Information Technology and Medical Missteps: Evidence from a Randomized Trial

We analyze the effect of a decision support tool designed to help physicians detect and correct medical "missteps". The data comes from a randomized trial of the technology on a population of commercial HMO patients. The key findings are that the new information technology lowers average charges by 6% relative to the control group. This reduction in resource utilization was the result of reduced in-patient charges (and associated professional charges) for the most costly patients. The rate at which identified issues were resolved was generally higher in the study group than in the control group, suggesting the possibility of improvements in care quality along measured dimensions and enhanced diffusion of new protocols based on new clinical evidence.

Cost-Effectiveness Model for Neovascular Age-Related Macular Degeneration: Comparing Early and Late Treatment with Pegaptanib Sodium Based on Visual Acuity

AbstractObjectiveTo compare the cost-effectiveness of pegaptanib and usual care within three distinct cohorts of subfoveal neovascular age-related macular degeneration (NV-AMD) patients, that is, those with early, moderate, and late disease, using a comprehensive economic model.MethodsA Markov framework was used to model lifetime movement of a subfoveal NV-AMD cohort through health states based on visual acuity. The model takes a US payer perspective of patients over the age of 65 years. Clinical efficacy was based on published results for the 0.3 mg pegaptanib and usual care groups. Expert interviews were conducted to determine adverse event treatment patterns and vision rehabilitation resource use. Incidence and costs of comorbidities such as depression and fractures associated with the effects of declining visual acuity were based on our previously published analysis of Medicare data. Transition probabilities were derived from published clinical trial data for each 3-month cycle. Utilities were derived from published sources. Three runs of the model were conducted with cohorts of newly diagnosed patients. Patients were classified as having early, moderate, or late NV-AMD defined as visual acuity in the better-seeing eye of 20/40 to more than 20/80, 20/80 to more than 20/200, and 20/200 to more than 20/400, respectively. Costs and outcomes were discounted 3.0% per annum.ResultsIncremental costs per vision-year gained and per quality-adjusted life-year (QALY) gained for early NV-AMD patients were approximately one-third those of patients with late disease ($15,279 vs.$57,230 and $36,282 vs.$132,381, respectively). On average, patients treated early with either pegaptanib or usual care incurred lower lifetime total direct costs than those treated later. Sensitivity analysis showed that base-case incremental costs per QALY gained for pegaptanib versus usual care were relatively robust.ConclusionsFor patients with subfoveal NV-AMD, treatment with pegaptanib should be started as early as possible to maximize the clinical and economic benefits

A preliminary investigation into the effects of antipsychotics on sub-chronic phencyclidine-induced deficits in attentional set-shifting in female rats

YesRationale The NMDA receptor antagonist, phencyclidine (PCP), has been shown to induce symptoms characteristic of schizophrenia. A loss in executive function and the ability to shift attention between stimulus dimensions is impaired in schizophrenia; this can be assessed in rodents by the perceptual attentional set-shifting task. Objective The aim of this study was to investigate whether the deficits induced by sub-chronic PCP in attentional set-shifting could be reversed by sub-chronic administration of clozapine, risperidone or haloperidol. Methods Adult female hooded-Lister rats received sub-chronic PCP (2 mg/kg) or vehicle (1 ml/kg) i.p. twice daily for 7 days, followed by a 7-day washout period. PCP-treated rats then received clozapine, risperidone, haloperidol or vehicle once daily for 7 days and were then tested in the perceptual set-shifting task. Results PCP significantly (p < 0.01) increased the number of trials to reach criterion in the EDS phase when compared to vehicle and this deficit was significantly (p < 0.01) attenuated by sub-chronic clozapine (2.5 mg/kg) and risperidone (0.2 mg/kg), but not by sub-chronic haloperidol treatment (0.05 mg/kg). Conclusions These data show that sub-chronic PCP produced a robust deficit within the EDS phase in the attentional set-shifting task, in female rats. Atypical antipsychotics, clozapine and risperidone, but not the classical agent, haloperidol, significantly improved the PCP-induced cognitive deficit

Association Between Eliminating Water From Surgical Hand Antisepsis at a Large Ophthalmic Surgical Hospital and Cost

Alcohol-based surgical scrub is recommended for presurgical antisepsis by leading health organizations. Despite this recommendation, water-based scrub techniques remain common practice at many institutions. To calculate the potential financial savings that a large, subspecialty ophthalmic surgical center can achieve with a conversion to waterless surgical hand preparation. A review of accounting records associated with the purchase of scrubbing materials and water company invoices was conducted to assess direct costs attributable to water consumption and scrub materials for brushless, alcohol-based surgical scrub and water-based presurgical scrub. The flow rate of scrub sinks to estimate water consumption per year was tested. Savings associated with operating room (OR) and personnel time were calculated based on the prescribed scrub times for waterless techniques vs traditional running-water techniques. The study was conducted from January 5 to March 1, 2019. The primary outcomes for this study were the quantity of water consumed by aqueous scrubbing procedures as well as the cost differences between alcohol-based surgical scrub and water-based scrub procedures per OR per year. Scrub sinks consumed 15.9 L of water in a 2-minute period, projecting a savings of 61 631 L and $277 in water and sewer cost per operating room per year. Alcohol-based surgical scrub cost$1083 less than aqueous soap applied from wall-mounted soap dispensers and $271 less than preimpregnated scrub brushes per OR per year in supply costs. The decrease in scrub time from adopting waterless scrub technique could save between approximately$280 000 and $348 000 per OR per year. Adopting waterless scrub techniques has the potential for economic savings attributable to water. Savings may be larger for surgical facilities performing more personnel-intensive procedures

Racial variations in treatment for glaucoma and cataract among Medicare recipients

Purpose: To identify the location of barriers to treatment for glaucoma and cataract among African-American Medicare beneficiaries. Methods: We examined the receipt of eye care in general and care for glaucoma and cataract in particular among black and white Medicare beneficiaries using 1991 Medicare physician claims data. Racial differences in treatment for glaucoma and cataract were examined both for the Medicare population as a whole and for identified eye care users. The results were compared to the expected value of black-white difference based on population prevalence data for each specific condition. Results: Thirty percent of black beneficiaries and 45% of white Medicare beneficiaries used eye care services in 1991. After adjusting for the expected difference in prevalence, black beneficiaries were half as likely to be surgically treated for glaucoma compared to white beneficiaries, and 80% as likely for cataract. When the analysis was restricted to those using eye care services, blacks continued to have lower than expected rates of treatment for glaucoma (observed RR = 3.2, 95% confidence interval = 3.1-3.4 vs an expected RR of 4.3, 95% confidence interval = 3.5-5.4), but a higher rate of treatment for cataract (RR = 1.2, 95% confidence interval = 1.2-1.3). Among those with physician diagnosed glaucoma and cataract, blacks were more likely to undergo surgical treatment for these conditions than whites (RR = 1.5 for glaucoma, 95% confidence interval = 1.4-1.5; RR = 1.2 for cataract, 95% confidence interval = 1.2-1.3). Medicare population as a whole and for identified eye care users. The results were compared to the expected value of black-white difference based on population prevalence data for each specific condition. Conclusion: Barriers to treatment for glaucoma and cataract among black Medicare beneficiaries involve primarily limitations in access to the eye care system. The undertreatment for glaucoma among black beneficiaries was reduced, but not eliminated, after removing the effect of unequal access to the eye care system

Information technology and medical missteps: Evidence from a randomized trial

We analyze the effect of a decision support tool designed to help physicians detect and correct medical "missteps". The data comes from a randomized trial of the technology on a population of commercial HMO patients. The key findings are that the new information technology lowers average charges by 6% relative to the control group. This reduction in resource utilization was the result of reduced in-patient charges (and associated professional charges) for the most costly patients. The rate at which identified issues were resolved was generally higher in the study group than in the control group, suggesting the possibility of improvements in care quality along measured dimensions and enhanced diffusion of new protocols based on new clinical evidence.

NRX-101 (D-cycloserine plus lurasidone) vs. lurasidone for the maintenance of initial stabilization after ketamine in patients with severe bipolar depression with acute suicidal ideation and behavior: a randomized prospective phase 2 trial

Abstract Background We tested the hypothesis that, after initial improvement with intravenous ketamine in patients with bipolar disorder (BD) with severe depression and acute suicidal thinking or behavior, a fixed-dose combination of oral D-cycloserine (DCS) and lurasidone (NRX-101) can maintain improvement more effectively than lurasidone alone. Methods This was a multi-center, double-blind, twostage, parallel randomized trial. Adult BD patients with depression and suicidal ideation or behavior were infused with ketamine or saline (Stage 1); those who improved were randomized to a fixed-dose combination of DCS and lurasidone vs. lurasidone alone (Stage 2) to maintain the improvement achieved in Stage 1. Depression was measured by the Montgomery Åsberg Depression Rating Scale (MADRS), and suicidal thinking and behavior was measured by the Columbia Suicide Severity Rating Scale (C-SSRS); global improvement was measured by the clinical global severity scale (CGI-S). Clinicaltrials.gov NCT02974010; Registered: November 22, 2016. Results Thirty-seven patients were screened and 22 were enrolled, randomized, and treated. All 22 patients treated in Stage 1 (17 with ketamine and 5 with saline) were enrolled into Stage 2, and 11 completed the study. The fixed-dose combination of DCS and lurasidone was significantly more effective than lurasidone alone in maintaining improvement in depression (MADRS LMS Δ-7.7; p = 0.03) and reducing suicidal ideation, as measured by C-SSRS (Δ-1.5; p = 0.02) and by CGI-SS (Δ-2.9; p = 0.03), and with a non-statistically significant decrease in depressive relapse (0% vs. 40%; p = 0.07). This sequential treatment regimen did not cause any significant safety events and demonstrated improvements in patient-reported side effects. Conclusions Sequential treatment of a single infusion of ketamine followed by NRX-101 maintenance is a promising therapeutic approach for reducing depression and suicidal ideation in patients with bipolar depression who require hospitalization due to acute suicidal ideation and behavior. On the basis of these findings, Breakthrough Therapy Designation was awarded, and a Special Protocol Agreement was granted by the FDA for a registrational trial

The prevalence of blindness and visual impairment among nursing home residents in baltimore

Although the prevalence of blindness and visual impairment increases with age, most surveys of ocular disease do not include nursing home residents. We conducted a population-based prevalence survey of persons 40 years of age or older residing in nursing homes in the Baltimore area. Of 738 eligible subjects in 30 nursing homes, 499 (67.6 percent) participated in the study. They had their eyes examined and their visual acuity tested and were interviewed in detail. The nonparticipants were more likely to be older, to be white, and to have lower scores on the Mini–Mental State Examination. The prevalence of bilateral blindness (visual acuity \u3c20/200) was 17.0 percent. The prevalence of visual impairment (\u3c20/40 but =20/200) was 18.8 percent. The frequency of blindness increased from 15.2 percent among those under 60 years of age to 28.6 percent among those 90 or older. The age-adjusted prevalence of blindness was 50 percent higher among blacks than among whites (P\u3c0.01). As compared with the noninstitutionalized population from the same communities, the rate of blindness among nursing home residents was 13.1 times higher for blacks and 15.6 times higher for whites. Cataract was the leading cause of blindness, followed by corneal opacity, macular degeneration, and glaucoma. We judged that 20 percent of the functional blindness and 37 percent of the visual impairment could be remedied by adequate refractive correction. Blindness and visual impairment are highly prevalent among nursing home residents. Much of this loss of vision could be treated or prevented with appropriate ophthalmologic care. © 1995, Massachusetts Medical Society. All rights reserved