Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease : cost effectiveness study

Peer reviewedPublisher PD

Effects of Conflict-of-Interest Policies in Psychiatry Residency on Antidepressant Prescribing

Concerns about the pharmaceutical industry’s influence in academic medical centers and on medical education have led many medical schools and teaching hospitals to adopt conflict-of-interest (COI) policies. Although the restrictiveness of these policies differs, the goal is the same: to shield physicians-in-training from the persuasive aspects of pharmaceutical promotion. But do these policies work? This Issue Brief examines how COI policies affect the prescribing patterns of antidepressants, one of the most heavily promoted drug classes in the past decade. As such, it provides the first empirical evidence of the effects of COI policies in residency on the subsequent prescribing patterns of practicing physicians

An App for Third Party Beneficiaries

Every year, more than 100 reported court opinions consider the question of whether an outsider can sue for damages under a contract made by others—in part because the law is so ambiguous. While contract enforcement by a third party is controlled largely by the facts of the particular case, it also materially depends upon the relevant legal standards. At present, not just the standards, but also the reasons for these standards, are unclear. Eighty years ago, Lon Fuller, a professor teaching contracts at a then-Southern law school, and William Perdue, a student at that school, significantly clarified and improved decision-making on damages issues in contract law by proposing a new vocabulary and analytical model. The senior author of this Article is a professor at a Southern law school, but he does not need an academic Lloyd Bentsen to tell him that he is “no Lon Fuller,” and the younger co-authors hold no “William Perdue illusion,” given that Mr. Perdue was the father-in-law of their law school dean. Nonetheless, we believe that the new vocabulary and analytical model we are proposing would clarify and improve decision-making on third party contract rights

Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals

Importance: Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown. Objective: To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals. Design, Setting, and Participants: Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted. Medical records were reviewed from January 1, 2017, to March 31, 2018. Main Outcomes and Measures: Clinicians reviewed cases for sepsis during hospitalization using Sepsis-3 criteria, hospice-qualifying criteria on admission, immediate and underlying causes of death, and suboptimal sepsis-related care such as inappropriate or delayed antibiotics, inadequate source control, or other medical errors. The preventability of each sepsis-associated death was rated on a 6-point Likert scale. Results: The study cohort included 568 patients (289 [50.9%] men; mean [SD] age, 70.5 [16.1] years) who died in the hospital or were discharged to hospice. Sepsis was present in 300 hospitalizations (52.8%; 95% CI, 48.6%-57.0%) and was the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%-38.9%). The next most common immediate causes of death were progressive cancer (92 [16.2%]) and heart failure (39 [6.9%]). The most common underlying causes of death in patients with sepsis were solid cancer (63 of 300 [21.0%]), chronic heart disease (46 of 300 [15.3%]), hematologic cancer (31 of 300 [10.3%]), dementia (29 of 300 [9.7%]), and chronic lung disease (27 of 300 [9.0%]). Hospice-qualifying conditions were present on admission in 121 of 300 sepsis-associated deaths (40.3%; 95% CI 34.7%-46.1%), most commonly end-stage cancer. Suboptimal care, most commonly delays in antibiotics, was identified in 68 of 300 sepsis-associated deaths (22.7%). However, only 11 sepsis-associated deaths (3.7%) were judged definitely or moderately likely preventable; another 25 sepsis-associated deaths (8.3%) were considered possibly preventable. Conclusions and Relevance: In this cohort from 6 US hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved

Optimising surveillance and re-intervention strategy following elective endovascular repair of abdominal aortic aneurysms

Background Elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm has an initial survival advantage over open repair (OR), but more frequent complications increase costs and long-term aneurysm-related mortality. Randomised controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient’s lifetime. However, in the EVAR-1 trial, post-operative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked. Methods Real-world data informed a discrete event simulation model of post-operative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from five alternative post-operative surveillance and re-intervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored. Results Compared with observed EVAR-1 outcomes, modelling full adherence to the EVAR-1 scan protocol reduced AAA deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory CT if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions. Conclusions All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.Financial support from National Institute of Health Research and Camelia Botnar Arterial Foundation. The National Institute of Health Research (NIHR) had no role in study design, data collection, data analysis, data interpretation, in the writing of the report or in the decision to submit the article for publication. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the NIHR, UK NHS, or Department of Health. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication

Optimizing Surveillance and Re-intervention Strategy Following Elective Endovascular Repair of Abdominal Aortic Aneurysms

Background: EVAR for abdominal aortic aneurysm has an initial survival advantage over OR, but more frequent complications increase costs and long-term aneurysm-related mortality. Randomized controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient's lifetime. However, in the EVAR-1 trial, postoperative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked. Methods: Real-world data informed a discrete event simulation model of postoperative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from 5 alternative postoperative surveillance and reintervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored. Results: Compared with observed EVAR-1 outcomes, modeling full adherence to the EVAR-1 scan protocol reduced abdominal aortic aneurysm (AAA) deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory computed tomography if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions. Conclusions: All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.Peer reviewe

Comparison of Intravenous Medetomidine and Medetomidine/Ketamine for Immobilization of Free-Ranging Variable Flying Foxes (Pteropus hypomelanus)

Medetomidine (0.03 mg/kg) and medetomidine/ketamine (0.05/5.0 and 0.025/2.5 mg/kg), administered by intravenous injection, were evaluated for short-term immobilization of wild-caught variable flying foxes (Pteropus hypomelanus). Medetomidine alone produced incomplete chemical restraint and a stressful, prolonged induction. Both ketamine/medetomidine doses produced a smooth induction and complete immobilization. The combined medetomidine/ketamine dose of 0.025/2.5 mg/kg produced a rapid induction (232±224 sec) with minimal struggling and vocalization, a complete and effective immobilization period, and tended to lead to a faster and better quality recovery than medetomidine alone or a higher dose of medetomidine and ketamine (0.05/5.0 mg/kg), thus reducing holding time and permitting an earlier release of the bat back into the wild