Value-based Care
ACP cost-effectiveness analysis: Newer antidiabetic medications in type 2 diabetes – Ann Intern Med
3 May, 2024 | 13:57h | UTCThis systematic review evaluates the cost-effectiveness of newer antidiabetic medications for type 2 diabetes from U.S. clinical and economic perspectives. Analyzing non-industry funded cost-effectiveness analyses (CEAs) using GRADE and Drummond criteria, the study identifies varying cost per quality-adjusted life-year (QALY) values for medications such as GLP1a and SGLT2i. It concludes that while GLP1a and SGLT2i offer low value as primary therapies due to high costs, they may present intermediate value as adjunct treatments to metformin. The study highlights the methodological variability in CEAs and the influence of drug cost and effectiveness assumptions on outcomes. The results suggest cautious interpretation in clinical decision-making due to varied evidence quality and cost-effectiveness profiles among the reviewed medications.
Reference (link to free full-text):
Meta-Analysis: Effectiveness of therapist-guided remote vs. in-person cognitive behavioral therapy
20 Mar, 2024 | 19:32h | UTCStudy Design and Population: This systematic review and meta-analysis investigated the efficacy of therapist-guided remote cognitive behavioral therapy (CBT) compared to traditional in-person CBT. The authors conducted a comprehensive search across several databases, including MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials, up to July 4, 2023. A total of 54 randomized controlled trials (RCTs) were included, encompassing 5463 adult patients presenting with various clinical conditions. The study meticulously assessed the risk of bias and extracted data using a standardized approach, and outcomes were analyzed using a random-effects model.
Main Findings: The primary analysis focused on patient-important outcomes, comparing the effectiveness of remote and in-person CBT across diverse conditions such as anxiety and related disorders, depressive symptoms, insomnia, chronic pain or fatigue syndromes, body image or eating disorders, tinnitus, alcohol use disorder, and mood and anxiety disorders. The meta-analysis, based on moderate-certainty evidence, found little to no difference in effectiveness between remote and in-person CBT (standardized mean difference [SMD] −0.02, 95% confidence interval −0.12 to 0.07), suggesting that both delivery methods are comparably effective across a range of disorders.
Implications for Practice: The findings indicate that therapist-guided remote CBT is nearly as effective as in-person CBT for treating a variety of mental health and somatic disorders. This supports the potential for remote CBT to significantly increase access to evidence-based care, especially in settings where in-person therapy is not feasible or is limited by geographic, economic, or social barriers. Future research should explore optimizing remote CBT delivery methods to further enhance accessibility and efficacy.
Reference: Zandieh, S. et al (2024). Therapist-guided remote versus in-person cognitive behavioural therapy: a systematic review and meta-analysis of randomized controlled trials. CMAJ, 196(10), E327-E340. [Link]
Study | The high financial and human cost of quality metric reporting in hospitals
11 Aug, 2023 | 15:36h | UTCThe Volume and Cost of Quality Metric Reporting – JAMA (link to abstract – $ for full-text)
Author Interview: The Costs of Quality Reporting – JAMA
Commentaries:
The Cost of “Quality” – Emergency Medicine Literature of Note
How John Hopkins spent $5m and 108,478 hours on quality reporting in one year – HealthLeaders
The cost of quality metric reporting – Becker’s Hospital Review
Study | Uncovering the potential overuse of laboratory tests by combining cost, abnormal result proportion, and physician variation
11 Aug, 2023 | 15:34h | UTC
Perspective | An AI-enhanced electronic health record could boost primary care productivity
9 Aug, 2023 | 15:36h | UTCAn AI-Enhanced Electronic Health Record Could Boost Primary Care Productivity – JAMA (free for a limited period)
What are effective strategies to reduce low-value care? An analysis of 121 randomized deimplementation studies
17 Jul, 2023 | 13:55h | UTC
AHA Policy Statement | Value-based payment for clinicians treating cardiovascular disease
13 Jul, 2023 | 13:13h | UTCNews Release: Policy guidance offers strategies to shift to value-based health care and payment – American Heart Association
Commentary: AHA Reviews Value-Based Payment Systems and Proposes Next Steps – TCTMD
Cohort Study | Increased revision rates seen in shoulder replacement surgeries by surgeons with less than 10 procedures annually
27 Jun, 2023 | 13:48h | UTCSummary: This prospective cohort study investigated the correlation between surgeon volume and patient outcomes after elective shoulder replacement surgeries. Utilizing data from 39,281 procedures performed by 638 surgeons in UK public and private hospitals between 2012-20, the study focuses on adults aged 18 years or older.
The results indicate a significant connection between a surgeon’s mean annual volume and risk of adverse patient outcomes. Surgeons performing fewer than 10.4 procedures per year demonstrated a significantly increased risk of revision surgery, with the hazard ratio being almost twice as high as that of the lowest risk surgeons. Higher mean annual surgical volume correlated with lower risks of reoperations, fewer serious adverse events, and shorter hospital stays.
These findings suggest the need for strategic resource planning in surgical services, with considerations given to surgeon’s annual procedure volume to improve patient outcomes after shoulder replacement surgery. It should be noted that the study was limited in scope to surgeries performed within the NHS and private hospitals in England. Furthermore, potential confounding factors like patients’ social circumstances, carer availability, or body mass index were not considered.
Editorial: Surgeon volume and patient outcomes in shoulder replacement surgery – The BMJ
News Release: Patients do better when surgeon averages 10 + annual shoulder ops – BMJ Newsroom
M-A | Biosimilar and reference biologics in rheumatoid arthritis show equivalent results
15 Jun, 2023 | 14:47h | UTCCommentary: Adalimumab, Etanercept, Infliximab Biosimilars Show Clinically Equivalence to Biologics in RA – HCP Live
Saving time and money in biomedical publishing: the case for free-format submissions with minimal requirements
13 Jun, 2023 | 14:08h | UTCCommentary: Revealed: the millions of dollars in time wasted making papers fit journal guidelines – Nature
RCT | Immediate vs. delayed sequential bilateral cataract surgery: non-inferior in safety, higher cost-effectiveness
6 Jun, 2023 | 14:41h | UTCSafety, effectiveness, and cost-effectiveness of immediate versus delayed sequential bilateral cataract surgery in the Netherlands (BICAT-NL study): a multicentre, non-inferiority, randomised controlled trial – The Lancet (link to abstract – $ for full-text)
News Release: Cataract surgery: two-sided treatment better than one-by-one approach – Maastricht University
Quality-improvement intervention | Impact of stopping preoperative screening for asymptomatic bacteriuria
2 Jun, 2023 | 12:29h | UTCCommentary: Hospital intervention reduces unnecessary screening, antibiotics for bacteriuria – CIDRAP
SR | Unclear evidence on the efficacy of case management in integrated care for frail elderly
31 May, 2023 | 13:50h | UTCSummary: Case management programmes for older people living with frailty in the community – Cochrane Library
The future of cancer care at home: findings from an American Cancer Society summit
31 May, 2023 | 13:48h | UTC
RCT | Morning discharge prioritization fails to shorten hospital stay or expedite orders
9 May, 2023 | 14:58h | UTCCommentary: “Discharge Before Noon”: Time to Jump Off the Bandwagon? – Physician’s First Watch
Position Statement | Telehealth policy, practice, and education
4 May, 2023 | 14:01h | UTC
Top POEMs (Patient-Oriented Evidence that Matters) of 2022 for choosing wisely in practice
27 Mar, 2023 | 13:30h | UTCSummary: Top POEMs of 2022 for choosing wisely in practice are based on Canadian Medical Association member ratings. These recommendations promote evidence-based and cost-effective clinical practices while reducing unnecessary treatments and diagnostic procedures.
Key recommendations from the article:
- Hypnotic agents are effective for insomnia but have adverse effects; avoid benzodiazepines as the first choice for older adults.
- For type 2 diabetes in older adults, avoid medications causing hypoglycemia to achieve A1c <7.5%; moderate control is better.
- Postoperative opioids provide no better pain relief than nonopioids; avoid prolonged use beyond the immediate postoperative period.
- Arthroscopic debridement is not recommended as the primary treatment for knee osteoarthritis.
- Proton pump inhibitor (PPI) use is associated with an increased risk of gastric cancer, although the association is observational and does not imply causation. Use the lowest dose and duration possible.
- For children with community-acquired pneumonia, low-dose amoxicillin for 3 days is noninferior to high-dose for 7 days.
- White blood cells in urine do not equate to bacterial cells; avoid urine dip tests or cultures unless urinary tract symptoms are present.
- Avoid measuring vitamin D in low-risk adults as a routine test.
- Antidepressants should not be routinely used as first-line treatment for mild or subsyndromal depressive symptoms in adults.
- ACG guideline for GERD management: try discontinuing PPIs after an 8-week trial in patients with classic GERD symptoms & no alarming symptoms.
- British Society of Gastroenterology guidelines for IBS management: colonoscopy only for alarming signs or microscopic colitis risk.
- USPSTF advises against ASA initiation for primary prevention of cardiovascular disease in adults >60.
Top POEMs of 2022 for choosing wisely in practice – Canadian Family Physician
See complete lists of low-value practices: Choosing Wisely U.S. / Choosing Wisely UK / Choosing Wisely Australia AND Choosing Wisely Canada
SR | Interventions to reduce repetitive ordering of low-value inpatient laboratory tests
27 Mar, 2023 | 13:22h | UTC
Study reveals overuse of surveillance colonoscopy in older adults with limited life expectancy
23 Mar, 2023 | 13:11h | UTCSummary: This study investigated the association between estimated life expectancy, surveillance colonoscopy findings, and follow-up recommendations among older adults. The study utilized data from the New Hampshire Colonoscopy Registry and included adults over 65 who underwent colonoscopy for surveillance after prior polyps.
Life expectancy was estimated using a validated prediction model and categorized into three groups: less than 5 years, 5 to less than 10 years, and 10 or more years.
Out of the 9,831 adults included in the study, 8% had advanced polyps or CRC. Among the 5,281 patients with available recommendations, 86.9% were advised to return for a future colonoscopy. Surprisingly, 58.1% of older adults with less than 5 years of life expectancy were also recommended to return for future surveillance colonoscopy.
The study concluded that many older adults with limited life expectancy are still recommended for future surveillance colonoscopy. This data could help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.
Article: Association of Life Expectancy With Surveillance Colonoscopy Findings and Follow-up Recommendations in Older Adults – JAMA Internal Medicine (link to abstract – $ for full-text)
JAMA Patient Page: What Should I Know About Stopping Routine Cancer Screening?
Commentary on Twitter
Findings suggest that recommending against future surveillance colonoscopy in older adults with low-risk colonoscopy findings and/or limited life expectancy should be considered more frequently than is currently practiced. https://t.co/7jKpYyuZON
— JAMA Internal Medicine (@JAMAInternalMed) March 13, 2023
Analysis | Networks of care to strengthen primary healthcare in resource constrained settings
21 Mar, 2023 | 13:08h | UTCNetworks of care to strengthen primary healthcare in resource constrained settings – The BMJ
M-A | Low-intensity follow-up after cancer surgery does not reduce patient satisfaction or well-being
16 Mar, 2023 | 13:10h | UTCOncological surgery follow-up and quality of life: meta-analysis – British Journal of Surgery
An overview of systematic reviews and meta-analyses on the effect of medication interventions targeting polypharmacy for frail older adults
3 Mar, 2023 | 14:07h | UTCSummary: This overview of published systematic reviews examined the effectiveness of medication reviews on managing polypharmacy in frail older adults. The overview identified 10 systematic reviews, which included 154 studies. Medication reviews were the most common intervention, and the evidence suggests that they help reduce inappropriate medication use in frail older adults, but their impact on frailty scores and hospital admission is unclear. Pharmacist-led medication interventions were the most common, reducing inappropriate prescriptions in various settings. Tools, such as clinical decision-making computer support tools, were also found to be effective. The evidence quality ranged from moderate to critically low, highlighting the need for further research to establish if interventions directed at polypharmacy could have an impact on frailty syndromes.
Related:
RCT | A deprescribing intervention reduced medication burden among older adults in post-acute care
Deprescribing proton pump inhibitors – Australian Journal of General Practice
Antihypertensive Deprescribing in Older Adults: a Practical Guide – Current Hypertension Reports
Deprescribing in Palliative Cancer Care – Life
Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review – Kidney360
Polypharmacy Management in Older Patients – Mayo Clinic Proceedings
Eliminating Medication Overload: A National Action Plan – Lown Institute
Common ED Medication Errors: Polypharmacy – emDocs
Current and future perspectives on the management of polypharmacy – BMC Family Practice
Polypharmacy—an Upward Trend with Unpredictable Effects – Deutsches Ärzteblatt international
Clinical Consequences of Polypharmacy in Elderly – Expert Opinion on Drug Safety
Choosing Wisely in Cardiology | New ACC list of five things physicians and patients should question
28 Feb, 2023 | 14:03h | UTCSummary: The American College of Cardiology (ACC) has released a list of “Five Things Physicians and Patients Should Question” in cardiology as part of the Choosing Wisely campaign, which encourages conversations between clinicians and patients about potentially unnecessary tests, treatments, and procedures. The list includes recommendations to:
- Avoid the routine use of invasive hemodynamic monitoring with pulmonary artery catheters in patients with uncomplicated acute decompensated heart failure.
- Avoid performing atrial fibrillation ablation for the sole purpose of discontinuing chronic anticoagulation.
- Avoid routine imaging stress tests or coronary CT angiography for the workup of palpitations or presyncope.
- Avoid obtaining a coronary artery calcium score in patients with known clinical atherosclerotic cardiovascular disease.
- Avoid obtaining routine serial echocardiograms for chronic heart failure if there has been no change in signs, symptoms, or management.
The recommendations are based on published national guidelines and aim to broadly represent the field of cardiology.
Commentary: ACC Releases New List of Choosing Wisely Recommendations – American College of Cardiology
See complete lists of low-value practices: Choosing Wisely U.S. / Choosing Wisely UK / Choosing Wisely Australia AND Choosing Wisely Canada
Perspective | Beware of overdiagnosis harms from screening, lower diagnostic thresholds, and incidentalomas
27 Feb, 2023 | 13:18h | UTCSummary: This article discusses the concept of overdiagnosis and its relevance to clinical practice guidelines. Overdiagnosis is the diagnosis of a condition that, if unrecognized, would not result in symptoms or cause a patient harm during their lifetime, such as discovering a low-grade cancer that will never lead to symptoms at the end of life. But, unlike false positives, overdiagnosed individuals truly have the condition; they just don’t benefit from the diagnosis. Overdiagnosis can also result from lowering diagnostic thresholds for diagnosing a disease, which inflates diagnosis rates among patients and leads to recommendations for subsequent interventions without clear benefits. The article highlights the importance of providing accurate information to patients about the possibility and burden of overdiagnosis to inform shared decision-making and minimize the harms of screening interventions.
Related:
Overdiagnosis: it’s official – The BMJ
Overdiagnosis: what it is and what it isn’t – BMJ Evidence Based Medicine
Overdiagnosis across medical disciplines: a scoping review – The BMJ Open
Too much medical care: bad for you, bad for health care systems – STAT News
Overdiagnosis: causes and consequences in primary health care – Canadian Family Physician
Five warning signs of overdiagnosis – The Conversation
What is overdiagnosed cancer? And why does it matter? – Croakey
Blame rising cancer overdiagnosis on ‘irrational exuberance’ for early detection – STAT
A food allergy epidemic… or just another case of overdiagnosis?
An epidemic of overdiagnosis: Melanoma diagnoses sky rocket
Innovative models of healthcare delivery: an umbrella review of reviews
27 Feb, 2023 | 12:37h | UTCInnovative models of healthcare delivery: an umbrella review of reviews – BMJ Open