Transient elastography for the diagnosis of liver fibrosis: a systematic review of economic evaluations.

BACKGROUND: Liver biopsy remains the gold standard for the diagnosis of liver fibrosis, but its use as a diagnostic tool is limited by its invasive nature and high cost. OBJECTIVE: The aim of this study was to systematically review the cost-effectiveness of transient elastography (TE) with and without controlled attenuation parameter (CAP) for the diagnosis of liver fibrosis or steatosis in patients with hepatitis B, hepatitis C, alcoholic liver disease and non-alcoholic fatty liver disease. METHODS: An economic literature search was performed. Eligibility criteria included systematic reviews, health technology assessments or economic evaluations of TE compared to liver biopsy and other non-invasive tests. After abstract screening, full-text reports of potentially relevant articles were assessed in duplicate. The methodological quality of the included studies was also appraised. RESULTS: The database search yielded 253 records; four cost-effectiveness and four cost-utility studies were included. The methodological quality of the included studies varies. High-quality cost-effectiveness studies not only suggested that TE is less costly but also less accurate than liver biopsy. The incremental cost-effectiveness ratio (ICER) of TE improves with a greater level of diagnostic accuracy and a higher degree of liver fibrosis. High-quality cost-utility studies indicated that TE is a cost-effective alternative to biopsy with ICER between $9000 and $14 000 per QALY for patients with hepatitis C. We did not find studies that assessed the cost-effectiveness of TE with CAP for the diagnosis of liver steatosis. CONCLUSIONS: Transient elastography is an economically attractive alternative to liver biopsy and other non-invasive diagnostic tests especially for patients with a higher degree of liver fibrosis.

Association between in-hospital supportive visits by primary care physicians and patient outcomes: A population-based cohort study.

BACKGROUND: One long-standing method for continuity of care as patients transition between the hospital and community are supportive visits by primary care physicians during hospitalization. METHODS: This retrospective cohort study used administrative data of adults hospitalized from 2008 to 2009 and primary care physicians who conduct supportive visits. Patients who received a visit from their primary care physician while hospitalized were compared to those who did not. Composite outcomes of death, emergency department visit, or emergent readmission within 30 and 90 days were assessed. Postdischarge home-care utilization and primary care physician visits were also examined. Multivariate logistic regression models adjusted for age, sex, low income, rurality, and readmission risk. RESULTS: Of the 164,059 patients linked to 3236 primary care physicians, 12.0% received visits while hospitalized. Visited patients had more readmissions, more deaths, and fewer emergency department visits than patients who did not. However, after adjusting, visited patients had a lower risk for the composite outcome at 30 days (adjusted OR [aOR]: 0.92; 95% confidence interval [CI]: 0.89-0.96) and 90 days (aOR: 0.90; 95% CI: 0.87-0.92). Visited patients were also more likely to access community primary care-provider visits and more home-care services. The in-hospital visit resulted in an increased likelihood of health services utilization at 30 days (aOR: 1.16; 95% CI: 1.11-1.22) and 90 days (aOR: 1.20; 95% CI: 1.12-1.27). CONCLUSION: A hospital supportive-care visit from a primary care physician resulted in lower risks of adverse patient outcomes and increased access to community health services. Journal of Hospital Medicine 2016;11:418-424. © 2016 Society of Hospital Medicine.

Unintentional Discontinuation of Chronic Medications for Seniors in Nursing Homes: Evaluation of a National Medication Reconciliation Accreditation Requirement Using a Population-Based Cohort Study.

Transitions of care leave patients vulnerable to the unintentional discontinuation of medications with proven efficacy for treating chronic diseases. Older adults residing in nursing homes may be especially susceptible to this preventable adverse event. The effect of large-scale policy changes on improving this practice is unknown.The objective of this study was to analyze the effect of a national medication reconciliation accreditation requirement for nursing homes on rates of unintentional medication discontinuation after hospital discharge.It was a population-based retrospective cohort study that used linked administrative records between 2003 and 2012 of all hospitalizations in Ontario, Canada. We identified nursing home residents aged ≥66 years who had continuous use of ≥1 of the 3 selected medications for chronic disease: levothyroxine, HMG-CoA reductase inhibitors (statins), and proton pump inhibitors (PPIs).In 2008 medication reconciliation became a required practice for accreditation of Canadian nursing homes.The main outcome measures included the proportion of patients who restarted the medication of interest after hospital discharge at 7 days. We also performed a time series analysis to examine the impact of the accreditation requirement on rates of unintentional medication discontinuation.The study included 113,088 adults aged ≥66 years who were nursing home residents, had an acute hospitalization, and were discharged alive to the same nursing home. Overall rates of discontinuation at 7-days after hospital discharge were highest in 2003-2004 for all nursing homes: 23.9% for thyroxine, 26.4% for statins, and 23.9% for PPIs. In most of the cases, these overall rates decreased annually and were lowest in 2011-2012: 4.0% for thyroxine, 10.6% for statins, and 8.3% for PPIs. The time series analysis found that nursing home accreditation did not significantly lower medication discontinuation rates for any of the 3 drug groups.From 2003 to 2012, there were marked improvements in rates of unintentional medication discontinuation among hospitalized older adults who were admitted from and discharged to nursing homes. This change was not directly associated with the new medication reconciliation accreditation requirement, but the overall improvements observed may have been reflective of multiple processes and not 1 individual intervention.

Use of a structured panel process to define quality metrics for antimicrobial stewardship programs.

INTRODUCTION: Antimicrobial stewardship programs are being implemented in health care to reduce inappropriate antimicrobial use, adverse events, Clostridium difficile infection, and antimicrobial resistance. There is no standardized approach to evaluate the impact of these programs. OBJECTIVE: To use a structured panel process to define quality improvement metrics for evaluating antimicrobial stewardship programs in hospital settings that also have the potential to be used as part of public reporting efforts. DESIGN: A multiphase modified Delphi technique. SETTING: Paper-based survey supplemented with a 1-day consensus meeting. PARTICIPANTS: A 10-member expert panel from Canada and the United States was assembled to evaluate indicators for relevance, effectiveness, and the potential to aid quality improvement efforts. RESULTS: There were a total of 5 final metrics selected by the panel: (1) days of therapy per 1000 patient-days; (2) number of patients with specific organisms that are drug resistant; (3) mortality related to antimicrobial-resistant organisms; (4) conservable days of therapy among patients with community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), or sepsis and bloodstream infections (BSI); and (5) unplanned hospital readmission within 30 days after discharge from the hospital in which the most responsible diagnosis was one of CAP, SSTI, sepsis or BSI. The first and second indicators were also identified as useful for accountability purposes, such as public reporting. CONCLUSION: We have successfully identified 2 measures for public reporting purposes and 5 measures that can be used internally in healthcare settings as quality indicators. These indicators can be implemented across diverse healthcare systems to enable ongoing evaluation of antimicrobial stewardship programs and complement efforts for improved patient safety.

Quality measures for medication continuity in long-term care facilities, using a structured panel process.

BACKGROUND: Patient transitions, such as transfers between acute and long-term care (LTC), aposare times when the likelihood of communication failure between healthcare providers is increased. Employing appropriate health quality indicators helps support improvement efforts. To date, few quality indicators that evaluate the continuity of medication use between acute and LTC facilities have been described. OBJECTIVE: The aim of the study was to develop quality indicators signalling the potential discontinuation of previously prescribed medications for chronic diseases when residents return to LTC following an acute-care hospitalization. METHODS: A literature review for the selection of potential indicators was conducted, followed by a three-step process: (i) initial screening round that rated the indicators; (ii) a 1-day in-person consensus meeting in which the panel refined the parameters regarding the proposed quality indicators; and (iii) a final anonymous survey that assessed consensus among panel members. The study setting was a survey and consensus meeting with national representation, held in Toronto, ON, Canada. A ten-member expert panel with broad geographical and clinical representation participated and was made up of registered nurses, physicians, pharmacists, policy makers and academic researchers. A 75% agreement threshold was required for consensus, as measured on a 9-point Likert-type scale. The panel evaluated quality indicators for effectiveness, relevance and feasibility, using currently available healthcare administrative data. RESULTS: The panel reached consensus on four quality indicators to assess the unintentional discontinuation of medications prescribed to LTC residents for chronic diseases upon return to LTC after an acute-care admission. The selected indicators were (i) HMG-CoA reductase inhibitors (statins) for all indications; (ii) anticoagulants (e.g. warfarin) for the indication of atrial fibrillation; (iii) proton-pump inhibitors for the indication of post-gastrointestinal haemorrhage; and (iv) thyroxine for all indications. The panel identified three additional treatment groups for future consideration as quality indicators: anti-Parkinson's disease, anti-diabetes and antidepressant medications. CONCLUSION: A novel set of quality indicators has been developed to evaluate medication continuity between acute and LTC facilities. The adoption and implementation of these indicators in clinical practice can help inform quality improvement efforts at various local and regional levels.

Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases.

CONTEXT: Patients discharged from acute care hospitals may be at risk for unintentional discontinuation of medications prescribed for chronic diseases. The intensive care unit (ICU) may pose an even greater risk because of the focus on acute events and the presence of multiple transitions in care. OBJECTIVE: To evaluate rates of potentially unintentional discontinuation of medications following hospital or ICU admission. DESIGN, SETTING, AND PATIENTS: A population-based cohort study using administrative records from 1997 to 2009 of all hospitalizations and outpatient prescriptions in Ontario, Canada; it included 396,380 patients aged 66 years or older with continuous use of at least 1 of 5 evidence-based medication groups prescribed for long-term use: (1) statins, (2) antiplatelet/anticoagulant agents, (3) levothyroxine, (4) respiratory inhalers, and (5) gastric acid-suppressing drugs. Rates of medication discontinuation were compared across 3 groups: patients admitted to the ICU, patients hospitalized without ICU admission, and nonhospitalized patients (controls). Odds ratios (ORs) were calculated and adjusted for patient demographics, clinical factors, and health services use. MAIN OUTCOME MEASURES: The primary outcome was failure to renew the prescription within 90 days after hospital discharge. RESULTS: Patients admitted to the hospital (n = 187,912) were more likely to experience potentially unintentional discontinuation of medications than controls (n = 208,468) across all medication groups examined. The adjusted ORs (AORs) ranged from 1.18 (95% CI, 1.14-1.23) for discontinuing levothyroxine in 12.3% of hospitalized patients (n = 6831) vs 11.0% of controls (n = 7114) to an AOR of 1.86 (95% CI, 1.77-1.97) for discontinuing antiplatelet/anticoagulant agents in 19.4% of hospitalized patients (n = 5564) vs 11.8% of controls (n = 2535). With ICU exposure, the AORs ranged from 1.48 (95% CI, 1.39-1.57) for discontinuing statins in 14.6% of ICU patients (n = 1484) to an AOR of 2.31 (95% CI, 2.07-2.57) for discontinuing antiplatelet/anticoagulant agents in 22.8% of ICU patients (n = 522) vs the control group. Admission to an ICU was associated with an additional risk of medication discontinuation in 4 of 5 medication groups vs hospitalizations without an ICU admission. One-year follow-up of patients who discontinued medications showed an elevated AOR for the secondary composite outcome of death, emergency department visit, or emergent hospitalization of 1.07 (95% CI, 1.03-1.11) in the statins group and of 1.10 (95% CI, 1.03-1.16) in the antiplatelet/anticoagulant agents group. CONCLUSIONS: Patients prescribed medications for chronic diseases were at risk for potentially unintentional discontinuation after hospital admission. Admission to the ICU was generally associated with an even higher risk of medication discontinuation.

Cost-effectiveness analysis of a reduction in diagnostic imaging in degenerative spinal disorders.

BACKGROUND: Advanced imaging technologies such as computed tomography (CT) and magnetic resonance imaging (MRI) are highly sensitive, but often non-specific, diagnostic tools. Despite this, CT and MRI are overutilized in degenerative spinal disorder diagnosis. From the perspective of the Ministry of Health, we evaluated against usual care the cost-effectiveness of a hypothetical triage program for non-emergent spinal disorders that reduces unnecessary imaging uses. METHODS: Diagnostic and surgical data were prospectively collected on 2,046 outpatients who received consultation with the senior surgical author at Toronto Western Hospital, University Health Network, between September 2005 and April 2008. Using these data, we modelled an evidence-based diagnostic triage program wherein spine-focused clinical assessments and plain X-ray imaging would be applied prior to CT and MRI. Incremental costs were the incurred expenses from additional consultations and plain X-rays less the cost savings from the eliminated CT and MRI scans, expressed in 2009 Canadian dollars. Outcomes were expressed as the number of surgical candidates identified per MRI used in diagnosis, reflecting the efficiency of diagnostic imaging. RESULTS: The triage program incurred $109,720 from additional consultations and plain X-rays and saved $2,117,697 from eliminated CT and MRI scans, resulting in net cost savings of $2,007,977 for the 31 months of the study period, or $777,282 per year. In usual care, 0.328~0.418 surgical candidates were identified per MRI whereas in the triage program, 0.736~0.885 surgical candidates were identified per MRI, resulting in over a twofold improvement in MRI efficiency. The triage program was therefore dominating. Applying to high-volume spine surgeons in Ontario, we estimated that the implementation of the triage program would save the province $24,234,929 per year. INTERPRETATION: Based on the assumptions made in our modelling, eliminating unnecessary imaging in spinal disorder diagnosis can save healthcare significant resources.

A nuclear localization signal at the SAM-SAM domain interface of AIDA-1 suggests a requirement for domain uncoupling prior to nuclear import.

The neuronal scaffolding protein AIDA-1 is believed to act as a convener of signals arising at postsynaptic densities. Among the readily identifiable domains in AIDA-1, two closely juxtaposed sterile alpha motif (SAM) domains and a phosphotyrosine binding domain are located within the C-terminus of the longest splice variant and exclusively in four shorter splice variants. As a first step towards understanding the possible emergent properties arising from this assembly of ligand binding domains, we have used NMR methods to solve the first structure of a SAM domain tandem. Separated by a 15-aa linker, the two SAM domains are fused in a head-to-tail orientation that has been observed in other hetero- and homotypic SAM domain structures. The basic nuclear import signal for AIDA-1 is buried at the interface between the two SAM domains. An observed disparity between the thermal stabilities of the two SAM domains suggests a mechanism whereby the second SAM domain decouples from the first SAM domain to facilitate translocation of AIDA-1 to the nucleus.