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Displaying 771 - 780 of 6853 in Annals of Internal Medicine
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Prioritizing Quality Measures in Acute Stroke Care: A Cost-Effectiveness Analysis: Annals of Internal Medicine: Vol 176, No 5
Background: The American Heart Association and American Stroke Association (AHA/ASA) endorsed 15 process measures for acute ischemic stroke (AIS) to improve the quality of care. Identifying the highest-value measures could reduce the administrative burden of quality measure adoption while retaining much of the value of quality improvement. Objective: To prioritize AHA/ASA-endorsed quality measures for AIS on the basis of health impact and cost-effectiveness. Design: Individual-based stroke simulation model. Data Sources: Published literature. Target Population: U.S. patients with incident AIS. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Current versus complete (100%) implementation at the population level of quality measures endorsed by the AHA/ASA with sufficient clinical evidence (10 of 15). Outcome Measures: Life-years, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and incremental net health benefits. Results of Base-Case Analysis: Discounted life-years gained from complete implementation would range from 472 (tobacco use counseling) to 34 688 (early carotid imaging) for an annual AIS patient cohort. All AIS quality measures were cost-saving or highly cost-effective by AHA standards (<$50 000 per QALY for high-value care). Early carotid imaging and intravenous tissue plasminogen activator contributed the largest fraction of the total potential value of quality improvement (measured as incremental net health benefit), accounting for 72% of the total value. The top 5 quality measures accounted for 92% of the total potential value. Results of Sensitivity Analysis: A web-based user interface allows for context-specific sensitivity and scenario analyses. Limitation: Correlations between quality measures were not incorporated. Conclusion: Substantial variation exists in the potential net benefit of quality improvement across AIS quality measures. Benefits were highly concentrated among 5 of 10 measures assessed. Our results can help providers and payers set priorities for quality improvement efforts and value-based payments in AIS care. Primary Funding Source: National Institute of Neurological Disorders and Stroke.
Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings
Background: Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. Objective: To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. Design: Cross-sectional. Setting: Population-based. Participants: Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. Measurements: Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. Results: Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. Limitation: Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. Conclusion: Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. Primary Funding Source: Laura and John Arnold Foundation.
Tecovirimat Treatment of People With HIV During the 2022 Mpox Outbreak: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 176, No 5
Background: The recent mpox outbreak has disproportionately affected people with HIV (PWH) and resulted in the first widespread use of the novel antiviral tecovirimat. Whether treatment outcomes differ between PWH and those without HIV is unknown. Objective: To compare the clinical presentation and treatment outcomes of PWH and HIV-negative persons with mpox virus (MPXV) infection treated with tecovirimat. Design: Retrospective cohort study of patients treated with tecovirimat for confirmed MPXV infection from June to August 2022. Setting: Two academic medical centers in New York City. Participants: The study included 196 persons treated with tecovirimat from 20 June to 29 August 2022. Of 154 testing positive for MPXV, 72 were PWH and 4 had a CD4 count lower than 0.20 × 109 cells/L. Measurements: Patient demographic characteristics, clinical presentation, treatment outcomes, and safety data for tecovirimat. Results: Indications for tecovirimat treatment were similar between the PWH and HIV-negative groups. Four participants had serious adverse events; none were attributed to tecovirimat. Three of these 4 participants had HIV infection, and 2 had CD4 counts less than 0.20 × 109 cells/L. Twenty-two percent of participants had nonsevere adverse effects. Groups had similar rates of hospitalization, indications for treatment, and co-occurring infections, but PWH had fewer days from symptom onset to treatment (7.5 vs. 10). There was no difference in treatment outcomes, including days to improvement or rate of persistent symptoms. Limitation: Patients with mpox who were not treated with tecovirimat were not followed routinely and therefore lacked comparable outcome data, limiting evaluation of efficacy. Conclusion: In our cohort of patients treated with tecovirimat for severe mpox, HIV status did not seem to affect treatment outcomes. Primary Funding Source: National Institutes of Health.
Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department: A Retrospective Analysis: Annals of Internal Medicine: Vol 176, No 6
Background: Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). Objective: To measure any resulting change in CTPA use for suspected PE. Design: Retrospective analysis. Setting: 26 European EDs in 6 countries. Patients: Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019. Measurements: The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models. Results: 8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, −8.9% [CI, −17.1% to −0.3%]) were observed. Limitation: Data were limited to 7 days every 2 months. Conclusion: Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed. Primary Funding Source: None specific for this study.