model (H-L GOF P = .14, area under the ROC curve 0.808): Charlson comorbidity index (odds ratio [OR] 1.3 [1.1-1.5] per 1-point increase); triage venous PCO2 (OR 1.7 [1.2-2.4] per 10 mm Hg increase); and hospitalization within previous year (OR 9.1 [3.3-24.8]). CONCLUSIONS: The OCRS did not reliably predict SAEs in our population. We found 3 risk factors that were significantly associated with 30-d SAE in our United States ED population: triage [Formula: see text] level, Charlson comorbidity index, and hospitalization within the previous year. Further studies are needed to develop generalizable decision tools to improve safety and resource utilization for this patient population.

More work needed on decision analysis for shared decision-making: A scoping review.

OBJECTIVE: To explore and characterize published evidence on the ways decision analysis has been used to inform shared decision-making. STUDY DESIGN AND SETTING: For this scoping review, we searched five bibliographic databases (from inception until February 2021), reference lists of included studies, trial registries, a thesis database and websites of relevant interest groups. Studies were eligible if they evaluated the application of decision analysis in a shared decision-making encounter. Pairs of reviewers independently screened and selected studies for inclusion, extracted study information using a data extraction form developed by the research team and assessed risk of bias for all studies with an experimental or quasi-experimental design. Data were narratively synthesized. RESULTS: We identified 27 studies that varied greatly with regard to their patient population, design, content and delivery. A range of outcomes were evaluated to explore the effectiveness and acceptability of decision analytic interventions, with little information about the implementation process. Most studies found that decision analysis was broadly beneficial. CONCLUSION: Despite the compelling rationale on the potential for decision analysis to support shared decision-making, rigorous randomized controlled trials are needed to confirm these interventions' effectiveness, while qualitative studies should seek to understand their potential implementation.

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.

Incorporating Patients' Values and Preferences Into Decision Making About Transplantation of HCV-Naïve Recipients With Kidneys From HCV-Viremic Donors: A Feasibility Study.

Introduction. While use of (hepatitis C virus) HCV-viremic kidneys may result in net benefit for the average end-stage kidney disease (ESKD) patient awaiting transplantation, patients may have different values for ESKD-related health states. Thus, the best decision for any individual may be different depending on the balance of these factors. Our objective was to explore the feasibility of sampling health utilities from hemodialysis patients in order to perform patient-specific decision analyses considering various transplantation strategies. Study Design. We assessed utilities on a convenience sample of hemodialysis patients for health states including hemodialysis, and transplantation with either an HCV-uninfected kidney or an HCV-viremic kidney. We performed patient-specific decision analyses using each patient's age, race, gender, dialysis vintage, and utilities. We used a Markov state transition model considering strategies of continuing hemodialysis, transplantation with an HCV-unexposed kidney, and transplantation with an HCV-viremic kidney and HCV treatment. We interviewed 63 ESKD patients from four dialysis centers (Dialysis Clinic Inc., DCI) in the Cincinnati metropolitan area. Results. Utilities for ESKD-related health states varied widely from patient to patient. Mean values were highest for -transplantation with an HCV-uninfected kidney (0.89, SD: 0.18), and were 0.825 (SD: 0.231) and 0.755 (SD: 0.282), respectively, for hemodialysis and transplantation with an HCV-viremic kidney. Patient-specific decision analyses indicated 37 (59%) of the 63 ESKD patients in the cohort would have a net gain in quality-adjusted life years from transplantation of an HCV-viremic kidney, while 26 would have a net loss. Conclusions. It is feasible to gather dialysis patients' health state utilities and perform personalized decision analyses. This approach could be used in the future to guide shared decision-making discussions about transplantation strategies for ESKD patients.

Take Your Best Shot: Which SARS-CoV-2 Vaccine Should I Get?

Background. Three vaccines against SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) have now received emergency use authorization by the US Food and Drug Administration. Patients may have the opportunity to make a choice about which vaccine they prefer to receive. Vaccine hesitancy is a hurdle to the development of widespread immunity, with many patients struggling to decide whether to get vaccinated at all. Objective. Develop a decision model exploring the question, "Should I get vaccinated with mRNA or adenovirus vector vaccine (AVV) if either is available now?"Design. Markov state transition model with lifetime time horizon. Data Sources. MEDLINE searches, bibliographies from relevant English-language articles. Setting. United States, ambulatory clinical setting. Participants. Previously uninfected, nonimmunized adults in the United States. Interventions. 1) Do Not Vaccinate, 2) Vaccination with mRNA Vaccine, 3) Vaccination with Adenovirus Vector Vaccine. Main Measures. Quality-adjusted life years (QALYs). Key Results. Base case-for a healthy 65-year-old patient, both vaccines yield virtually equivalent results (difference of 0.0028 QALYs). In sensitivity analyses, receiving the AVV is preferred if the short-term morbidity associated with each vaccine dose exceeds 1.8 days. Both vaccines afford an even greater benefit compared with Do Not Vaccinate if the pandemic is in a surge phase with a rising incidence of infection or if the current 7-day incidence is greater than the base case estimate of 105 cases per 100,000. Conclusions. Preferred vaccination strategies change under differing assumptions, but differences in outcomes are negligible. The best advice for patients is to get vaccinated against COVID-19 disease with whatever vaccine is available first. Providing mRNA vaccine to the remaining eligible US population would result in an aggregate gain of 3.92 million QALYs.

A Scoping Review of Health Information Technology in Clinician Burnout.

BACKGROUND: Clinician burnout is a prevalent issue in healthcare, with detrimental implications in healthcare quality and medical costs due to errors. The inefficient use of health information technologies (HIT) is attributed to having a role in burnout. OBJECTIVE: This paper seeks to review the literature with the following two goals: (1) characterize and extract HIT trends in burnout studies over time, and (2) examine the evidence and synthesize themes of HIT's roles in burnout studies. METHODS: A scoping literature review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with two rounds of searches in PubMed, IEEE Xplore, ACM, and Google Scholar. The retrieved papers and their references were screened for eligibility by using developed inclusion and exclusion criteria. Data were extracted from included papers and summarized either statistically or qualitatively to demonstrate patterns. RESULTS: After narrowing down the initial 945 papers, 36 papers were included. All papers were published between 2013 and 2020; nearly half of them focused on primary care (n = 16; 44.4%). The most commonly studied variable was electronic health record (EHR) practices (e.g., number of clicks). The most common study population was physicians. HIT played multiple roles in burnout studies: it can contribute to burnout; it can be used to measure burnout; or it can intervene and mitigate burnout levels. CONCLUSION: This scoping review presents trends in HIT-centered burnout studies and synthesizes three roles for HIT in contributing to, measuring, and mitigating burnout. Four recommendations were generated accordingly for future burnout studies: (1) validate and standardize HIT burnout measures; (2) focus on EHR-based solutions to mitigate clinician burnout; (3) expand burnout studies to other specialties and types of healthcare providers, and (4) utilize mobile and tracking technology to study time efficiency.

Cost-Effectiveness of Utilization of Hepatitis B Virus-Positive Liver Donors for HBV-Negative Transplant Recipients.

BACKGROUND: Utilization of hepatitis B virus (HBV)-infected donors represents an opportunity to expand the liver transplantation (LT) donor pool. However, benefits of accepting HBV-positive donors for HBV-negative candidates, potentially expanding the donor pool resulting in earlier transplantation, must be balanced with costs of lifelong antiviral therapy. The aim of this study was to evaluate cost-effectiveness of this strategy. METHODS: We developed a Markov model with two strategies, transplant with (1) a HBV-positive donor versus and (2) a HBV-negative donor for a HBV-negative LT candidate. A healthcare system perspective was utilized, effectiveness measured in quality-adjusted life-years, and costs in 2018 USD. RESULTS: In the base-case, the HBV-positive donor strategy is more effective (gain of 0.46 QALYs), but $26,159 more expensive, yielding an incremental cost-effectiveness ratio (ICER) of $57,389/QALY. However, increasing the candidate's Model for End-Stage Liver Disease score resulted in increasing cost-effectiveness, ICER of $69,507/QALY (MELD 6-10) to $47,385/QALY (MELD > 30). Results were most sensitive to antiviral cost and cost after first year of LT. In probabilistic sensitivity analysis, the HBV-positive strategy was always more effective but more expensive, with average ICER of $64,883/QALY. This strategy was highly cost-effective (ICER < $50,000/QALY) 21% of the time and cost < $100/000/QALY 94% of the time. CONCLUSIONS: Consideration of these donors must be individualized to each candidate's severity of liver disease, associated costs, and personal preferences that impact quality of life. Expansion of the donor pool to include HBV-positive donors for appropriate recipients may be a cost-effective policy and may provide significant benefit for individual patients.

Cost-effectiveness of Sexually Transmitted Infection Screening for Adolescents and Young Adults in the Pediatric Emergency Department.

Importance: Adolescents and young adults compose almost 50% of all diagnosed sexually transmitted infection (STI) cases annually in the US. Given that these individuals frequently access health care through the emergency department (ED), the ED could be a strategic venue for examining the identification and treatment of STIs. Objective: To examine the cost-effectiveness of screening strategies for Chlamydia trachomatis and Neisseria gonorrhoeae (chlamydia and gonorrhea) in adolescents and young adults who seek acute care at pediatric EDs. Design, Setting, and Participants: This economic evaluation is a component of an ongoing, larger multicenter clinical trial at the Pediatric Emergency Care Applied Research Network. A decision analytic model, created using literature-based estimates for the key parameters, was developed to simulate the events and outcomes associated with 3 strategies for screening and testing chlamydial and gonococcal infections in individuals aged 15 to 21 years who sought acute care at pediatric EDs. Data sources included published (from January 1, 1997, to December 31, 2019) English-language articles indexed in MEDLINE, bibliographies in relevant articles, insurance claims data in the MarketScan database, and reimbursement payments from the Centers for Medicare and Medicaid Services. Because the events and outcomes were simulated, a hypothetical population of 10 000 ED visits by adolescents and young adults was used. Interventions: The 3 screening strategies were (1) no screening, (2) targeted screening, and (3) universally offered screening. Targeted screening involved the completion of a sexual health survey, which yielded an estimated STI risk (at risk, high risk, or low risk). Main Outcomes and Measures: Outcome metrics included cost (measured in 2019 US dollars) and the detection and successful treatment of STIs. The incremental cost-effectiveness ratio (ICER) of each strategy was calculated in a base case analysis. The ICER reflects the cost per case detected and successfully treated. Results: A 3.6% prevalence of chlamydia and gonorrhea was applied to a hypothetical population of 10 000 ED visits by adolescents and young adults. Targeted screening resulted in the detection and successful treatment of 95 of 360 STI cases (26.4%) at a cost of $313 063, and universally offered screening identified and treated 112 of 360 STI cases (31.1%) at a cost of $515 503. The ICER for targeted screening vs no screening was $6444, and the ICER for universally offered screening vs targeted screening was $12 139. Conclusions and Relevance: This economic evaluation found that targeted screening and universally offered screening compared with no screening appeared to be cost-effective strategies for identifying and treating chlamydial and gonococcal infections in adolescents and young adults who used the ED for acute care. Universally offered screening was associated with detecting and successfully treating a higher proportion of STIs in this population.

Data and meta-analysis for choosing sugammadex or neostigmine for routine reversal of rocuronium block in adult patients.

This meta-analysis was conducted to define clinical efficacy and side effects (bradycardia and post-operative nausea and vomiting [PONV]) in trials comparing sugammadex with neostigmine or placebo for reversal of rocuronium-induced neuromuscular blockade in adult patients. A search of PubMed, Google Scholar, and Cochrane Library electronic databases identified 111 clinical trials for potential inclusion. We performed a meta-analysis of 32 studies that quantitatively compared the efficacy and side effects of sugammadex with either neostigmine or placebo in adult patients requiring general anesthesia. Analyzed outcomes were reversal time, anesthesia time, duration of stay in the post-anesthesia care unit (PACU), and the occurrence of bradycardia or PONV. Odds ratios and 95% confidence intervals (CI) were calculated for binary data. Mean differences and 95% CI were calculated for continuous outcome data. Meta-analyses were performed using random and fixed-effects models. Heterogeneity across studies was assessed using Cochran's Q test and the I2 statistic. Quantification of these outcomes can better inform anesthetists and health systems of the relative costs and benefits of the two reversal agents. This information also forms a basis for a comparative cost analysis in a co-submitted manuscript [1].