Glass-to-Glass Fusion Bonding Quality and Strength Evaluation with Time, Applied Force, and Heat.

A bonding process was developed for glass-to-glass fusion bonding using Borofloat 33 wafers, resulting in high bonding yield and high flexural strength. The Borofloat 33 wafers went through a two-step process with a pre-bond and high-temperature bond in a furnace. The pre-bond process included surface activation bonding using O2 plasma and N2 microwave (MW) radical activation, where the glass wafers were brought into contact in a vacuum environment in an EVG 501 Wafer Bonder. The optimal hold time in the EVG 501 Wafer bonder was investigated and concluded to be a 3 h hold time. The bonding parameters in the furnace were investigated for hold time, applied force, and high bonding temperature. It was concluded that the optimal parameters for glass-to-glass Borofloat 33 wafer bonding were at 550 °C with a hold time of 1 h with 550 N of applied force.

Applied Informatics Decision Support Tool for Mortality Predictions in Patients With Cancer.

PURPOSE: With rapidly evolving treatment options in cancer, the complexity in the clinical decision-making process for oncologists represents a growing challenge magnified by oncologists' disposition of intuition-based assessment of treatment risks and overall mortality. Given the unmet need for accurate prognostication with meaningful clinical rationale, we developed a highly interpretable prediction tool to identify patients with high mortality risk before the start of treatment regimens. METHODS: We obtained electronic health record data between 2004 and 2014 from a large national cancer center and extracted 401 predictors, including demographics, diagnosis, gene mutations, treatment history, comorbidities, resource utilization, vital signs, and laboratory test results. We built an actionable tool using novel developments in modern machine learning to predict 60-, 90- and 180-day mortality from the start of an anticancer regimen. The model was validated in unseen data against benchmark models. RESULTS: We identified 23,983 patients who initiated 46,646 anticancer treatment lines, with a median survival of 514 days. Our proposed prediction models achieved significantly higher estimation quality in unseen data (area under the curve, 0.83 to 0.86) compared with benchmark models. We identified key predictors of mortality, such as change in weight and albumin levels. The results are presented in an interactive and interpretable tool ( www.oncomortality.com ). CONCLUSION: Our fully transparent prediction model was able to distinguish with high precision between highest- and lowest-risk patients. Given the rich data available in electronic health records and advances in machine learning methods, this tool can have significant implications for value-based shared decision making at the point of care and personalized goals-of-care management to catalyze practice reforms.

Personalized Diabetes Management Using Electronic Medical Records.

OBJECTIVE: Current clinical guidelines for managing type 2 diabetes do not differentiate based on patient-specific factors. We present a data-driven algorithm for personalized diabetes management that improves health outcomes relative to the standard of care. RESEARCH DESIGN AND METHODS: We modeled outcomes under 13 pharmacological therapies based on electronic medical records from 1999 to 2014 for 10,806 patients with type 2 diabetes from Boston Medical Center. For each patient visit, we analyzed the range of outcomes under alternative care using a k-nearest neighbor approach. The neighbors were chosen to maximize similarity on individual patient characteristics and medical history that were most predictive of health outcomes. The recommendation algorithm prescribes the regimen with best predicted outcome if the expected improvement from switching regimens exceeds a threshold. We evaluated the effect of recommendations on matched patient outcomes from unseen data. RESULTS: Among the 48,140 patient visits in the test set, the algorithm's recommendation mirrored the observed standard of care in 68.2% of visits. For patient visits in which the algorithmic recommendation differed from the standard of care, the mean posttreatment glycated hemoglobin A1c (HbA1c) under the algorithm was lower than standard of care by 0.44 ± 0.03% (4.8 ± 0.3 mmol/mol) (P < 0.001), from 8.37% under the standard of care to 7.93% under our algorithm (68.0 to 63.2 mmol/mol). CONCLUSIONS: A personalized approach to diabetes management yielded substantial improvements in HbA1c outcomes relative to the standard of care. Our prototyped dashboard visualizing the recommendation algorithm can be used by providers to inform diabetes care and improve outcomes.

Lifetime medical costs of knee osteoarthritis management in the United States: impact of extending indications for total knee arthroplasty.

OBJECTIVE: The impact of increasing utilization of total knee arthroplasty (TKA) on lifetime costs in persons with knee osteoarthritis (OA) is understudied. METHODS: We used the Osteoarthritis Policy Model to estimate total lifetime costs and TKA utilization under a range of TKA eligibility criteria among US persons with symptomatic knee OA. Current TKA utilization was estimated from the Multicenter Osteoarthritis Study and calibrated to Health Care Cost and Utilization Project data. OA treatment efficacy and toxicity were drawn from published literature. Costs in 2013 dollars were derived from Medicare reimbursement schedules and Red Book Online. Time costs were derived from published literature and the US Bureau of Labor Statistics. RESULTS: Estimated average discounted (3% per year) lifetime costs for persons diagnosed with knee OA were $140,300. Direct medical costs were $129,600, with $12,400 (10%) attributable to knee OA over 28 years. OA patients spent a mean ± SD of 13 ± 10 years waiting for TKA after failing nonsurgical regimens. Under current TKA eligibility criteria, 54% of knee OA patients underwent TKA over their lifetimes. Estimated OA-related discounted lifetime direct medical costs ranged from $12,400 (54% TKA uptake) when TKA eligibility was limited to Kellgren/Lawrence grades 3 or 4 to $16,000 (70% TKA uptake) when eligibility was expanded to include symptomatic OA with a lesser degree of structural damage. CONCLUSION: Because of low efficacy of nonsurgical regimens, knee OA treatment-attributable costs are low, representing a small portion of all costs for OA patients. Expanding TKA eligibility increases OA-related costs substantially for the population, underscoring the need for more effective nonoperative therapies.

Estimating the burden of total knee replacement in the United States.

BACKGROUND: In the last decade, the number of total knee replacements performed annually in the United States has doubled, with disproportionate increases among younger adults. While total knee replacement is a highly effective treatment for end-stage knee osteoarthritis, total knee replacement recipients can experience persistent pain and severe complications. We are aware of no current estimates of the prevalence of total knee replacement among adults in the U.S. METHODS: We used the Osteoarthritis Policy Model, a validated computer simulation model of knee osteoarthritis, and data on annual total knee replacement utilization to estimate the prevalence of primary and revision total knee replacement among adults fifty years of age or older in the U.S. We combined these prevalence estimates with U.S. Census data to estimate the number of adults in the U.S. currently living with total knee replacement. The annual incidence of total knee replacement was derived from two longitudinal knee osteoarthritis cohorts and ranged from 1.6% to 11.9% in males and from 2.0% to 10.9% in females. RESULTS: We estimated that 4.0 million (95% confidence interval [CI]: 3.6 million to 4.4 million) adults in the U.S. currently live with a total knee replacement, representing 4.2% (95% CI: 3.7% to 4.6%) of the population fifty years of age or older. The prevalence was higher among females (4.8%) than among males (3.4%) and increased with age. The lifetime risk of primary total knee replacement from the age of twenty-five years was 7.0% (95% CI: 6.1% to 7.8%) for males and 9.5% (95% CI: 8.5% to 10.5%) for females. Over half of adults in the U.S. diagnosed with knee osteoarthritis will undergo a total knee replacement. CONCLUSIONS: Among older adults in the U.S., total knee replacement is considerably more prevalent than rheumatoid arthritis and nearly as prevalent as congestive heart failure. Nearly 1.5 million of those with a primary total knee replacement are fifty to sixty-nine years old, indicating that a large population is at risk for costly revision surgery as well as possible long-term complications of total knee replacement.

Lifetime risk and age at diagnosis of symptomatic knee osteoarthritis in the US.

OBJECTIVE: To estimate the incidence and lifetime risk of diagnosed symptomatic knee osteoarthritis (OA) and the age at diagnosis of knee OA based on self-reports in the US population. METHODS: We estimated the incidence of diagnosed symptomatic knee OA in the US by combining data on age-, sex-, and obesity-specific prevalence from the 2007-2008 National Health Interview Survey, with disease duration estimates derived from the Osteoarthritis Policy (OAPol) Model, a validated computer simulation model of knee OA. We used the OAPol Model to estimate the mean and median ages at diagnosis and lifetime risk. RESULTS: The estimated incidence of diagnosed symptomatic knee OA was highest among adults ages 55-64 years, ranging from 0.37% per year for nonobese men to 1.02% per year for obese women. The estimated median age at knee OA diagnosis was 55 years. The estimated lifetime risk was 13.83%, ranging from 9.60% for nonobese men to 23.87% in obese women. Approximately 9.29% of the US population is diagnosed with symptomatic knee OA by age 60 years. CONCLUSION: The diagnosis of symptomatic knee OA occurs relatively early in life, suggesting that prevention programs should be offered relatively early in the life course. Further research is needed to understand the future burden of health care utilization resulting from earlier diagnosis of knee OA.

The cost-effectiveness of total joint arthroplasty: a systematic review of published literature.

OBJECTIVE: To summarise the state of the literature evaluating the cost-effectiveness of elective total hip and knee arthroplasty (THA and TKA). METHODS: We conducted a systematic review of published cost-effectiveness analyses of THA and TKA. To limit our search to high-quality published papers, we selected those papers included in the Cost-Effectiveness Analysis Registry (created by the Center for the Evaluation of Value and Risk in Health at Tufts University) and augmented the search with papers listed in PubMed. The data abstracted included incremental cost-effectiveness ratios, perspective of the analysis, time frame, sensitivity analyses conducted, and utility assessment. All cost-effectiveness ratios were converted to 2011 USD. RESULTS: Seven studies presenting cost-effectiveness ratios for TKA and six studies for THA were included in our review. All economic evaluations of TKA were published between 2006 and 2012. By contrast, THA studies were published between 1996 and 2008. Out of the 13 studies evaluated in this review, four were from the societal perspective and eight were from the payer perspective. Five studies spanned the lifetime horizon. Of the selected studies, six used probabilistic sensitivity analysis to address uncertainty in data parameters. Both procedures have been shown to be highly cost-effective from the societal perspective over the entire lifespan. CONCLUSION: THA and TKA have been found to be highly cost-effective in a number of high-quality studies. Further analyses are needed on the cost-effectiveness of alternative surgical options, particularly osteotomy. Future economic evaluations should address the expanding indications of THA and TKA to younger, more physically active individuals.

Impact of obesity and knee osteoarthritis on morbidity and mortality in older Americans.

BACKGROUND: Obesity and knee osteoarthritis are among the most frequent chronic conditions affecting Americans aged 50 to 84 years. OBJECTIVE: To estimate quality-adjusted life-years lost due to obesity and knee osteoarthritis and health benefits of reducing obesity prevalence to levels observed a decade ago. DESIGN: The U.S. Census and obesity data from national data sources were combined with estimated prevalence of symptomatic knee osteoarthritis to assign persons aged 50 to 84 years to 4 subpopulations: nonobese without knee osteoarthritis (reference group), nonobese with knee osteoarthritis, obese without knee osteoarthritis, and obese with knee osteoarthritis. The Osteoarthritis Policy Model, a computer simulation model of knee osteoarthritis and obesity, was used to estimate quality-adjusted life-year losses due to knee osteoarthritis and obesity in comparison with the reference group. SETTING: United States. PARTICIPANTS: U.S. population aged 50 to 84 years. MEASUREMENTS: Quality-adjusted life-years lost owing to knee osteoarthritis and obesity. RESULTS: Estimated total losses of per-person quality-adjusted life-years ranged from 1.857 in nonobese persons with knee osteoarthritis to 3.501 for persons affected by both conditions, resulting in a total of 86.0 million quality-adjusted life-years lost due to obesity, knee osteoarthritis, or both. Quality-adjusted life-years lost due to knee osteoarthritis and/or obesity represent 10% to 25% of the remaining quality-adjusted survival of persons aged 50 to 84 years. Hispanic and black women had disproportionately high losses. Model findings suggested that reversing obesity prevalence to levels seen 10 years ago would avert 178,071 cases of coronary heart disease, 889,872 cases of diabetes, and 111,206 total knee replacements. Such a reduction in obesity would increase the quantity of life by 6,318,030 years and improve life expectancy by 7,812,120 quality-adjusted years in U.S. adults aged 50 to 84 years. LIMITATIONS: Comorbidity incidences were derived from prevalence estimates on the basis of life expectancy of the general population, potentially resulting in conservative underestimates. Calibration analyses were conducted to ensure comparability of model-based projections and data from external sources. CONCLUSION: The number of quality-adjusted life-years lost owing to knee osteoarthritis and obesity seems to be substantial, with black and Hispanic women experiencing disproportionate losses. Reducing mean body mass index to the levels observed a decade ago in this population would yield substantial health benefits. PRIMARY FUNDING SOURCE: The National Institutes of Health and the Arthritis Foundation.