Burden of oral anticoagulation in embolic stroke of undetermined source without atrial fibrillation.

OBJECTIVE: Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. METHODS: CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. RESULTS: Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient's lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953-£7018 per patient (UK), €6683-€7368 (Netherlands), €4933-€9378 (Spain), AUD$5353-6539 (Australia) and $26,768-$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468-$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). CONCLUSIONS: Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients.

Cost-effectiveness of TYRX absorbable antibacterial envelope for prevention of cardiovascular implantable electronic device infection.

AIMS: Infection is a major complication of cardiovascular implantable electronic device (CIED) therapy that usually requires device extraction and is associated with increased morbidity and mortality. The TYRX Antibacterial Envelope is a polypropylene mesh that stabilizes the CIED and elutes minocycline and rifampin to reduce the risk of post-operative infection. METHODS: A decision tree was developed to assess the cost-effectiveness of TYRX vs standard of care (SOC) following implantation of four CIED device types. The model was parameterized for a UK National Health Service perspective. Probabilities were derived from the literature. Resource use included drug acquisition and administration, hospitalization, adverse events, device extraction, and replacement. Incremental cost-effectiveness ratios (ICERs) were calculated from costs and quality-adjusted life-years (QALYs). RESULTS: Over a 12-month time horizon, TYRX was less costly and more effective than SOC when utilized in patients with an ICD or CRT-D. TYRX was associated with ICERs of £46,548 and £21,768 per QALY gained in patients with an IPG or CRT-P, respectively. TYRX was cost-effective at a £30,000 threshold at baseline probabilities of infection exceeding 1.65% (CRT-D), 1.95% (CRT-P), 1.87% (IPG), and 1.38% (ICD). LIMITATIONS AND CONCLUSIONS: Device-specific infection rates for high-risk patients were not available in the literature and not used in this analysis, potentially under-estimating the impact of TYRX in certain devices. Nevertheless, TYRX is associated with a reduction in post-operative infection risk relative to SOC, resulting in reduced healthcare resource utilization at an initial cost. The ICERs are below the accepted willingness-to-pay thresholds used by UK decision-makers. TYRX, therefore, represents a cost-effective prevention option for CIED patients at high-risk of post-operative infection.

Recruitment efforts to reduce adverse impact: targeted recruiting for personality, cognitive ability, and diversity.

Noting the presumed tradeoff between diversity and performance goals in contemporary selection practice, the authors elaborate on recruiting-based methods for avoiding adverse impact while maintaining aggregate individual productivity. To extend earlier work on the primacy of applicant pool characteristics for resolving adverse impact, they illustrate the advantages of simultaneous cognitive ability- and personality-based recruiting. Results of an algebraic recruiting model support general recruiting for cognitive ability, combined with recruiting for conscientiousness within the underrepresented group. For realistic recruiting effect sizes, this type of recruiting strategy greatly increases average performance of hires and percentage of hires from the underrepresented group. Further results from a policy-capturing study provide initial guidance on how features of organizational image can attract applicants with particular job-related personalities and abilities, in addition to attracting applicants on the basis of demographic background.

Improving patient safety in intensive care units in Michigan.

PURPOSE: The aim of this study was to describe the design and lessons learned from implementing a large-scale patient safety collaborative and the impact of an intervention on teamwork climate in intensive care units (ICUs) across the state of Michigan. MATERIALS AND METHODS: This study used a collaborative model for improvement involving researchers from the Johns Hopkins University and Michigan Health and Hospital Association. A quality improvement team in each ICU collected and submitted baseline data and implemented quality improvement interventions. Primary outcome measures were improvements in safety culture scores using the Teamwork Climate Scale of the Safety Attitudes Questionnaire (SAQ); 99 ICUs provided baseline SAQ data. Baseline performance for adherence to evidence-based interventions for ventilated patients is also reported. The intervention to improve safety culture was the comprehensive unit-based safety program. The rwg statistic measures the extent to which there is a group consensus. RESULTS: Overall response rate for the baseline SAQ was 72%. Statistical tests confirmed that teamwork climate scores provided a valid measure of teamwork climate consensus among caregivers in an ICU, mean rwg was 0.840 (SD = 0.07). Teamwork climate varied significantly among ICUs at baseline (F98, 5325 = 5.90, P < .001), ranging from 16% to 92% of caregivers in an ICU reporting good teamwork climate. A subset of 72 ICUs repeated the culture assessment in 2005, and a 2-tailed paired samples t test showed that teamwork climate improved from 2004 to 2005, t(71) = -2.921, P < .005. Adherence to using evidence-based interventions ranged from a mean of 25% for maintaining glucose at 110 mg/dL or less to 89% for stress ulcer prophylaxis. CONCLUSION: This study describes the first statewide effort to improve patient safety in ICUs. The use of the comprehensive unit-based safety program was associated with significant improvements in safety culture. This collaborative may serve as a model to implement feasible and methodologically rigorous methods to improve and sustain patient safety on a larger scale.

Manager personality, manager service quality orientation, and service climate: test of a model.

This article conceptually and empirically explores the relationships among manager personality, manager service quality orientation, and climate for customer service. Data were collected from 1,486 employees and 145 managers in grocery store departments (N = 145) to test the authors' theoretical model. Largely consistent with hypotheses, results revealed that core self-evaluations were positively related to managers' service quality orientation, even after dimensions of the Big Five model of personality were controlled, and that service quality orientation fully mediated the relationship between personality and global service climate. Implications for personality and organizational climate research are discussed.

Aerosol-borne quinones and reactive oxygen species generation by particulate matter extracts.

The mass loadings of quinones and their ability to generate reactive oxygen species (ROS) were investigated in total suspended particulate samples collected in Fresno, CA, over a 12-month period. Particles were collected on Teflon filters and were analyzed for the presence of 12 quinones containing one to four aromatic rings by gas chromatography with mass spectrometry. Measured levels are generally greater than mass loadings reported at other locations. The mass loadings were highest during winter months and were strongly anticorrelated with temperature. ROS generation was investigated by measuring the rate of hydrogen peroxide production from the reaction of laboratory standards and ambient samples with dithiothreitol (DTT). ROS generation from ambient samples shows a strong positive correlation with the mass loadings of the three most reactive quinones and may account for all of the ROS formed in the DTT test.