Faculty Bibliography

ABSTRACT: BACKGROUND: Hospitalization may be a particularly important time to promote smoking cessation, especially in the immediate post-discharge period. However, there are few studies to date that shed light on the most effective or cost-effective methods to provide post-discharge cessation treatment, especially among low-income populations and those with a heavy burden of mental illness and substance use disorders. METHODS/DESIGN: This randomized trial will compare the effectiveness and cost-effectiveness of two approaches to smoking cessation treatment among patients discharged from two urban public hospitals in New York City. During hospitalization, staff will be prompted to ask about smoking and to offer nicotine replacement therapy (NRT) on admission and at discharge. Subjects will be randomized on discharge to one of two arms: one arm will be proactive multi-session telephone counseling with motivational enhancement delivered by study staff, and the other will be a faxed or online referral to the New York State Quitline. The primary outcome is 30-day point-prevalence abstinence from smoking at 6-month follow-up post-discharge. We will also examine cost-effectiveness from a societal and a payer perspective, as well as explore subgroup analyses related to patient location of hospitalization, race/ethnicity, immigrant status, and inpatient diagnosis. DISCUSSION: This study will explore issues of implementation feasibility in a post-hospitalization patient population, as well as add information about the effectiveness and cost-effectiveness of different strategies for designing smoking cessation programs for hospitalized patients. TRIAL REGISTRATION: Clinicaltrials.gov ID# NCT01363245.

OBJECTIVE: To estimate the survival and quality-adjusted life-years (QALYs) of Full Code versus Do Not Intubate (DNI) advance directives in patients with severe chronic obstructive pulmonary disease and to evaluate how patient preferences and place of residence influence these outcomes. METHODS: A Markov decision model using published data for COPD exacerbation outcomes. The advance directives that were modeled were as follows: DNI, allowing only noninvasive mechanical ventilation, or Full Code, allowing all forms of mechanical ventilation including invasive mechanical ventilation with endotracheal tube (ETT) insertion. RESULTS: In community-dwellers, Full Code resulted in a greater likelihood of survival and higher QALYs (4-year survival: 23% Full Code, 18% DNI; QALYs: 1.34 Full Code, 1.24 DNI). When considering patient preferences regarding complications, however, if patients were willing to give up >3 months of life expectancy to avoid ETT complications, or >1 month of life expectancy to avoid long-term institutionalization, DNI resulted in higher QALYs. For patients in long-term institutions, DNI resulted in a greater likelihood of survival and higher QALYs (4-year survival: 2% DNI, 1% Full Code; QALYs: 0.29 DNI, 0.24 Full Code). In sensitivity analyses, the model was sensitive to the probabilities of ETT complication and noninvasive mechanical ventilation failure and to patient preferences about ETT complications and long-term institutionalization. CONCLUSION: Our model demonstrates that patient preferences regarding ETT complications and long-term institutionalization, as well as baseline place of residence, affect the advance directive recommendation when considered in terms of both survival and QALYs. Decision modeling can demonstrate the potential trade-off between survival and quality of life, using patient preferences and disease-specific data, to inform the shared advance directive decision.

Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.

The objective was to investigate the impact of a pay-for-performance program (P4P) on quality care and outcomes among cardiovascular disease (CVD) patients. Claims data were used to identify CVD patients in a commercial plan in 1999-2006. Multivariate analyses were employed to examine the impact of P4P on quality care (lipid monitoring and treatment) and quality care on outcomes (new coronary events, hospitalizations, and lipid control). Patients who were treated by physicians participating in P4P were more likely to receive quality care than patients who were not. Patients who received quality care were less likely to have new coronary events (odds ratio [OR] = 0.80; 95% confidence interval [CI] = 0.69-0.92), be hospitalized (OR = 0.76; 95% CI = 0.69-0.83), or have uncontrolled lipids (OR = 0.67; 95% CI = 0.61-0.73) than patients who did not. A P4P program was associated with increased lipid monitoring and treatment. Receipt of this quality care was associated with improved lipid control and reduced likelihood of new coronary events and hospitalizations.

OBJECTIVE: To identify cardiovascular health services with a high level of evidence to suggest that they deliver favorable value. STUDY DESIGN: Evidence synthesis using the Cost-Effectiveness Analysis Registry. METHODS: We queried the registry to identify published cost-effectiveness analyses of cardiovascular health services in the United States. In addition to searching the registry, we performed supplementary searches of published literature for cost-effectiveness studies of cardiovascular interventions that were endorsed by guidelines of national medical and scientific societies. We defined favorable value as an incremental costeffectiveness ratio of $100,000 or less per qualityadjusted life-year. RESULTS: Our initial review of cardiovascular health services in the United States revealed 174 separate peer-reviewed studies. Of those, 157 studies did not meet our inclusion criteria, leaving 17 studies for further evaluation that covered the following services with potentially high value: statins to prevent myocardial infarction (for primary and secondary prevention), screening for and treatment of high blood pressure (diuretics or beta-blockers and angiotensin-converting enzyme inhibitors in the case of diabetes) to prevent myocardial infarction and stroke, warfarin sodium and low-molecular-weight heparin to prevent pulmonary emboli, implantable cardiac defibrillators for patients at high risk of sudden death, antiplatelet drugs (aspirin and clopidogrel bisulfate) to prevent future myocardial infarction, beta-blockers for patients who have had myocardial infarction, warfarin to prevent future stroke in persons with nonvalvular atrial fibrillation, and percutaneous procedures to relieve claudication symptoms. CONCLUSION: We describe a new way of synthesizing cost-effectiveness evidence for use by consumers, payers, and other decision makers

BACKGROUND: Guidelines with short-term harms and long-term benefits are often applied to chronically ill patients who may not benefit. The payoff time framework has been proposed (i.e., do not apply a guideline if a patient's life expectancy (LE) is shorter than when a guideline's cumulative incremental benefits first exceed its cumulative incremental harms), but its health impact is unclear. OBJECTIVE: To investigate whether the payoff time framework improves LE and/or quality-adjusted life-years (QALY) for chronically ill patients. METHODS: I evaluate impact of the payoff time framework on LE and QALYs, assuming (1) high and constant background mortality rate from chronic illness (>/= 10% per year), (2) immediate guideline-related harm with probability < 1, and (3) constant guideline-related benefit that occurs over an extended time. I apply the framework to questions of whether to screen chronically ill 50-year-old women for colorectal cancer using colonoscopy, and whether to advocate intensive glucose control for chronically ill diabetics. RESULTS: If a guideline's payoff time is greater than a patient's LE, then withholding that guideline will increase LE and QALYs for that patient. For a 50-year-old chronically ill woman with background mortality > 0.15 per year (corresponding to LE < 6.5 years), withholding CR screening will increase LE. For a diabetic with background mortality > 0.11 per year (corresponding to LE < 9.4 years), withholding CR screening will increase QALYs. CONCLUSION: The payoff time framework may indicate when withholding a guideline with short-term harms and long-term benefits may increase LE and/or QALY

OBJECTIVE: To systematically evaluate the literature addressing the role of magnetic resonance imaging (MRI) in the diagnosis and prognosis of early undifferentiated inflammatory arthritis and rheumatoid arthritis (RA). METHODS: We performed a systematic literature review of the performance characteristics of MRI for diagnosing and prognosticating RA. We searched Ovid, supplementing this with manual searches of bibliographies, journals, meeting proceedings, and the ClinicalTrials.gov web site. To identify diagnostic studies, we included studies of any duration that prospectively examined whether MRI findings predicted RA diagnosis and reported adequate information to calculate sensitivity and specificity. To identify prognostic studies, we included prospective studies with at least a 12-month followup period that measured both baseline MRI findings and clinical and/or radiographic outcomes. RESULTS: For diagnostic studies (n = 11), sensitivity and specificity of MRI findings for RA diagnosis ranged from 20-100% and 0-100%, respectively, depending upon the criteria used. Diagnostic performance of MRI improved when lower-quality studies or studies with longer disease duration were excluded. For prognostic studies (n = 17), MRI findings did not predict clinical remission, and the ability to predict radiographic progression varied significantly (range 18-100% for sensitivity and 5.9-97% for specificity). Restricting the analysis to specific MRI findings or earlier disease improved MRI prognostic performance. The only prognostic study reporting 100% of a priori quality criteria found MRI bone edema to be the strongest predictor of radiographic progression. CONCLUSION: Data evaluating MRI for the diagnosis and prognosis of early RA are currently inadequate to justify widespread use of this technology for these purposes, although MRI bone edema may be predictive of progression in certain RA populations